Uptravi (selexipag tablets) — Cigna

Initial criteria

• Patient has a diagnosis of World Health Organization (WHO) Group 1 pulmonary arterial hypertension (PAH); AND
• Patient has had a right heart catheterization [documentation required]; AND
• Results for the right heart catheterization confirm the diagnosis of WHO Group 1 PAH; AND
• Patient has tried or is currently receiving at least one oral medication for PAH from one of the three following different categories (either alone or in combination) each for ≥ 60 days: one phosphodiesterase type 5 (PDE5) inhibitor, one endothelin receptor antagonist (ERA), or Adempas (riociguat tablets); OR Patient is currently receiving, or has a history of receiving, one prostacyclin therapy for PAH; AND
• Medication is prescribed by, or in consultation with, a cardiologist or a pulmonologist.

Reauthorization criteria

• Patient has a diagnosis of World Health Organization (WHO) Group 1 pulmonary arterial hypertension (PAH); AND
• Patient has had a right heart catheterization prior to starting therapy with a medication for WHO Group 1 PAH; AND
• Results of the right heart catheterization confirm the diagnosis of WHO Group 1 PAH; AND
• Medication is prescribed by or in consultation with a cardiologist or a pulmonologist.

Approval duration

1 year