01Already effective 10/01/2025: Billing team: Obtain prior authorization for these medications, because prior authorization is required and the use of samples is not considered current or stable therapy.
02Before submitting, confirm the initial criteria are met.
03For pulmonary arterial hypertension (WHO Group 1), the diagnosis must be confirmed by right heart catheterization with medical records, with mean pulmonary arterial pressure greater than 20 mmHg, pulmonary capillary wedge pressure less than 15 mmHg and pulmonary vascular resistance of at least 2 Wood units, and the individual must be WHO functional class II or greater.
04For pulmonary hypertension associated with interstitial lung disease (WHO Group 3), the individual must have an FVC less than 70% predicted, extensive parenchymal changes on CT, and must be currently treated and continuing standard of care ILD therapy such as Ofev.
05For chronic thromboembolic pulmonary hypertension (WHO Group 4), the requested agent must be Adempas (riociguat), the diagnosis must be confirmed by a ventilation-perfusion scan and a confirmatory selective pulmonary angiography, and the individual must not be a candidate for surgery or must have had a pulmonary endarterectomy with persistent or recurrent disease.
06The prescriber must be a specialist or have consulted with a specialist such as a cardiologist or pulmonologist, the individual must have no FDA-labeled contraindications, and the prescribed dose must be within program quantity limits based on FDA-labeled dosing.
07For renewal, the individual must have been previously approved through the BCBSMS PA process and must have had clinical benefit, with the same prescriber and dose requirements.
08Perform a formulary drug search on the patient's member ID to confirm the prescription drug is covered under the patient's benefit plan, because these medications may not be covered under a specific member's benefit plan.
09For State Health Plan members, submit any required Prior Authorization Requests to the Plan's Pharmacy Benefit Manager.
10Services related to delivery or administration of a medication determined to be not medically necessary are also considered not medically necessary, and services related to delivery or administration of a self-administered drug are not covered.