- Quantity Limit: limit maximum 3 EA PER 1 day(s)
- 1. Diagnosis of pulmonary arterial hypertension (PAH) (WHO Group 1) AND 2. For patients less than 18 years of age, failure or clinically significant adverse effects to two other PAH therapies. Coverage is Not Authorized For: 1. Patients taking nitrates (e.g., Nitrodur, Nitrobid, Nitrostat, Isordil, Ismo). 2. Patients taking gunylate cyclase (GC) stimulators (e.g., Adempas) 3. Patients taking phosphodiesterase type 5 (PDE5) inhibitors. Authorization Limit: Length of benefit.
- Prior Authorization: 1. Diagnosis of pulmonary arterial hypertension (PAH) (WHO Group 1) AND 2. For patients less than 18 years of age, failure or clinically significant adverse effects to two other PAH therapies. Coverage is Not Authorized For: 1. Patients taking nitrates (e.g., Nitrodur, Nitrobid, Nitrostat, Isordil, Ismo). 2. Patients taking gunylate cyclase (GC) stimulators (e.g., Adempas) 3. Patients taking phosphodiesterase type 5 (PDE5) inhibitors. Authorization Limit: Length of benefit.
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