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),
- 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
Revatio: 20 mg three times a day
Adcirca: 40 mg daily
Cialis: 5 mg daily for BPH
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: November 2011 Reviewed: December 2013