CurrentCignaPolicy N/A

Remodulin (Treprostinil) Prior Authorization Form

A Cigna prior authorization request form to collect clinical, demographic, and prescribing information needed to review coverage for Remodulin (treprostinil) and related treprostinil products, including indication, prior treatments, diagnostics (right heart catheterization), prescriber specialty, dispensing site, and urgency.

Policy Summary

PayerCigna

PolicyRemodulin (Treprostinil) Prior Authorization Form

Policy CodePolicy N/A

Change TypeForm / Prior Authorization

Effective Date

Next Review Date

Key ActionProvider must complete all asterisked patient and prescriber items on the form and attach required medical documentation (e.g., right heart catheterization report) for PAH initial therapy to avoid denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes — this document is a prior authorization form used to collect clinical and administrative information for review of Remodulin (treprostinil) and related products.

FormDocument Type

RemodulinMedication Covered

AccredoPreferred Specialty Pharmacy

Policy / Form Summary

This prior authorization form collects clinical, demographic, and prescribing information to support coverage review for Remodulin (brand treprostinil) and related treprostinil products for pulmonary hypertension indications, including pulmonary arterial hypertension (PAH; WHO Group 1) and chronic thromboembolic pulmonary hypertension (CTEPH). It requests the prescriber specialty (intended for cardiologists or pulmonologists), diagnostic confirmation including attachment of a right heart catheterization report for PAH initial therapy, documentation of prior therapies and functional class, and the prescriber’s dispensing preference (including options for the preferred specialty pharmacy Accredo, prescriber office stock billed on a medical claim, retail pharmacy, home health/home infusion vendor, or other). Remodulin is the brand name for treprostinil and the form includes fields to indicate whether the patient is already on therapy or has tried generic treprostinil when requesting the brand.

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Authorization Criteria Logic

Information and condition checklist for PAH/CTEPH and therapy

Form captures conditions and supporting items to determine prior authorization eligibility; providers must indicate answers and attach documentation where requested.

Select diagnosis

Chronic obstructive pulmonary disease (COPD) in a patient without PAH (WHO Group 1)
Chronic thromboembolic pulmonary hypertension (CTEPH)
Pulmonary arterial hypertension (PAH) (World Health Organization [WHO] Group 1)
Other (specify)

PAH (if selected)

Right heart catheterization documentation (if currently receiving or initial therapy)
- Does the patient have a diagnosis of WHO Group 1 pulmonary arterial hypertension (PAH)?
  Yes/No
- Is the requested medication being prescribed by, or in consultation with, a cardiologist or a pulmonologist?
  Yes/No
- Has the patient had a right heart catheterization? (This refers to prior to starting therapy with a medication for WHO Group 1 PAH.)
  Yes/No; If initial therapy, documentation must be attached.
- Did the results of the right heart catheterization confirm the diagnosis of WHO Group 1 PAH?
  Yes/No
Functional class for initial therapy
- If Initial therapy: Is the patient in Functional Class III or IV?
  Yes/No
- If not Functional Class III/IV: Is the patient in Functional Class II?
  Yes/No
Functional Class II additional requirements
- Has the patient tried or is the patient currently receiving one oral agent for PAH (examples: bosentan, ambrisentan, macitentan, riociguat, sildenafil, tadalafil, etc.)?
  Yes/No
- If no oral agent trial: Has the patient tried one inhaled or parenteral prostacyclin product for PAH (examples: Ventavis, Tyvaso, Tyvaso DPI, Yutrepia, epoprostenol)?
  Yes/No
Idiopathic PAH vasodilator testing
- If Initial therapy: Does the patient have idiopathic PAH?
  Yes/No
- If idiopathic PAH: Did the patient have vasodilator testing?
  Yes/No
- If no vasodilator testing: Is the patient unable to undergo a vasodilator test according to the prescriber?
  Yes/No
- If yes vasodilator testing: According to the prescriber, did the patient have an acute response to vasodilator testing?
  Yes/No
- If yes acute response: Did the acute response occur during the right heart catheterization (example defined: decrease in mean PAP >=10 mm Hg to <40 mm Hg without decrease in cardiac output)?
  Yes/No
If PAH and requesting Remodulin (brand only): Has the patient already been started on Remodulin or treprostinil therapy?
Yes/No
Brand Remodulin specific
- If not already started on Remodulin: Has the patient tried generic treprostinil?
  Yes/No
- If not tried generic treprostinil: Will the patient be using the requested medication for continuous subcutaneous infusion?
  Yes/No
- If yes continuous subcutaneous infusion: Is the patient unable to take generic treprostinil because appropriate durable medical equipment is not available (e.g., compatible pump)?
  Yes/No

CTEPH (if selected)

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

Concomitant prostacyclin therapy question: Will the patient be taking the requested medication with parenteral epoprostenol products, oral prostacyclin products, or inhaled prostacyclin agents used for pulmonary hypertension (examples provided)?

Yes/No

Required Provider Actions & Billing Rules

Prior Authorization

Submit completed PA form with documentation

Provider must complete all asterisked patient and prescriber items on the form and attach required medical documentation (for example, right heart catheterization report) for PAH initial therapy to avoid denial. Prior documentation submitted for a different WHO Group 1 PAH medication may be considered sufficient to meet the documentation requirement.

Documentation Required

Right heart catheterization documentation required for PAH

For initial therapy in WHO Group 1 PAH, documentation of right heart catheterization results confirming the diagnosis must be attached. Medical documentation must include patient-specific identifying information (examples: chart notes, catheterization laboratory reports). If documentation is not attached, the request could be denied.

Prior Authorization

Urgent request attestation

Checking the Urgent box attests that applying the standard review timeframe may seriously jeopardize the patient's life, health, or ability to regain maximum function. If the request is urgent, the provider should call to expedite the request.

Billing Rule

Specify dispensing site and billing mechanism

Indicate where the medication will be obtained and the billing mechanism. Options include Cigna's preferred specialty pharmacy (Accredo), prescriber's office stock billed on a medical claim, retail pharmacy, home health/home infusion vendor, or Other. If a facility or doctor will dispense or administer the injectable, provide facility name and Tax ID.

Documentation Required

Brand vs generic justification for Remodulin brand

When requesting branded Remodulin, document whether the patient has already been started on Remodulin or other treprostinil. If not started on brand, document prior use of generic treprostinil. If the patient cannot use generic treprostinil because appropriate durable medical equipment (for example, a compatible pump) is not available, indicate and document that reason.

OpenPayer

Remodulin (Treprostinil) Prior Authorization Form

Policy / Form Summary

Authorization Criteria Logic

Form Requested Codes / Fields

Required Provider Actions & Billing Rules

Key Definitions

Document Changes / Review Dates