Appeal type: Prescription Drug
Decision: Favorable

You asked the Plan to cover Uptravi 1000 mcg tablet. The Plan did not grant this request. We received this case to conduct an independent review.We asked our Physician Reviewer to determine whether the Part D Plan was correct in denying the request for Uptravi 1000 mcg tablet.Uptravi 1000 mcg tablet is requested for ongoing treatment of WHO group 1 pulmonary arterial hypertension secondary to connective tissue disease. The plan denied coverage because they indicate that the diagnosis was noted to be WHO group 3 pulmonary hypertension. Extensive medical records were submitted and consistency is noted regarding the stated diagnosis The medical record cited by the plan from a patient encounter on December 6, 2019 concludes that the enrollee has worsening WHO FUNCTIONAL CLASS III symptoms due to her pulmonary hypertension and right ventricular dysfunction. The listed diagnoses in the summary from that visit include pulmonary arterial hypertension (WHO group1), WHO functional class III. Although the enrollee is noted to have interstitial lung disease related to Sjogren's, it is well documented that enrollee does indeed have WHO group 1 pulmonary arterial hypertension. Of note, the World Health Organization(WHO) group system classifies what type of pulmonary hypertension a patient has while the WHO functional class system gives information about how affected they are by their disease. The diagnosis of WHO group I pulmonary arterial hypertension is supported by the severity of the pulmonary hypertension prior to treatment - pulmonary arterial pressure in April 2013 was 88/39 with a mean of 57, pulmonary capillary wedge pressure was 10, and peripheral vascular resistance was 1073. WHO group III pulmonary hypertension (secondary to lung disease) does not typically result in severe pulmonary arterial hypertension. Additionally the medical record repeatedly documents that the enrollee was enrolled in the AMBITION trial in June 2013- [Ambrisentan or Tadalafil monotherapy vs combination therapy in patients with pulmonary arterial hypertension (i.e. WHO group 1 pulmonary hypertension)]. The enrollee is stable on a multi-drug regimen that includes the requested drug; the prescriber has indicated that the enrollee is at risk for significant adverse clinical outcome with a medication change. The enrollee satisfies the Plan's coverage criteria. Our Physician Reviewer's opinion is that prior authorization criteria are met.Medicare rules allow a Part D Plan to manage its formulary by requiring prior approval for certain drugs. Based on the available documentation, our Physician Reviewer's opinion is that prior approval criteria are met. Therefore, our decision is the Plan is required to cover Uptravi.Please note that if the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The health plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will notify you in writing that the case is being reviewed again and the outcome of the reopening.