Adempas (riociguat) prior authorization
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This policy governs prior authorization requirements for Adempas (riociguat) for members of CareOregon; it specifies approval length and clinical criteria for use in pulmonary arterial hypertension (WHO Group 1).
No material clinical or coverage changes in this revision.
Coverage Criteria for Adempas (riociguat)
Initial Therapy
Covered when ALL of the following are met
- Primary diagnosis: Diagnosis of WHO group 1 (pulmonary arterial hypertension)
Referenced in approval criteria section 1.1.1
See prior authorization and approval length policy statements.
This policy governs prior authorization for Adempas (riociguat). Coverage for initial therapy is available when the member has a documented diagnosis of WHO Group 1 (pulmonary arterial hypertension) and all other approval elements in the criteria are met. The policy lists the authorization requirements and specifies that the approval length is Lifetime.
Prior authorization is required before dispensing Adempas (riociguat). Providers must submit documentation that supports the WHO Group 1 PAH diagnosis and any additional information necessary to demonstrate that the patient meets each element of the approval criteria. Requests that do not demonstrate the required diagnosis or supporting information may be denied.
Provider Actions, Authorization & Documentation Requirements
Prior authorization required
Prior authorization is required for Adempas (riociguat). Approval length is lifetime.
Submit PA request with required clinical details
Submit a completed prior authorization request for Adempas with clinical documentation that directly supports the approval criteria specified in the policy.
- Include diagnosis and supporting clinical information required under the approval criteria.
- Ensure prior authorization request reflects product name Adempas (riociguat) and intended lifetime approval length.
Required documentation to support authorization
Document the diagnosis of WHO Group 1 (pulmonary arterial hypertension) and include information supporting each element required under the approval criteria.
- Record the specific diagnosis: "WHO group 1 (pulmonary arterial hypertension)" as stated in the criteria (section 1.1.1).
- Attach clinical evidence and notes that substantiate the elements of the approval criteria referenced in the policy.
Denial risk for unmet diagnosis criteria
Requests may be denied if the criteria for WHO Group 1 pulmonary arterial hypertension and the approval conditions are not met.
- Denial risk applies when the submitted diagnosis and supporting documentation do not demonstrate the required WHO Group 1 PAH criteria.
Background
Riociguat (Adempas) is an approved therapy for pulmonary arterial hypertension (WHO Group 1). It is identified in this policy as the product subject to prior authorization, with an approval length of Lifetime, and authorization decisions are based on confirmation of the WHO Group 1 diagnosis and fulfillment of the policy criteria.
Definitions
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