Yutrepia — Cigna

Initial criteria

• Patient has a diagnosis of World Health Organization (WHO) Group 3 pulmonary hypertension associated with interstitial lung disease; AND
• Patient with connective tissue disease is required to have a baseline forced vital capacity < 70%; AND
• Patient has evidence of diffuse parenchymal lung disease on computed tomography of the chest; AND
• Patient meets BOTH of the following (a and b): a) Patient has had a right heart catheterization [documentation required]; AND b) Results of the right heart catheterization confirm the diagnosis of WHO Group 3 pulmonary hypertension associated with interstitial lung disease; AND
• The 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 3 pulmonary hypertension associated with interstitial lung disease; AND
• Patient meets BOTH of the following (a and b): a) Patient has had a right heart catheterization; AND b) Results of the right heart catheterization confirm the diagnosis of World Health Organization (WHO) Group 3 pulmonary hypertension associated with interstitial lung disease; AND
• According to the prescriber, patient has had a response to therapy (e.g., increase or maintenance in six‑minute walk distance from baseline, improved exercise capacity, decrease in N‑terminal pro‑B‑type natriuretic peptide levels, lessened clinical worsening, or reduced rate of exacerbations of underlying lung disease); AND
• The medication is prescribed by or in consultation with a cardiologist or a pulmonologist

Approval duration

initial 4 months; renewal 1 year