REVATIO (sildenafil citrate)
SELF ADMINISTRATION - ORAL
Indications for Prior Authorization:
- Indicated for the treatment of pulmonary arterial hypertension (WHO [World Health Organization] Group I) in adults to improve exercise ability and delay clinical worsening. The delay in clinical worsening was demonstrated when Sildenafil was added to background epoprostenol therapy
Patients must meet the following criteria for the indication(s) above:
- Revatio® (tablets), Adcirca®, Alyq™:
- Patient has a diagnosis of Pulmonary Arterial Hypertension (WHO Group 1) with class II, III, or IV symptoms confirmed by a specialist (e.g., cardiologist, pulmonologist) (medical record documentation required)
- Revatio® (suspension):
- Patient has a diagnosis of Pulmonary Arterial Hypertension (WHO Group 1) with 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
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
- Alyq™: 40 mg daily
Approval:
- One year
Last review date: August 10, 2020