Epoprostenol (Flolan, Veletri) Medication Precertification Request
Customize your policy alerts
Sign up for all Aetna policy alerts
Know when Aetna releases new policies or updates existing guidance.
Monitor payer policy activity
This document is Aetna's precertification request form for initiation or continuation of therapy with epoprostenol (Flolan or Veletri) and governs what clinical and administrative information must be submitted for coverage review.
No material clinical or coverage changes in this revision.
Coverage Criteria
Precertification clinical criteria
Covered when documentation provided and clinical criteria are met per precertification form.
Form asks provider to confirm pulmonologist or cardiologist involvement (Yes/No).
Form requires selection of WHO pulmonary hypertension classification and confirmation of PAH diagnosis.
Form provides selectable pretreatment ranges: mPAP (<=20 mmHg or >20 mmHg); PCWP (<=15 mmHg or >15 mmHg); PVR (<3 Wood units, >=3 Wood units, or No).
Form asks whether patient is currently receiving product and whether therapy shows stability or improvement (select stability or improvement).
The precertification form asks whether the patient is an infant less than one year of age and provides checkboxes for “Yes” or “No.” The form does not state an explicit coverage exclusion tied to infant age; it records this demographic/clinical detail as part of the required information for review.
The precertification form does not list any specific conditions or scenarios that are explicitly labeled as not medically necessary. The Acknowledgement section reiterates legal and fraud provisions but contains no language defining services that would be considered not medically necessary on the form itself.
Coding
| Administration code(s) (CPT): | Place to list CPT administration codes as applicable |
| Primary ICD Code: | Place to list primary diagnosis ICD-10 code |
Provider Actions / Requirements
Prior Authorization Required
Precertification is required for this medication. Requests must be submitted via the Aetna Precertification Notification phone or fax (see contact numbers).
- Phone: 1-866-752-7021
- FAX: 1-888-267-3277
- For Medicare Advantage Part B: Use Medicare Request Form
Administration / Dispensing Specification
Indicate the place of administration and specify the dispensing provider on the precertification form. Options must include self-administered, physician office, outpatient infusion center, home infusion center, or other as applicable. If administration occurs in a facility or via infusion services, include administration CPT code(s) on the form.
- Place of Administration: Self-administered; Physician's Office; Outpatient Infusion Center; Home Infusion Center; Other
- Include Administration code(s) (CPT) when applicable
- Dispensing Provider/Pharmacy: Physician's Office; Retail Pharmacy; Specialty Pharmacy; Other
Required Documentation for Precertification
Complete and legible precertification form fields are required for review. Ensure all patient demographics, insurance information, prescriber and dispensing provider details, product requested, dose/frequency, diagnosis (ICD code), and required clinical documentation (see initiation and continuation sections) are provided.
- Patient demographics and contact information
- Prescriber details (name, specialty, NPI, license, contact)
- Dispensing provider/pharmacy details (name, address, TIN/PIN, phone, fax)
- Product, dose, frequency and diagnosis (primary ICD code)
- Required clinical documentation: WHO classification, confirmation of PAH, right heart catheterization results, hemodynamics (mPAP, PCWP, PVR), echocardiogram results, and continuation benefit documentation where applicable
Fraud / False Information
By signing the request, the requester acknowledges that submitting materially false information or concealing material information may result in denial of the request and may subject the submitter to fraud investigation and civil/criminal penalties.
- Request Completed By (Signature Required)
- Fraudulent insurance act warning as stated on the form
Background
Epoprostenol (Flolan, Veletri) is requested for management of pulmonary arterial hypertension (PAH). The form requires the World Health Organization (WHO) classification of pulmonary hypertension and asks whether the patient has a diagnosis of PAH and whether that diagnosis has been confirmed by right heart catheterization. It also requests pretreatment hemodynamic values — mean pulmonary arterial pressure (mPAP) (≤ 20 mmHg or > 20 mmHg), pulmonary capillary wedge pressure (PCWP) (≤ 15 mmHg or > 15 mmHg), and pulmonary vascular resistance (PVR) (< 3 Wood units, ≥ 3 Wood units, or No) — and whether a Doppler echocardiogram has been performed. Precertification requests must be completed in full so these elements are available to support medical necessity for initiation or continuation of epoprostenol therapy.
Definitions and Assessment Elements
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.