Actemra (Tocilizumab) prior authorization for pulmonary hypertension indications
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This document sets prior authorization requirements for Actemra (and listed related medications) for Network Health Plan of Wisconsin members, describing clinical prerequisites, exclusions, prescriber limits, and documentation needed for coverage decisions.
No material clinical or coverage changes in this revision.
Coverage Criteria and Clinical Requirements
Initial Therapy — Covered when ALL of the following are met
Covered when ALL of the following are met
Documentation of right heart catheterization required
CTEPH — Covered when ALL of the following are met
Covered when ALL of the following are met
General and prescriber criteria — Covered when documentation and specialist prescribing requirements are met:
Covered when documentation and specialist prescribing requirements are met:
Disease-specific criteria (examples)
Examples of disease-specific approval conditions included in the document:
Initial approval (migraine indication) — Covered when ALL of the following are met for initial approval (as specified):
Covered when ALL of the following are met for initial approval (as specified):
Coverage duration — Coverage duration rules:
Coverage duration rules:
IBS Initial Approval — Severe diarrhea-predominant IBS — Initial criteria
Severe diarrhea-predominant Irritable Bowel Syndrome (IBS) — Initial and continuation criteria
Initial IBS approval
- a: Patient has experienced chronic IBS symptoms for 6 months or longer>=6 months
- b: Anatomic or biochemical abnormalities of the gastrointestinal tract excluded
- c: Patient has tried and failed one antidiarrheal agent (e.g., loperamide)
- d: Patient has tried and failed one antispasmodic agent (e.g., dicyclomine)
Continuation IBS approval
- a: If patient is new to plan, initial criteria were met at the time therapy was started
- b: Documented dose and frequency are within FDA‑approved dosing and frequency
- c: Patient is experiencing a positive clinical response to therapy
IBS Continuation Approval — Severe diarrhea-predominant IBS — Continuation criteria
Severe diarrhea-predominant Irritable Bowel Syndrome (IBS) — Continuation criteria
Continuation IBS approval
- a: If patient is new to plan, initial criteria were met at the time therapy was started
- b: Documented dose and frequency are within FDA‑approved dosing and frequency
- c: Patient is experiencing a positive clinical response to therapy
PAH (WHO Group 1) - Initial/ongoing coverage — Covered when ALL of the following are met
Covered when ALL of the following are met
Coverage duration for qualifying PAH entries may be lifetime
Anticonvulsant Therapy - Non-preferred product coverage — Covered when ALL of the following are met
Covered when ALL of the following are met
IV Antifungals and Aranesp coverage criteria — Coverage as specified by PA indicator and required clinical information; certain exclusions apply.
Coverage as specified by PA indicator and required clinical information; certain exclusions apply.
Initial and continuation criteria by indication — Covered when ALL of the following are met for each specific indication
Covered when ALL of the following are met for each specific indication
Initial and Continuation Coverage for MAC Lung Disease — Covered when ALL of the following are met
Covered when ALL of the following are met
Atypical Antipsychotics - Other Criteria — Covered when ALL of the following are met for specified atypical antipsychotics:
Covered when ALL of the following are met for specified atypical antipsychotics:
Basal Insulin - Other Criteria — Covered when ALL of the following are met for basal insulin products (product-specific variants apply):
Covered when ALL of the following are met for basal insulin products (product-specific variants apply):
Lupus Nephritis — Initial and Continuation — Covered when ALL of the following are met
Covered when ALL of the following are met
SLE — Initial and Continuation — Covered when ALL of the following are met
Covered when ALL of the following are met
PAH WHO Group 1 — Initial Coverage — Covered when ALL of the following are met
Covered when ALL of the following are met
CTEPH — Coverage — Covered when ALL of the following are met
Covered when ALL of the following are met
Pulmonary arterial hypertension (PAH) WHO Group 1 — Approve when ALL of the following are met
Approve when ALL of the following are met
Chronic thromboembolic pulmonary hypertension (CTEPH) — Approve when ALL of the following are met
Approve when ALL of the following are met
Mantle Cell Lymphoma / CLL / SLL - BRUKINSA related criteria — Approve if patient meets one of the following
Approve if patient meets one of the following
NAGS deficiency and hyperammonemia approvals — Approve when ALL of the following are met
Approve when ALL of the following are met
PA or MMA with hyperammonemia, acute treatment — Approve when ALL of the following are met
Approve when ALL of the following are met
Cayston for cystic fibrosis — Approve when ALL of the following are met
Approve when ALL of the following are met
Chenodeoxycholic acid (chenodal) — Initial and continuation therapy — Covered when ALL of the following are met:
Covered when ALL of the following are met:
Tadalafil 2.5 mg / 5 mg for BPH — Initial and continuation therapy — Covered when ALL of the following are met:
Covered when ALL of the following are met:
Initial Therapy (BPH indication) — Covered when ALL of the following are met
Covered when ALL of the following are met
Initial Therapy (Schizophrenia indication) — Covered when ALL of the following are met
Covered when ALL of the following are met
Covered with criteria — Cosentyx coverage when specified administrative and clinical criteria are met
Cosentyx is covered when specified administrative and clinical criteria are met
Concurrent use with phosphodiesterase type-5 inhibitors indicated for pulmonary hypertension (e.g., sildenafil, tadalafil) or with other soluble guanylate cyclase (sGC) stimulators is an exclusion. Requests that propose concomitant use of these agents with the requested therapy may be denied.
Concurrent use of more than one phenylbutyrate product is excluded. Coverage requests that list multiple phenylbutyrate products concurrently will not meet criteria.
Combination therapy with a calcitonin gene–related peptide (CGRP) antagonist is excluded when the CGRP antagonist is being used for prophylaxis. Requests that pair the requested agent with a prophylactic CGRP antagonist should be denied.
Certain medication entries exclude use in patients who are biologically male. For those specific products, requests for biologically male patients do not meet the exclusion‑adjusted coverage criteria and should be denied per the policy entry.
In the provided excerpts there are no explicit exclusion criteria listed for Alpha1 proteinase inhibitors or for ambrisentan. The policy sections for these agents show N/A for exclusion entries in the available text.
Off‑label uses and exclusion criteria fields for ambrisentan in the extracted excerpts are listed as N/A, indicating no off‑label uses or specific exclusions are provided in the available segments.
The policy excludes use in patients with uncontrolled hypertension and in certain anemic states not listed among approved diagnoses (for example anemia due to iron/folate deficiency, hemolysis, or GI bleeding). It also excludes use for immediate anemia correction or as a substitute for emergency transfusion, and excludes patients receiving certain therapies (e.g., hormonal agents, therapeutic biologics, or radiotherapy) unless they are also receiving concomitant myelosuppressive chemotherapy.
Concurrent use with a biologic drug or a targeted synthetic disease‑modifying agent is an exclusion. Requests that propose concomitant treatment with another biologic or targeted synthetic will be considered excluded and may be denied.
No additional exclusion criteria are noted in the provided excerpt for this section of the policy.
For systemic lupus erythematosus (SLE) indications, concurrent use with other biologics (including specified agents such as Lupkynis or Saphnelo) is an exclusion. Use in patients with active central nervous system lupus is also excluded for these entries.
The SLE and lupus nephritis related entries explicitly exclude concurrent use with other biologics (including Lupkynis or Saphnelo) and exclude treatment of patients with active central nervous system lupus.
N/A
N/A
For chenodeoxycholic acid (chenodal), patients with calcified (radiopaque) gallstones are excluded. For tadalafil, use for erectile dysfunction and concomitant use with nitrates are excluded per the policy entries.
Exclusion criteria include history of urinary retention, any degree of hepatic impairment (mild, moderate, or severe), gastric retention, untreated narrow‑angle glaucoma, history of hypersensitivity to the referenced agents (e.g., Cobenfy or trospium), and moderate or severe renal impairment defined as eGFR < 60 ml/min.
Concurrent use with strong CYP3A4 inhibitors or inducers is excluded. Use in patients with familial short QT syndrome is also listed as an exclusion and may trigger denial.
There are no not‑medically‑necessary conditions specified in the available excerpts for this policy segment.
Requests for non‑preferred anticonvulsant products may be denied if documentation of prior trial(s) of preferred agents (with dates and reasons for failure, intolerance, or contraindication) is not provided. Lack of the required documentation does not meet the policy's prerequisite information requirements.
Use of the agent as an immediate measure to correct anemia or as a substitute for emergency transfusion is explicitly not appropriate and is listed as an exclusion in the policy.
Off‑label uses are listed as N/A in the provided excerpts for this section, indicating no off‑label approvals are specified in the available text.
For Mycobacterium avium complex (MAC) lung disease, requests are not approved if the MAC isolate has an amikacin minimum inhibitory concentration (MIC) greater than 64 µg/mL. Requests are also not appropriate if the patient has achieved sustained negative sputum cultures since completion of the most recent background multidrug regimen.
No explicit not‑medically‑necessary statements are included in the provided excerpt for this section of the policy.
Use in patients meeting the listed exclusion conditions (for example, eGFR < 60 ml/min) is considered not appropriate per the exclusion criteria and may be denied.
Prior Authorization, Documentation, and Denial Triggers
Prior authorization required for all FDA‑approved indications; prerequisite therapy required
Prior authorization is required for all FDA‑approved indications; prerequisite therapy is required — preferred agents (e.g., ambrisentan or bosentan; sildenafil or tadalafil) must be tried and documentation of failure, dates, and reasons provided, or document contraindication/adverse reaction to those agents.
- Document dates and reasons for failure for preferred endothelin receptor antagonists (ambrisentan or bosentan) or document contraindication/adverse reaction.
- Document dates and reasons for failure for preferred PDE5 inhibitors (sildenafil or tadalafil) or document contraindication/adverse reaction.
- Provide diagnosis and relevant genetic/enzymatic/laboratory test results as applicable.
Actemra prior authorization applies to all FDA‑approved indications; coverage typically 1 year
Prior authorization is required for Actemra and applies to all FDA‑approved indications. Standard approved coverage duration is 1 year (note: some entries list initial 6 months and continuation 1 year where specified).
- Coverage duration: 1 year for Actemra per PA entry.
- Some medication-specific entries specify initial 6 months with continuation approvals of 1 year (see Actemra-specific duration language).
PA applies to all FDA‑approved indications
Prior authorization applies to all FDA‑approved indications for the listed medications — requests must be submitted under the 'All FDA‑Approved Indications' PA indicator.
- Ensure the request is submitted under PA indicator 'All FDA‑Approved Indications'.
- Provide the diagnosis and required supporting documentation for the indicated FDA-approved use.
PA required; Actemra initial approvals may be 6 months with 1‑year continuation (prerequisite therapy required)
Prior authorization is required; for Actemra some entries specify initial approvals of 6 months with continuation approvals of 1 year. Prerequisite therapy is required and must be documented.
- If initial-duration language applies, initial approval may be 6 months with continuation at 1 year.
- Document prerequisite therapy trials and reasons for failure or contraindication as required.
PA requires specialist prescriber or consultation (cardiologist or pulmonologist)
Prior authorization requires that the prescriber be a specialist or consult with one — for PAH agents the prescriber must be a cardiologist or pulmonologist. Some agents (e.g., ambrisentan) have lifetime coverage when PAH criteria are met.
- Prescriptions for PAH therapies must be by or in consultation with a cardiologist or pulmonologist.
- When PAH criteria are met for ambrisentan, coverage duration is listed as lifetime.
Submit PA under the appropriate PA indication indicator (e.g., All FDA‑Approved Indications)
Prior authorization is required per PA indication indicators: certain products (e.g., voriconazole) are covered for all FDA‑approved indications; other groups (e.g., Aranesp) may include medically‑accepted indications — submit under the appropriate PA indicator.
- Check the PA indication indicator on the request (e.g., 'All FDA‑Approved Indications' or 'All FDA‑Approved Indications, Some Medically‑Accepted Indications').
- Provide the diagnosis and required clinical information for the specific indication.
PA required for listed medications under the 'All FDA‑Approved Indications' indicator
Prior authorization is required for medications listed under the PA indicator; the PA applies to all FDA‑approved indications for those products and must include required documentation.
- Ensure PA submission includes diagnosis and required supporting documentation per the medication group.
- Use the PA indicator 'All FDA‑Approved Indications' when applicable.
Chemotherapy‑related anemia: document recent and planned chemotherapy
For non‑myeloid malignancy chemotherapy‑related anemia, prior authorization requires that the member received chemotherapy in the past 8 weeks and will be receiving chemotherapy for a minimum of 2 months; Part B vs Part D determination is made at PA review.
- Document dates of chemotherapy (within past 8 weeks) and planned chemotherapy duration (minimum 2 months).
- PA review will determine Part B vs Part D applicability per CMS guidance.
PA required for FDA‑approved indications; document prior background multidrug regimen when applicable
Prior authorization is required for all FDA‑approved indications; for some agents (e.g., Arikayce) document prior background multidrug regimen and that the agent will be used in conjunction with that regimen.
- Document prior background multidrug regimen (typical regimen: macrolide + ethambutol + rifamycin) and dates.
- Confirm Arikayce will be used with the background multidrug regimen.
PA required for atypical antipsychotics and basal insulin; basal insulin PA covers all FDA‑approved indications
Prior authorization is required for atypical antipsychotics and basal insulin; basal insulin PA covers all FDA‑approved indications and requires documentation of prior therapies when applicable.
- Provide documentation of previous therapies or reasons for exception when requesting basal insulin products.
- Submit diagnosis and required clinical information per the basal insulin criteria.
PA requires specialist prescriber or consultation for SLE/lupus nephritis
Prior authorization is required. For SLE prescriptions, the prescriber must be or consult with a rheumatologist, clinical immunologist, nephrologist, neurologist, or dermatologist; lupus nephritis prescriptions require nephrology or rheumatology involvement.
- Document specialist involvement (prescriber or consult) for SLE or lupus nephritis requests.
- Include ANA/anti‑dsDNA levels and SELENA‑SLEDAI score as required medical information.
PA required for listed medications; applies to FDA‑approved indications
Prior authorization is required for the listed medications and applies to their FDA‑approved indications; submit required documentation as specified in the policy.
- Ensure the PA includes diagnosis and any condition‑specific test results or prior therapy documentation.
- Follow medication‑specific required medical information fields.
Coverage duration varies by indication (examples: NAGS 3 mo without genetic test, 12 mo with test; Cayston 1 year)
Prior authorization coverage durations vary by indication: for NAGS deficiency without genetic test approvals may be 3 months and with genetic test 12 months; Cayston for cystic fibrosis is 1 year; other durations depend on the listed indication.
- If genetic testing confirms NAGS deficiency, coverage duration may be 12 months; without genetic test, initial duration may be 3 months.
- Cayston (CF) coverage duration is 1 year.
- Check the specific medication entry for the applicable coverage duration.
Use the listed PA indicator (often 'All FDA‑Approved Indications') on submissions
The PA indicator for many entries lists 'All FDA‑Approved Indications' — ensure the PA submission references that indicator when applicable.
- Confirm and use the PA indicator shown on the medication entry (e.g., '1 - All FDA‑Approved Indications').
PA requires documented symptom severity (AUA‑SI ≥ 8) and prior trials for BPH/tadalafil
Prior authorization requires documentation of moderate‑or‑worse symptoms (AUA‑SI ≥ 8) and that the member tried and failed, is intolerant of, or has contraindications to required therapies (e.g., two drugs from two therapeutic classes) for BPH/tadalafil requests.
- Document AUA‑SI score ≥ 8 and prior trials with dates and durations for required drug classes.
- Provide reasons for failure/intolerance or contraindications if applicable.
Cosentyx PA: All FDA‑approved indications — submit diagnosis, prior meds, and dosing info
Prior authorization is required for Cosentyx; it covers all FDA‑approved indications and requires diagnosis, prior medication trials, and dosing within FDA‑approved ranges.
- Provide diagnosis, other medications tried, and documentation that dose and frequency are within FDA‑approved dosing.
- Cosentyx PA indicator: All FDA‑Approved Indications; age restriction applies where noted (e.g., ≥6 years for some indications).
Step therapy: trial and documented failure/intolerance to preferred ERAs and PDE5 inhibitors for PAH
Step therapy requires trial and documented failure, intolerance, or contraindication to preferred endothelin receptor antagonists (ambrisentan or bosentan) and preferred PDE5 inhibitors (sildenafil or tadalafil) before coverage for PAH therapies.
- Provide documentation of trials, dates, dosing, and reasons for failure or intolerance for preferred agents.
- Alternatively document contraindication or expected adverse reaction to both agents in the class.
Some entries list no prerequisite therapy required — confirm on medication entry
No prerequisite or prior therapy is required for certain entries marked 'N/A' — check the specific medication group entry to confirm when prerequisite therapy is not required.
- Confirm 'PREREQUISITE THERAPY REQUIRED: N/A' on the specific medication entry before omitting prerequisite trials.
IBS prerequisite: document trials of one antidiarrheal and one antispasmodic plus chronicity/exclusion
For severe diarrhea‑predominant IBS, prior to PA approval the patient must have tried and failed one antidiarrheal (e.g., loperamide) and one antispasmodic (e.g., dicyclomine); document chronicity (≥6 months) and exclusion of anatomic/biochemical GI abnormalities.
- Document chronicity of symptoms ≥6 months and exclusion of anatomic/biochemical causes.
- Provide dates and evidence of trials and failures with the antidiarrheal and antispasmodic agents.
Verify 'N/A' prerequisite therapy status where indicated
No prerequisite therapy is required for certain entries explicitly marked 'PREREQUISITE THERAPY REQUIRED: N/A' — verify on the specific policy entry.
- Confirm the 'N/A' prerequisite status on the medication's policy entry before proceeding.
Pericarditis prerequisite: trial/failure of at least two standard therapies required
For pericarditis initial approval, document trial and failure of at least two standard therapy agents (e.g., colchicine, NSAIDs, corticosteroids) and provide evidence of positive clinical response for continuation.
- Document trials and failures of at least two standard therapies with dates.
- For continuation, provide documentation of positive clinical response (e.g., reduced recurrence, symptom improvement, CRP changes).
Arikayce PA: document background multidrug regimen, culture status, and amikacin MIC ≤ 64 µg/mL
Arikayce (MAC lung disease) requires prior authorization and prerequisite therapy: document that the patient has not achieved negative sputum cultures since the most recent background multidrug regimen, that Arikayce will be used with a background regimen (macrolide + ethambutol + rifamycin), and that the MAC isolate's amikacin MIC ≤ 64 µg/mL.
- Provide amikacin MIC for the MAC isolate and documentation it is ≤ 64 µg/mL.
- Document prior background multidrug regimen and that Arikayce will be used concurrently.
- Confirm patient has not achieved negative sputum cultures since completion of the most recent background regimen.
Document failure/intolerance/contraindication to preferred formulary alternatives for step‑therapy exceptions
Step therapy/Preferred‑product trial is required for many drug groups — members must show failure, intolerance, contraindication, or adverse reaction to specified preferred formulary alternatives; document trials with dates and reasons.
- Include documentation of preferred product trials, dates, dosing, and reasons for failure/intolerance or contraindication.
- If no listed preferred alternative exists, provide supporting guideline/literature rationale.
SLE/LN prerequisite: use concurrently with/after standard therapies; include serology and disease activity documentation
For SLE and lupus nephritis, prerequisite and concurrent therapy requirements apply: Actemra (where listed) must be used concurrently with or after standard therapies (corticosteroids, antimalarials, immunosuppressants); include ANA/anti‑dsDNA levels and SELENA‑SLEDAI score when applicable.
- Document concurrent or prior use of standard therapies and provide serologic test results (ANA or anti‑dsDNA) and SELENA‑SLEDAI score as required.
- For lupus nephritis, include biopsy‑proven lupus nephritis documentation.
Oncology indications: document intolerance/contraindication to preferred oncology products (e.g., Calquence)
For certain oncology indications (e.g., mantle cell lymphoma/CLL/SLL), step/prerequisite therapy may require demonstration of intolerance, contraindication, or adverse reaction to preferred products such as Calquence; document trials or contraindications.
- Provide documentation of intolerance, contraindication, or adverse reaction to preferred oncology products with dates and reasons.
- State if no preferred alternative exists per guidelines.
Cayston PA: document CF diagnosis and prior tobramycin trial or documented resistance
Cayston for cystic fibrosis requires prior tobramycin inhalation solution trial or documented tobramycin resistance prior to approval; document CF diagnosis and prior inhaled tobramycin history.
- Document diagnosis of cystic fibrosis and history of prior tobramycin inhalation solution use with dates and outcomes.
- If tobramycin resistance documented, include microbiology reports.
Chenodal PA: document trial/failure of ursodiol and imaging confirming radiolucent gallstones
Chenodeoxycholic acid (chenodal) requires prior trial and failure, intolerance, or contraindication to ursodiol and documentation of radiolucent gallstones on oral cholecystography; provide imaging and prior therapy documentation.
- Provide oral cholecystography or ultrasonogram showing radiolucent gallstones in a well‑opacifying gallbladder.
- Document prior trial/failure or contraindication to ursodiol.
Tadalafil PA for BPH: document AUA‑SI ≥ 8 and required prior trials with durations
Tadalafil (BPH) PA requires documented AUA‑SI ≥ 8, daily dosing of 2.5 mg or 5 mg, and trials of two drugs from two therapeutic classes (alpha‑1 blockers and 5‑alpha reductase inhibitors) with specified minimum durations; document dates and reasons for failure/intolerance.
- Include AUA‑SI score ≥ 8.
- Document prior trials: alpha‑1 blocker ≥1 month at max tolerated dose; 5‑alpha reductase inhibitor ≥4 months at max tolerated dose (or combination as specified).
- Provide reasons for failure/intolerance or contraindications.
Document required prior trials for BPH and schizophrenia step‑therapy entries
Step therapy for BPH and schizophrenia entries requires trials and failures of specified agents — document prior antipsychotic trials (two agents) or intolerance/contraindication as specified.
- For schizophrenia, document trial and inadequate response to two of Lybalvi, Vraylar, or Caplyta or document intolerance/contraindication.
- For BPH, document required prior trials and durations per policy.
Cosentyx PA: submit diagnosis, prior meds, dosing, prescriber specialty, and prerequisite therapy documentation for fungal indications
Cosentyx coverage requires diagnosis, other medications tried, dosing within FDA‑approved ranges, prescriber specialty (infectious disease specialist where indicated), age restrictions (e.g., ≥6 years where noted), and proof of prerequisite therapy for invasive fungal indications when applicable.
- Provide diagnosis and history of other medications tried and dosing information.
- If for invasive fungal disease, document failure/intolerance or contraindication to posaconazole and/or voriconazole with dates and reasons.
Medication and Diagnostic Codes, Key Clinical Thresholds
| TYENNE 162 MG/0.9 ML SYRINGE | listed medication presentation |
| TYENNE AUTOINJECTOR | listed medication presentation |
| CERDELGA | listed medication |
| CEREZYME | listed medication |
| ELELYSO | listed medication |
| MIGLUSTAT | listed medication |
| VPRIV | listed medication |
| YARGESA | listed medication |
| ADEMPAS | listed medication |
| AIMOVIG AUTOINJECTOR | Medication listed in document |
| ALOSETRON HCL | Medication listed in document |
| BRIVARACETAM 100 MG TABLET | listed medication |
| BRIVARACETAM 10 MG/ML ORAL SOL | listed medication |
| BRIVARACETAM 10 MG TABLET | listed medication |
| BRIVARACETAM 25 MG TABLET | listed medication |
| BRIVARACETAM 50 MG TABLET | listed medication |
| BRIVARACETAM 75 MG TABLET | listed medication |
| DIACOMIT | listed medication |
| DILANTIN 30 MG CAPSULE | listed medication |
| ESLICARBAZEPINE ACETATE | listed medication |
| METHSUXIMIDE | listed medication |
| Carbamazepine | preferred product |
| Epitol | preferred product |
| Divalproex | preferred product |
| ethosuximide | preferred product |
| felbamate | preferred product |
| gabapentin | preferred product |
| lamotrigine | preferred product |
| levetiracetam | preferred product |
| oxcarbazepine | preferred product (immediate release or oral suspension) |
| phenytoin | preferred product |
| 1 | All FDA-Approved Indications |
| 4 | All FDA-Approved Indications, Some Medically-Accepted Indications |
| 1 | All FDA-Approved Indications (PA indication indicator) |
| No codes listed |
| BOSENTAN 125 MG TABLET | BOSENTAN 125 MG TABLET |
| BOSENTAN 62.5 MG TABLET | BOSENTAN 62.5 MG TABLET |
| BRUKINSA | Medication listed |
| CARGLUMIC ACID | Medication listed |
Background and Definitions
Pulmonary arterial hypertension (PAH, WHO Group 1) and chronic thromboembolic pulmonary hypertension (CTEPH) require hemodynamic confirmation by pretreatment right heart catheterization. Key thresholds for PAH diagnosis include a mean pulmonary arterial pressure mPAP ≥ 25 mm Hg, pulmonary vascular resistance PVR > 3 Wood units, and a pulmonary capillary wedge pressure/PAWP/left ventricular end‑diastolic pressure ≤ 15 mm Hg. For PAH, the patient must also have WHO functional class II–IV symptoms.
Key Definitions and Clinical Thresholds
Policy Revision History
Prior Authorization Criteria last updated (document header).
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