Uptravi — United Healthcare

Preferred products

• sildenafil citrate (generic Revatio)
• tadalafil (generic Adcirca)
• ambrisentan (generic Letairis)
• bosentan (generic Tracleer)

Initial criteria

• EITHER: ALL of the following: Continuation of therapy AND No receipt of manufacturer supplied sample or free assistance at prescriber's office AND Not taking in combination with prostanoid/prostacyclin analogue (e.g., epoprostenol, iloprost, treprostinil) AND Prescribed by or in consultation with cardiologist, pulmonologist, or rheumatologist
• OR: ALL of the following: (EITHER: (Pulmonary arterial hypertension is symptomatic AND Diagnosis confirmed by right heart catheterization) OR Patient currently on any therapy for pulmonary arterial hypertension) AND Failure, contraindication, or intolerance to BOTH (One of the following: PDE-5 inhibitor [e.g., sildenafil citrate, tadalafil] OR Adempas) AND (One of the following: ERA [e.g., ambrisentan, Opsumit, bosentan]) AND Not taking in combination with prostanoid/prostacyclin analogue AND Prescribed by or in consultation with cardiologist, pulmonologist, or rheumatologist

Reauthorization criteria

• Documentation that patient is receiving clinical benefit to therapy
• Patient not taking in combination with prostanoid/prostacyclin analogue (e.g., epoprostenol, iloprost, treprostinil)

Approval duration

12 months