Tadliq — Highmark
WHO Group 1 pulmonary arterial hypertension (PAH)
Preferred products
- generic sildenafil
- generic tadalafil
- Alyq
- generic ambrisentan
Initial criteria
- Prescribed by or in consultation with a cardiovascular or pulmonary specialist
- Diagnosis of WHO Group 1 PAH (ICD-10: I27.0, I27.21)
- Documented NYHA or WHO Functional Class II or III symptoms from baseline
- Results of right heart catheterization showing ALL of the following: mean pulmonary arterial pressure (mPAP) > 20 mmHg at rest AND pulmonary wedge pressure (PWP) ≤ 15 mmHg AND pulmonary vascular resistance (PVR) ≥ 3 Wood units
- If request is for brand Adcirca: member experienced therapeutic failure or intolerance to generic tadalafil or Alyq
- If request is for brand Letairis: member experienced therapeutic failure or intolerance to generic ambrisentan
- If request is for Tadliq: member experienced therapeutic failure, contraindication, or intolerance to ALL of the following plan‑preferred generics: sildenafil AND tadalafil or Alyq
- For new starts to dual therapy: member experienced therapeutic failure, contraindication, or intolerance to plan‑preferred generic sildenafil monotherapy