LETAIRIS (ambrisentan)

LETAIRIS (ambrisentan)

SELF-ADMINISTRATION - Oral

Diagnosis considered for coverage:

• Pulmonary Arterial Hypertension (PAH): Indicated for the treatment of PAH (WHO Group I) to 1) improve exercise ability and delay clinical worsening and 2) in combination with tadalafil to reduce the risks of disease progression and hospitalization for worsening PAH, and to improve exercise ability

Coverage Criteria:

For diagnosis of pulmonary arterial hypertension (PAH):

• Dose does not exceed 10 mg once daily, AND
• Diagnosis of PAH, AND
• PAH is symptomatic, AND
• One of the following (A or B):
  • A) Diagnosis of PAH was confirmed by right heart catheterization, or
  • B) Patient is currently on any therapy for the diagnosis of PAH, AND
• Prescribed by or in consultation with a cardiologist or pulmonologist, AND
• For brand Letairis tablet only: Trial and failure or intolerance to generic ambrisentan

Reauthorization Criteria:

For diagnosis of pulmonary arterial hypertension (PAH):

• Dose does not exceed 10 mg once daily, AND
• Documentation of positive clinical response to therapy

Coverage Duration: 

• Initial: 6 months
• Reauthorization: 1 year

Dosing:

• Initiate treatment at 5 mg once daily, with or without tadalafil 20 mg once daily. At 4-week intervals, either the dose of Letairis or tadalafil can be increased, as needed and tolerated, to Letairis 10 mg or tadalafil 40 mg.
   

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:

• 2/24/2020 – New policy approved by P&T.
• 3/01/2024 – Policy updated, generic medication added, reauthorization criteria added

References:

1. Letairis Prescribing Information. Gilead Sciences, Inc. Foster City, CA. August 2019