UTILIZATION MANAGEMENT MEDICAL POLICY
Defines prior authorization and medical necessity criteria, dosing, approvals, and exclusions for epoprostenol intravenous infusion products (Veletri, Flolan, generics) for PAH (WHO Group 1) and select use in CTEPH under a medical benefit.
Annual revision notes indicate no criteria changes for the 10/04/2023 review; 10/09/2024 review performed.
Coverage Summary
Epoprostenol intravenous infusion products (examples: Veletri, Flolan, generics) are covered with criteria for the treatment of World Health Organization (WHO) Group 1 pulmonary arterial hypertension (PAH) and are supported for select use in chronic thromboembolic pulmonary hypertension (CTEPH) when prescribed by or in consultation with an appropriate specialist. Prior authorization is required for medical benefit coverage; approvals are generally provided for 1 year when criteria are met, with short-term approvals (up to 14 days) allowed for current users with insufficient information. Dosing is limited to a maximum of 45 ng/kg/min intravenously unless reviewed case-by-case.
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