FLOLAN, Epoprostenol Sodium VELETRI, Epoprostenol Sodium Form

Epoprostenol (Flolan®, Veletri®) is a prostacyclin. FDA Approved Indication(s) Flolan and Veletri are indicated for the treatment of pulmonary arterial hypertension (PAH) (World Health Organization [WHO] Group 1) to improve exercise capacity.
Studies establishing effectiveness included predominantly patients with New York Heart Association (NYHA) Functional Class III-IV symptoms and etiologies of idiopathic or heritable PAH or PAH associated with connective tissue diseases.
Policy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.
It is the policy of health plans affiliated with Centene Corporation® that epoprostenol is
necessary when the following criteria are met:
I. Initial Approval Criteria
A. Pulmonary Arterial Hypertension (must meet all):

1. Diagnosis of PAH;
   2. Prescribed by or in consultation with a cardiologist or pulmonologist;
   3. Failure of a calcium channel blocker (see Appendix B), unless member meets one of the following (a or b):
      a. Inadequate response or contraindication to acute vasodilator testing; b. Contraindication or clinically significant adverse effects to calcium channel blockers are experienced;
2. If request is for brand Flolan or brand Veletri, member must use generic epoprostenol sodium, unless contraindicated or clinically significant adverse effects are experienced;

3. Provider must submit treatment plan detailing pump rate, dose and quantity (in mL). Approval duration:
   Medicaid/HIM – 6 months
   Commercial – 12 months or duration of request, whichever is less Page 1 of 8

   CLINICAL POLICY Epoprostenol B. Other diagnoses/indications (must meet 1 or 2):

4. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b): a. For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace, and CP.PMN.255 for Medicaid; or b. For drugs NOT on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace, and CP.PMN.16 for Medicaid; or
5. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid.
   II. Continued Therapy A. Pulmonary Arterial Hypertension (must meet all):
   1. Member meets one of the following (a or b): a. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; b. Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations (refer to state specific addendums for CC.PHARM.03A and CC.PHARM.03B);
   2. Member is responding positively to therapy;
   3. If request is for brand Flolan or brand Veletri, member must use generic epoprostenol sodium, unless contraindicated or clinically significant adverse effects are experienced;
6. Provider must submit treatment plan detailing pump rate, dose and quantity (in mL). Approval duration:
   Medicaid/HIM – 12 months Commercial – 12 months or duration of request, whichever is less B. Other diagnoses/indications (must meet 1 or 2):

7. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b): a. For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace, and CP.PMN.255 for Medicaid; or b. For drugs NOT on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the non-formulary policy for the relevant line of business: Page 2 of 8

   CLINICAL POLICY Epoprostenol CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace, and CP.PMN.16 for Medicaid; or

8. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid.
   III. Diagnoses/Indications for which coverage is NOT authorized:
   A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policies – CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid, or evidence of coverage documents. IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key CTEPH: chronic thromboembolic
   pulmonary hypertension FC: functional class FDA: Food and Drug Administration
   NYHA: New York Heart Association PA: physical activity PAH: pulmonary arterial hypertension PH: pulmonary hypertension WHO: World Health Organization Appendix B: Therapeutic Alternatives
   This table provides a listing of preferred alternative therapy recommended in the approval criteria. The drugs listed here may not be a formulary agent and may require prior authorization.
   Drug Name Dosing Regimen nifedipine (Adalat® CC, Procardia XL®) Dose Limit/ Maximum Dose 240 mg/day 60 mg PO QD; may increase to 120 to 240 mg/day 720 to 960 mg PO QD 960 mg/day diltiazem (Dilacor XR®, Dilt-XR®, Cardizem® CD, Cartia XT®, Tiazac®, Taztia XT®, Cardizem® LA, Matzim® LA) amlodipine (Norvasc®) Therapeutic alternatives are listed as Brand name® (generic) when the drug is available by brand name only and generic (Brand name®) when the drug is available by both brand and generic. 20 to 30 mg PO QD 30 mg/day Appendix C: Contraindications/Boxed Warnings • Contraindication(s): o Congestive heart failure due to severe left ventricular systolic dysfunction o Pulmonary edema (Veletri only) o Hypersensitivity to the drug or to structurally related compounds • Boxed warning(s): none reported Page 3 of 8

   CLINICAL POLICY
   Epoprostenol Appendix D: Pulmonary Hypertension: WHO Classification • Group 1: PAH
   • Group 2: PH due to left heart disease • Group 3: PH due to lung disease and/or hypoxemia • Group 4: CTEPH
   • Group 5: PH due to unclear multifactorial mechanisms Monitoring for progression of PH and treatment of co- existing conditions Advanced treatment of PH with PH- targeted therapy

   • see Appendix F Appendix E: Pulmonary Hypertension: WHO/NYHA Functional Classes (FC) Treatment Approach Status at Rest PA Limitations FC Heart Failure I Comfortable at rest Tolerance of Physical Activity (PA) No limitation Ordinary PA does not cause undue dyspnea or fatigue, chest pain, or near syncope. II III IV Comfortable at rest Slight limitation Comfortable at rest Marked limitation Dyspnea or fatigue may be present at rest Inability to carry out any PA without symptoms Ordinary PA causes undue dyspnea or fatigue, chest pain, or near syncope. Less than ordinary PA causes undue dyspnea or fatigue, chest pain, or near syncope. Discomfort is increased by any PA.
     Signs of right heart failure PH supportive measures may include diuretics, oxygen therapy, anticoagulation, digoxin, exercise, pneumococcal vaccination. Advanced treatment options also include calcium channel blockers. Appendix F: Pulmonary Hypertension: Targeted Therapies Mechanism of Action Drug Subclass Drug Class Drug Brand/Generic Formulations Prostacyclin pathway agonist Prostacyclin Member of the prostanoid class of fatty acid derivatives. Synthetic prostacyclin analog Reduction of pulmonary arterial pressure through vasodilation Epoprostenol Veletri (IV) Flolan (IV) Flolan generic (IV) Treprostinil Orenitram (oral tablet) Remodulin (IV) Tyvaso (inhalation) Ventavis (inhalation) Iloprost Page 4 of 8

   CLINICAL POLICY
   Epoprostenol Mechanism of Action Drug Class Drug Subclass Drug Selexipag Brand/Generic Formulations Uptravi (oral tablet) Ambrisentan Letairis (oral Endothelin receptor antagonist (ETRA) Nitric oxide- cyclic guanosine monophosphate enhancer Non-prostanoid prostacyclin receptor (IP receptor) agonist Selective receptor antagonist Nonselective dual action receptor antagonist Phosphodiesterase type 5 (PDE5) inhibitor Guanylate cyclase stimulant (sGC) Bosentan Macitentan Sildenafil Tadalafil Riociguat tablet) Tracleer (oral tablet) Opsumit (oral tablet) Revatio (IV, oral tablet, oral suspension) Adcirca (oral tablet) Adempas (oral tablet) Maximum Dose Based on clinical response Based on clinical response V. Dosage and Administration
   Drug Name Epoprostenol (Flolan) Dosing Regimen 2 ng/kg/min IV, increased by 1-2 ng/kg/min at intervals of at least 15 minutes Epoprostenol (Veletri) 2 ng/kg/min IV, increased by 2 ng/kg/min every 15 minutes or longer VI. Product Availability
   Drug Name Epoprostenol (Flolan) Vial with powder for reconstitution: 0.5 mg, 1.5 mg Epoprostenol (Veletri) Availability Vial with powder for reconstitution: 0.5 mg, 1.5 mg VII.