Sildenafil citrate (Revatio®) Tadalafil (Adcirca®, Cialis®)

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Indicated for the treatment of pulmonary hypertension to improve exercise ability
  • Benign prostatic hyperplasia (BPH)

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
  • Diagnosis of BPH and treatment failure on two or more of the following FDA-approved drugs classes for BPH:
    • Finasteride (Proscar), dutasteride (Avodart), dutasteride plus tamsulosin (Jalyn), AND
    • An alpha-blocker: terazosin (Hytrin), doxazosin (Cardura), tamsulosin (Flomax), alfuzosin (Uroxatral), and silodosin (Rapaflo)
  • Drugs may be tried individually or in combination therapy

The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee:

  • Peripheral vasoconstriction
  • Patients taking nitrates
  • All non-FDA approved uses not listed in the approved indications

Dosing:

  • Revatio: 20 mg three times a day
  • Adcirca: 40 mg daily
  • Cialis: 5 mg daily for BPH

Approval:

One year


 

Last review date: December 2, 2013

The site you are transferring to is not hosted by WHA. WHA's Terms of Use and internet Privacy Practices do not apply to your use of this linked site. Please review the policies on privacy and terms of use for the linked site. WHA does not control the accuracy, completeness, or timeliness of the content on the linked site.