Tadalafil (Adcirca®), 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
Patients must meet the following criteria for the indication(s) above:
  • Revatio, Adcirca, Alyq (tablets):
    • Diagnosis of primary pulmonary hypertension class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required)
  • Revatio (suspension):
    • Diagnosis of primary pulmonary hypertension class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required), AND
    • Patient cannot swallow or has difficulty swallowing tablet formulation, OR
    • Patient requires administration of a dose that cannot be obtained with generic sildenafil 20 mg tablets.
  • 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
Approval:

One year


Last review date: February 24, 2020

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