TYVASO (treprostinil)

Self-Administration – oral inhalation

Diagnosis considered for coverage:
  • Indicated for the treatment of PAH (WHO Group I) to improve exercise ability.

  • Indicated for the treatment of pulmonary hypertension associated with ILD (PH-ILD; WHO Group 3) to improve exercise ability

Coverage Criteria:
  1. For the diagnosis of Pulmonary Arterial Hypertension (PAH):
    • One of the following:

      • Tyvaso: Dose does not exceed 12 breaths per treatment session (72 mcg) four times daily

      • Tyvaso DPI: Dose does not exceed 64 mcg per treatment session four times daily; AND

    • Prescribed by or in consultation with a pulmonologist or cardiologist; AND

    • Diagnosis of Pulmonary Arterial Hypertension; AND

    • Documentation supporting pulmonary arterial hypertension is symptomatic

  2. For the diagnosis of Pulmonary Hypertension associated with Interstitial Lung Disease (ILD):
    • One of the following:

      • Tyvaso: Dose does not exceed 12 breaths per treatment session (72 mcg) four times daily

      • Tyvaso DPI: Dose does not exceed 64 mcg per treatment session four times daily; AND

    • Prescribed by or in consultation with a pulmonologist or cardiologist; AND

    • Diagnosis of pulmonary hypertension associated with interstitial lung disease confirmed by diagnostic test(s) (e.g., right heart catheterization, doppler echocardiogram, computerized tomography imaging)

Reauthorization Criteria:
  1. For the diagnosis of Pulmonary Arterial Hypertension (PAH):

    • One of the following:

      • Tyvaso: Dose does not exceed 12 breaths per treatment session (72 mcg) four times daily

      • Tyvaso DPI: Dose does not exceed 64 mcg per treatment session four times daily; AND

    • Documentation of a positive clinical response to therapy

  2. For the diagnosis of Pulmonary Hypertension associated with Interstitial Lung Disease (ILD):

    • One of the following:

      • Tyvaso: Dose does not exceed 12 breaths per treatment session (72 mcg) four times daily

      • Tyvaso DPI: Dose does not exceed 64 mcg per treatment session four times daily; AND

    • Documentation of a positive clinical response to therapy

Coverage Duration:

 
•    Initial: 6 months
•    Reauthorization: 1 year

Authorization is not covered for the following:


The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Policy Updates:
  • 11/15/2022 – Updated policy and format
  • 04/2019 - Last reviewed
References:
  1. Tyvaso Prescribing Information. United Therapeutics Corp. Research Triangle Park, NC. March 2021.
  2. Tyvaso DPI Prescribing Information. United Therapeutics Corporation. Research Triangle Park, NC. May 2022.

Last review date: December 1, 2022

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