Self administration - Oral
Indications for Prior Authorization
- indicated for the treatment of pulmonary hypertension to improve exercise ability.
Patients must meet the following criteria for the indication(s) above.
Diagnosis of primary pulmonary hypertension class II, III, or IV symptoms confirmed by a cardiologist/pulmonologist/rheumatologist.
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee.
- peripheral vasoconstriction
- patients on tadalafil or sildenafil therapy
- All non-FDA approved uses not listed in the approved indications
Patient < 40 Kg
- Tracleer: 62.5 mg twice a day
- Maximum dose: 125 mg per day
Patient > 40 Kg
- Tracleer: Start at 62.5 mg twice a day for 4 weeks, then 125 mg twice a day
- Maximum dose: 250 mg per day; adjust dose for impair liver function
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: March 2011 Reviewed: December 2013