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Coverage criteria policies

Advanced drug therapy for pulmonary hypertension: epoprostenol (generic, Flolan® and Veletri®), treprostinil (generic, Remodulin® and Tyvaso®), iloprost (Ventavis®) and sildenafil injection (Revatio®)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative Process

Advanced drug therapies for pulmonary hypertension require prior authorization from HealthPartners Pharmacy Administration.

Coverage

Advanced drug therapy is generally covered subject to the indications listed below when all of the following criteria are met, and per member plan documents:

Initial authorizations:

Prescribed by a pulmonologist or cardiologist, and

  1. A diagnosis of either vasoreactive pulmonary arterial hypertension after trial and failure of calcium channel blocker therapy or in non-vasoreactive pulmonary arterial hypertension, and
  2. A diagnosis of PAH defined as WHO group 1 class of pulmonary hypertension as confirmed by right heart catherization with all of the following pretreatment results:
    1. mPAP ≥ 25 mmHg
    2. PCWP ≤ 15 mmHg
    3. PVR > 3 Wood units
  3. For medications where a generic equivalent is available, HealthPartners requires use of the generic product. Brand name requests require documentation of an allergic reaction to the generic equivalent prior to approval of the brand name drug.

Utilization for all other indications will be reviewed for medical necessity.

Sequential combination use requires documentation of medical necessity (including response to single-drug therapy, and rationale for adding a medication).

Use of sildenafil injection requires verification of medical necessity for the parenteral formulation.

Initial approvals will be for 12 months.

Reauthorizations:

  1. Medical chart documentation that the patient has been seen in the past 12 months; and,
  2. Clinical documentation that the patient has experienced clinical benefit from the therapy

Reauthorizations will be approved for 12 months.

Definitions

Pulmonary hypertension (PH) is characterized by elevated pulmonary arterial pressure and subsequent right ventricular failure. It is diagnosed by right heart catheterization measurements and defined by a mean pulmonary artery pressure of ≥25mmHg at rest.

Epoprostenol (VELETRI and generic) is a prostanoid vasodilator indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) to improve exercise capacity. Studies establishing effectiveness included predominantly patients with NYHA Functional Class III-IV symptoms and etiologies of idiopathic or heritable PAH or PAH associated with connective tissue diseases.

FLOLAN is a prostacyclin vasodilator indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group I) to improve exercise capacity. Studies establishing effectiveness included predominantly (97%) patients with NYHA Functional Class III-IV symptoms and etiologies of idiopathic or heritable PAH (49%) or PAH associated with connective tissue diseases (51%).

Treprostinil (Remodulin) is for a prostacyclin vasodilator indicated for:

  1. Treatment of pulmonary arterial hypertension (PAH; WHO Group 1) to diminish symptoms associated with exercise. Studies establishing effectiveness included patients with NYHA Functional Class II-IV symptoms and etiologies of idiopathic or heritable PAH (58%), PAH associated with congenital systemic-to-pulmonary shunts (23%), or PAH associated with connective tissue diseases (19%).
  2. Patients who require transition from epoprostenol, to reduce the rate of clinical deterioration. The risks and benefits of each drug should be carefully considered prior to transition.

Treprostinil inhaled (Tyvaso) is a prostacyclin vasodilator indicated for the treatment of pulmonary arterial hypertension (PAH; WHO Group 1) to improve exercise ability. Studies establishing effectiveness included predominately patients with NYHA Functional Class III symptoms and etiologies of idiopathic or heritable PAH (56%) or PAH associated with connective tissue diseases (33%).

Iloprost inhaled (Ventavis) is a synthetic analog of prostacyclin indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) to improve a composite endpoint consisting of exercise tolerance, symptoms (NYHA Class), and lack of deterioration. Studies establishing effectiveness included predominately patients with NYHA Functional Class III-IV symptoms and etiologies of idiopathic or heritable PAH (65%) or PAH associated with connective tissue diseases (23%).

Sildenafil injection (Revatio) is a phosphodiesterase 5 (PDE5) inhibitor FDA-approved for the treatment of pulmonary arterial hypertension (WHO Group I) in adults to improve exercise ability and delay clinical worsening. Studies establishing effectiveness included predominately patients with NYHA Functional Class II-III symptoms and etiologies of primary pulmonary hypertension or pulmonary hypertension associated with connective tissue disease. Limitation of Use: Adding sildenafil to bosentan therapy does not result in any beneficial effect on exercise capacity.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Codes

Codes

Description

J1325

Injection, epoprostenol, 0.5mg

S0155

Sterile diluents for epoprostenol, 50 mL (Not used with Veletri)

J3490

Revatio 10 mg/12.5mL SOLN – Unclassified drugs

Sterile Diluent for Remodulin SOLN

J3285

Injection, treprostinil, 1 mg

J7686

Treprostinil, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, 1.74 mg

Q4074

Iloprost, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose form, up to 20 mcg (Please note: AWP/WAC pricing is the same for the 10 mcg and 20 mcg unit dose vials. Therefore bill/reimburse 1 unit of the code regardless of strength used)

S9347

Home infusion therapy, uninterrupted, long term, controlled rate intravenous or subcutaneous infusion therapy (e.g., epoprostenol); administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem

NDC Codes

Codes

Description

00703198501

epoprostenol sodium 0.5 mg SOLR

00703199501

epoprostenol sodium 1.5 mg SOLR

00703925809

Sterile Diluent/Epoprostenol SOLN

00173051700

Flolan 0.5 mg SOLR

00173051900

Flolan 1.5 mg SOLR

66215040301

Veletri 0.5mg SOLR

66215040201

Veletri 1.5mg SOLR

55150016613

sildenafil citrate 10mg/12.5ml vial

00173051801

Sterile Diluent for Flolan SOLN

00173085702

Sterile Diluent Flolan pH 12 SOLN

66302010101

Remodulin 1 mg/mL 20 mL SOLN

66302011001

Remodulin 10 mg/mL 20 mL SOLN

66302010201

Remodulin 2.5 mg/mL 20 mL SOLN

66302010501

Remodulin 5 mg/mL 20 mL SOLN

00781342080

Treprostinil 1 mg/mL 20 mL SOLN

00781342580

Treprostinil 2.5 mg/mL 20 mL SOLN

00781342780

Treprostinil 5 mg/mL 20 mL SOLN

00781343080

Treprostinil 10 mg/mL 20 mL SOLN

66302015050

Sterile Diluent for Remodulin SOLN

66302020603

Tyvaso 0.6 mg/mL SOLN

66302020602

Tyvaso refill 0.6 mg/mL SOLN

66302020601

Tyvaso starter 0.6 mg/mL SOLN

66302020604

Tyvaso starter 0.6 mg/mL SOLN

66215030200

Ventavis 10 mcg/mL SOLN

66215030230

Ventavis 10 mcg/mL SOLN

66215030300

Ventavis 20 mcg/mL SOLN

66215030330

Ventavis 20 mcg/mL SOLN

00069033801

Revatio 10 mg/12.5 mL SOLN

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Flolan Prescribing Information. GlaxoSmithKline. 12/2018
  2. Veletri Prescribing Information. Actelion Pharmaceuticals 12/2018
  3. Remodulin Prescribing Information. United Therapeutics Corporation. 7/2018
  4. Tyvaso Prescribing Information. United Therapeutics Corporation. 10/2017
  5. Ventavis Prescribing Information. Actelion Pharmaceuticals 10/2017
  6. Revatio Prescribing Information. Pfizer Pharmaceuticals, Inc. 2/2018

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Policy activity

  • 07/29/2010 - Date of origin
  • 07/01/2019 - Effective date
Review date
  • 05/2019
Revision date
  • 05/06/2019

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