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

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

  • Revatio (sildenafil 20mg tablets or 10mg/mL oral suspension), Adcirca: Indicated for the treatment of pulmonary hypertension to improve exercise ability
  • Cialis for daily use: Benign prostatic hyperplasia (BPH)

Patients must meet the following criteria for the indication(s) above:

  • Revatio, Adcirca:
    • Diagnosis of primary pulmonary hypertension class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documenation required)
  • Cialis for daily use:
    • Diagnosis of BPH and treatment failure on two or more of the following FDA-approved drugs classes for BPH:
      • A 5 alpha-reductase inhibitor: Finasteride (Proscar), dutasteride (Avodart), 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
  • Erectile dysfunction (ED)
  • 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
    • For ED, Cialis is limited to 8 tablets per 30 days at retail or 24 tablets per 90 days at mail order

Approval:

One year


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