Advanced Therapies for Pharmacologic Treatment of Pulmonary Hypertension

Covers advanced pharmacologic therapies for pulmonary hypertension that are FDA‑approved for WHO Group 1 (pulmonary arterial hypertension, including IPAH) and WHO Group 4 (chronic thromboembolic pulmonary hypertension), including combination therapy when agents from different classes are each individually medically necessary after inadequate response to monotherapy. Coverage is limited to FDA‑approved indications and to regimens consistent with FDA labeling and/or nationally recognized compendia/guidelines (off‑label uses require strong peer‑reviewed support), oral agents are managed under the pharmacy benefit, therapies for other WHO groups are generally investigational, and this policy is inactive and must not be used for adjudication.

"Requested therapy is covered when proven effective for the relevant diagnosis or procedure based on current evidence."

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