CurrentAetnaPolicy N/A

Winrevair ™ (sotatercept-csrk) Medication Precertification Request

Aetna precertification notification form to request authorization for Winrevair (sotatercept-csrk) or related PAH therapies, collecting patient, prescriber, dispensing, diagnosis, and clinical confirmation details required for review.

Policy Summary

PayerAetna

PolicyWinrevair ™ (sotatercept-csrk) Medication Precertification Request

Policy CodePolicy N/A

Change TypeInformational (administrative form)

Effective Date

Next Review Date

Key ActionComplete the precertification form fully and submit via Aetna Precertification Notification phone or fax including required clinical confirmation (e.g., right heart catheterization data) and administration CPT codes as applicable.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified for this precertification form.

1Page count

MultipleRequired clinical data sections

Yes/NoKey binary clinical checkpoints

Policy overview

This is an Aetna Precertification Notification form titled "Winrevair (sotatercept-csrk) Medication Precertification Request" used to request authorization for Winrevair and related pulmonary arterial hypertension (PAH) therapies. The form captures whether the request is for start of treatment or continuation of therapy and must be completed and legible for precertification review.

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Diagnosis and required clinical confirmation fields are included: primary and other ICD-10 code(s), WHO pulmonary hypertension classification, confirmation of diagnosis by right heart catheterization, hemodynamic parameters (mPAP, PCWP, and PVR thresholds), current PAH regimen (use of drugs from at least two listed classes), and whether the requested drug is being used as add-on therapy. Continuation requests must document patient benefit (disease stability or improvement).

Required clinical documentation and criteria

Required Clinical Documentation for All Requests

For ALL Requests (clinical documentation required):

Is the requested medication prescribed by or in consultation with a pulmonologist or cardiologist?Yes/No

Must indicate yes or no

Initiation Requests - Clinical Criteria

For Initiation Requests (clinical documentation required):

Please indicate the World Health Organization (WHO) classification of pulmonary hypertensionOptions: 1, 2, 3, 4, 5

Does the patient have pulmonary hypertension associated with interstitial lung disease?Yes/No

Has the diagnosis been confirmed by right heart catheterization?Yes/No

Patient's mean pulmonary arterial pressure (mPAP)Options: <= 20 mmHg, > 20 mmHg

Options: <= 20 mmHg, > 20 mmHg

Patient's pulmonary capillary wedge pressure (PCWP)Options: <= 15 mmHg, > 15 mmHg

Options: <= 15 mmHg, > 15 mmHg

Patient's pulmonary vascular resistance (PVR) while stable on at least two PAH drugsOptions: < 3 Wood units, >= 3 Wood units, No

Options: < 3 Wood units, >= 3 Wood units, No

Will the requested drug be used as add-on therapy?Yes/No

Patient currently receiving PAH therapy from at least two classes

Endothelin receptor antagonist (e.g., Letairis, Opsumit, Tracleer)
Phosphodiesterase-5 inhibitor (e.g., Adcirca, Revatio)
Soluble guanylate cyclase stimulator (e.g., Adempas)
Prostacyclin analog (e.g., Flolan, Orenitram, Remodulin, Tyvaso, Veletri, Ventavis)
Prostacyclin receptor agonist (e.g., Uptravi)

Continuation Requests - Clinical Criteria

For Continuation Requests (clinical documentation required):

Is the patient experiencing benefit from therapy as evidenced by disease stability or disease improvement?Yes/No

Numeric thresholds

mPAP (mean pulmonary arterial pressure)Options: less than or equal to 20 mmHg or greater than 20 mmHg

PCWP (pulmonary capillary wedge pressure)Options: less than or equal to 15 mmHg or greater than 15 mmHg

PVR (pulmonary vascular resistance)Options: less than 3 Wood units, greater than or equal to 3 Wood units, or No

What providers must do

Documentation Required

Complete precertification form fully

All fields must be completed and legible for precertification review; required clinical information must be provided for all initiation and continuation requests.

Prior Authorization

Precertification submission required

Submit precertification via Aetna Precertification Notification phone or fax; include start/continuation dates and required clinical confirmation including right heart catheterization data where applicable.

Billing Rule

Provide administration CPT code(s) if applicable

Form requests administration code(s) to be provided for site of care administration (physician office, outpatient infusion center, home infusion).

Documentation Required

Specialty/Prescriber specialty confirmation

Indicate whether medication prescribed by or in consultation with a pulmonologist or cardiologist and provide prescriber NPI, state license, DEA as applicable.

Denial Risk

Fraud warning and additional information

Form includes fraud warning and states the plan may request additional information or clarification; incomplete or false information may subject requester to penalties and could affect authorization.