Tracleer — Medical Mutual

Initial criteria

• The request is for bosentan (Tracleer, generic); AND
• The medication is prescribed by or in consultation with a cardiologist or pulmonologist; AND
• Patient has tried Adempas; OR use of Adempas is contraindicated; OR patient is currently receiving bosentan; AND
• The patient has been treated surgically or CTEPH is inoperable; AND
• For brand Tracleer, the patient has failed a trial of generic bosentan and/or the patient cannot take generic bosentan due to a formulation difference in the inactive ingredient(s) which would result in a significant allergy or serious adverse reaction per the prescribing physician

Approval duration

1 year