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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsHMSA Epoprostenol Prior Auth Coverage | OpenPayer
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    CurrentHawaii Medical Service Association (HMSA)Policy N/A

    Flolan, Veletri, and Epoprostenol Injection Coverage Criteria

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    This policy governs prior authorization and coverage of epoprostenol products for pulmonary arterial hypertension. It applies to eligible HMSA HMO, PPO, and QUEST members when the clinical and documentation criteria are met.

    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyFlolan, Veletri, and Epoprostenol Injection Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJun 1, 2026
    Last ReviewSep 1, 2025
    Next Review DateN/A
    Key ActionSubmit precertification using the HMSA medical specialty drug policy website fax form.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    WHO Group 1Covered pulmonary hypertension classification
    mPAP >20

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Required mean pulmonary arterial pressure
    PCWP ≤15Required pulmonary capillary wedge pressure
    PVR >2 WURequired pulmonary vascular resistance
    IndefinitePotential authorization duration
    RequiredPrior authorization requirement

    Coverage Criteria

    Initial Therapy Criteria

    Indefinite authorization may be granted when all criteria are met.

    Initial therapy for pulmonary arterial hypertension

    • Covered condition: Member has PAH defined as WHO Group 1 pulmonary hypertension.

    • Diagnostic confirmation

      • Pretreatment right heart catheterization demonstrates all of the following: mean pulmonary arterial pressure greater than 20 mmHg; pulmonary capillary wedge pressure less than or equal to 15 mmHg; and pulmonary vascular resistance greater than 2 Wood units. For pediatric members, pulmonary vascular resistance index greater than 3 Wood units × m² is also acceptable.mPAP >20 mmHg; PCWP ≤15 mmHg; PVR >2 Wood units; pediatric PVRI >3 Wood units × m²
      • Infant alternative diagnostic testing: For an infant less than one year of age, PAH is confirmed by Doppler echocardiogram when right heart catheterization cannot be performed.Age <1 year

    Clinical Thresholds

    Mean pulmonary arterial pressure
    Required thresholdMean pulmonary arterial pressure (mPAP) greater than 20 mmHg
    Required testingPretreatment right heart catheterization
    Diagnostic requirementThe catheterization must demonstrate all specified hemodynamic results
    Pulmonary capillary wedge pressure
    Required thresholdPulmonary capillary wedge pressure (PCWP) less than or equal to 15 mmHg
    Required testingPretreatment right heart catheterization
    Diagnostic requirement

    Authorization and Documentation Requirements

    Prior Authorization

    Precertification Required

    Precertification is required before treatment. Refer to the HMSA medical specialty drug policy website for the required fax form.

    Documentation Required

    Specialist Prescriber or Consultation Required

    The medication must be prescribed by, or used in consultation with, a pulmonologist or cardiologist.

    Documentation Required

    Pretreatment Pulmonary Hypertension Testing

    Submit pretreatment pulmonary hypertension testing from right heart catheterization, including the required hemodynamic measurements. For infants younger than one year when right heart catheterization cannot be performed, provide Doppler echocardiogram findings.

    Therapy Overview

    Flolan, Veletri, and epoprostenol injection are prostacyclin therapies used to treat pulmonary arterial hypertension (PAH), WHO Group 1, with the clinical purpose of improving exercise capacity. The supporting studies primarily included patients with NYHA Functional Class III-IV symptoms and idiopathic or heritable PAH or PAH associated with connective tissue disease.

    Pulmonary Arterial Hypertension Classification

    WHO Group 1 pulmonary arterial hypertension
    ClassificationGroup 1: Pulmonary arterial hypertension (PAH)
    Idiopathic or heritableIdiopathic PAH and heritable PAH
    Drugs and toxinsPAH associated with drugs and toxins
    Associated conditionsPAH associated with connective tissue diseases, HIV infection, portal hypertension, congenital heart diseases, or schistosomiasis
    Venous or capillary involvementPAH with features of pulmonary veno-occlusive disease or pulmonary capillary hemangiomatosis involvement
    Newborn conditionPersistent pulmonary hypertension of the newborn

    Initial Therapy

    Initial Therapy Criteria

    Indefinite authorization may be granted for treatment of PAH when all criteria are met.

    Initial therapy criteria

    • WHO Group 1 pulmonary arterial hypertension: Member has PAH defined as WHO Group 1 class of pulmonary hypertension.

    • Diagnostic confirmation pathway

      • Pretreatment right heart catheterization shows mean pulmonary arterial pressure greater than 20 mmHg, pulmonary capillary wedge pressure less than or equal to 15 mmHg, and pulmonary vascular resistance greater than 2 Wood units. For pediatric members, pulmonary vascular resistance index greater than 3 Wood units × m² is also acceptable.mPAP >20 mmHg; PCWP ≤15 mmHg; PVR >2 Wood units; pediatric PVRI >3 Wood units × m²

    Continuation Therapy

    Continuation Therapy Criteria

    Indefinite authorization may be granted for continuation therapy when the member is experiencing benefit from the requested drug.

    Continuation of therapy for pulmonary arterial hypertension: Member has pulmonary arterial hypertension and is experiencing benefit from continued treatment with the requested drug.

    This applies to new members and members currently receiving treatment without prior authorization.

    Policy Summary
    PayerHawaii Medical Service Association (HMSA)
    PolicyFlolan, Veletri, and Epoprostenol Injection Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateJun 1, 2026
    Last ReviewSep 1, 2025
    Next Review DateN/A
    Key ActionSubmit precertification using the HMSA medical specialty drug policy website fax form.
    SourceLink
    On This Page
    Coverage CriteriaClinical ThresholdsAuthorization and Documentation RequirementsTherapy OverviewPulmonary Arterial Hypertension ClassificationInitial TherapyContinuation Therapy
    The catheterization must demonstrate all specified hemodynamic results
    Pulmonary vascular resistance
    Required thresholdPulmonary vascular resistance (PVR) greater than 2 Wood units
    Required testingPretreatment right heart catheterization
    Pediatric alternative measureFor pediatric members, pulmonary vascular resistance index greater than 3 Wood units × m² is also acceptable
    Pediatric pulmonary vascular resistance index
    Required thresholdPulmonary vascular resistance index (PVRI) greater than 3 Wood units × m² for pediatric members
    Applicable testingPretreatment right heart catheterization
    Diagnostic pathwayFor infants less than one year of age, Doppler echocardiography may confirm PAH when right heart catheterization cannot be performed
    • Mean pulmonary artery pressure (mPAP)
    • Pulmonary capillary wedge pressure (PCWP)
    • Pulmonary vascular resistance (PVR)
    • For pediatric members, pulmonary vascular resistance index (PVRI) may also be acceptable
    Denial Risk

    Clinical Criteria Not Met

    Coverage may be denied when the required clinical criteria are not met, including absence of a diagnosis of PAH defined as WHO Group 1 pulmonary hypertension or failure to provide required confirmation of PAH.

    • PAH must be documented as WHO Group 1 pulmonary hypertension.
    • Required confirmation includes qualifying pretreatment right heart catheterization results: mPAP > 20 mmHg, PCWP ≤ 15 mmHg, and PVR > 2 Wood units.
    • For pediatric members, PVRI > 3 Wood units × m² is also acceptable.
    • For infants younger than one year, Doppler echocardiogram confirmation is permitted only when right heart catheterization cannot be performed.
    Infant Doppler pathway:
    For infants less than one year of age, Doppler echocardiography confirms PAH when right heart catheterization cannot be performed.
    Age <1 year