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