CurrentCignaPolicy N/A

Pulmonary Arterial Hypertension - Adempas Drug Quantity Management Policy - Per Rx

Defines Cigna's drug quantity limits and exception criteria for Adempas (riociguat) tablets for members covered under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyPulmonary Arterial Hypertension - Adempas Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateAug 5, 2025

Key ActionSubmit prior authorization requests with documentation showing smoker status when requesting exceptions to quantity limits (retail max 90 tablets; home delivery max 270 tablets).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

90retail max per Rx

270home delivery max per Rx

1 yrapproval duration

5tablet strengths

Coverage and Exception Criteria

Drug Quantity Limits and Smoker Exception

Policy Summary

PayerCigna

PolicyPulmonary Arterial Hypertension - Adempas Drug Quantity Management Policy - Per Rx

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateAug 5, 2025

Key ActionSubmit prior authorization requests with documentation showing smoker status when requesting exceptions to quantity limits (retail max 90 tablets; home delivery max 270 tablets).

SourceLink

On This Page

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Drug Quantity Limits: For each listed Adempas tablet strength (0.5, 1, 1.5, 2, and 2.5 mg), approve up to 90 tablets per retail prescription and up to 270 tablets per home delivery prescription.Retail <= 90 tablets; Home delivery <= 270 tablets

Approvals provided for 1 year in duration; see smoker exception below.

Exception for smokers: If the patient is a smoker, approve quantity sufficient for a 30-day supply at retail and a 90-day supply at home delivery.Smoker status documented

Any other exception to the quantity limits is considered not medically necessary.

Provider Requirements and Prior Authorization

Prior Authorization

Quantity limits and exception prior authorization

Quantity limits apply at point of sale; exceptions require prior authorization and documentation. Retail fills are limited to 90 tablets per Rx; home delivery fills are limited to 270 tablets per Rx. If the Drug Quantity Management rule is not met at POS, coverage will be determined by the criteria below and approvals, when granted, are for 1 year.

Adempas (riociguat) 0.5 mg: Retail max 90 tablets per Rx; Home Delivery max 270 tablets per Rx
Adempas (riociguat) 1 mg: Retail max 90 tablets per Rx; Home Delivery max 270 tablets per Rx
Adempas (riociguat) 1.5 mg: Retail max 90 tablets per Rx; Home Delivery max 270 tablets per Rx
Adempas (riociguat) 2 mg: Retail max 90 tablets per Rx; Home Delivery max 270 tablets per Rx
Adempas (riociguat) 2.5 mg: Retail max 90 tablets per Rx; Home Delivery max 270 tablets per Rx

Documentation Required

Submission and review expectations

Providers should submit quantity limit exception requests with documentation supporting medical necessity (for example, smoker status when requesting increased supply). Expect review against the policy criteria; approvals are issued for 1 year when criteria are met.

Required documentation: evidence of current smoker status when requesting exception
Approval duration: up to 1 year when criteria are met

Denial Risk

Quantity limit noncompliance may lead to denial

If the Drug Quantity Management rule is not met at the point of sale and no approved exception exists, the claim may be denied per the Drug Quantity Management rule.

Denial risk applies when requested quantity exceeds Retail (90) or Home Delivery (270) limits and no approved exception prior authorization is on file
Providers may request an exception prior authorization with supporting documentation to avoid denial

Indications and Definitions

Approved indications for Adempas (riociguat)

CTEPH indicationTreatment of adults with chronic thromboembolic pulmonary hypertension (CTEPH) — persistent/recurrent after surgical treatment, or inoperable — to improve exercise capacity and WHO functional class

PAH indicationTreatment of adults with pulmonary arterial hypertension (WHO Group 1) to improve exercise capacity, WHO functional class, and delay clinical worsening

PopulationAdults (per prescribing information)

OpenPayer

Pulmonary Arterial Hypertension - Adempas Drug Quantity Management Policy - Per Rx

Coverage and Exception Criteria

Drug Coding and Quantity Limits

Provider Requirements and Prior Authorization

Clinical Background

Indications and Definitions