Pulmonary Arterial Hypertension - Endothelian Receptor Antagonists - (IP0631)
Defines prior authorization and medical necessity criteria for ambrisentan (Letairis, generic), macitentan (Opsumit), macitentan/tadalafil combination (Opsynvi), and bosentan (Tracleer, generic) for PAH (WHO Group 1), and for bosentan in CTEPH and digital ulcers in systemic sclerosis, across Cigna-administered health benefit plans.
New stand-alone policy created; criteria were previously in Pulmonary Hypertension Therapy class policy.
PAH criteria clarified for 'Initial Therapy' versus 'Patient is Currently Receiving the Requested Endothelin Receptor Antagonist' and removed echocardiogram as an option for confirmation of PAH diagnosis (right heart catheterization required).
Added Opsynvi to the policy with additional preferred product criteria requirements for Individual and Family Plans.
Added new criteria supporting bosentan for CTEPH and for digital ulcers in systemic sclerosis, with preferred product criteria requirements for Tracleer.
Conditions Not Covered: Added statement that Opsynvi concurrent use with guanylate cyclase stimulators is contraindicated.
Documentation requirement for right heart catheterization added to PAH indication and noted that bosentan tablets for oral suspension are available as generic.
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