Pulmonary Hypertension Agents [Ambrisentan (Letairis®), Bosentan (Tracleer®), Iloprost (Ventavis®) or Sildenafil (Revatio®)] Prior Authorization Criteria

Ventavis Prior Authorization Request Form

Covered Uses

• Patient has a diagnosis of pulmonary arterial hypertension according to the World Health Organization (WHO) Group I classification (See Appendix, Table 1) documented by catheterization AND
  • Presents with a non-idiopathic form of pulmonary arterial hypertension, OR
  • Presents with idiopathic pulmonary arterial hypertension and showed a negative response to the acute vasodilator testing

Exclusion Criteria

If the patient showed a positive response to the acute vasodilator testing, a calcium channel blocker must be used unless contraindicated

Required Medical Information

• Cardiac catheterization results
  • Mean pulmonary artery pressure (mmHg) and
  • Pulmonary capillary wedge pressure (mmHg)
• Acute vasodilator testing result (required for patients with Idiopathic Pulmonary Arterial Hypertension ONLY)
• Diagnosis according to the WHO Classification of Pulmonary Hypertension (Idiopathic Pulmonary Arterial Hypertension, Non-idiopathic Pulmonary Arterial Hypertension)
• NYHA/WHO Functional Classification

Age Restrictions

None

Prescriber Restrictions

• Neumologist
• Pulmonologist
• Cardiologist
• Intensivist

Coverage Duration

Every prescription is authorized for up to six (6) months depending on refills written in prescription

Other Criteria

• Pulmonary arterial hypertension (PAH) is defined as a mean pulmonary artery pressure (PAPm) equal or more than 25 mm Hg with a pulmonary capillary wedge pressure equal or less than 15 mm Hg measured by cardiac catheterization (Badesch, D. B. et al. Chest 2007, 131:1917-1928).
• Part D vs. Part B evaluation also applies for iloprost