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Adempas (riociguat) — Highmark

WHO Group 4 chronic thromboembolic pulmonary hypertension (CTEPH)

Initial criteria

  • Prescribed by or in consultation with a cardiovascular or pulmonary specialist
  • Diagnosis of WHO Group 4 CTEPH (ICD-10: I27.24)
  • Results of right heart catheterization and V/Q scan showing ALL of the following: mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest AND pulmonary wedge pressure (PWP) ≤ 15 mmHg AND documented presence of occlusive thrombi within the pulmonary arteries
  • Using Adempas for recurrent or residual pulmonary hypertension after surgery OR if disease is inoperable