Tyvaso — Medical Mutual

Initial criteria

• Patient age ≥ 18 years; AND
• Diagnosis of WHO Group 3 pulmonary hypertension associated with interstitial lung disease; AND
• If patient has connective tissue disease, baseline forced vital capacity < 70%; AND
• Evidence of diffuse parenchymal lung disease on computed tomography of the chest; AND
• Patient has had a right heart catheterization; AND
• Right heart catheterization confirms WHO Group 3 interstitial lung disease associated with pulmonary hypertension; AND
• Medication is prescribed by or in consultation with a cardiologist or pulmonologist

Reauthorization criteria

• Patient age ≥ 18 years; AND
• Diagnosis of WHO Group 3 interstitial lung disease associated with pulmonary hypertension; AND
• Patient has had a right heart catheterization prior to starting therapy; AND
• Right heart catheterization confirms WHO Group 3 interstitial lung disease associated with pulmonary hypertension; AND
• Patient has had a response to therapy according to the prescriber (e.g., increase/maintenance in six-minute walk distance, improved exercise capacity, decreased NT-proBNP, lessened clinical worsening, reduced rate of exacerbations of underlying lung disease); AND
• Medication is prescribed by, or in consultation with, a cardiologist or pulmonologist

Approval duration

Initial: 4 months; Continuation: 1 year