Revatio — Blue Cross Blue Shield of Alabama

Preferred products

• sildenafil (tablet, oral suspension)
• tadalafil
• bosentan 62.5 mg and 125 mg tablets
• ambrisentan

Initial criteria

• - Patient has been previously approved for the requested agent through the plan’s prior authorization process
• - Patient has had clinical benefit with the requested agent (e.g., stabilization, decreased disease progression) (medical records required)
• - If Tyvaso requested for diagnosis of PH-ILD (WHO group 3), patient will continue standard of care therapy for ILD (e.g., Ofev)
• - If requesting brand agent with a generic equivalent (Revatio, Adcirca, Tracleer, Letairis), ONE of the following: • Patient has intolerance or hypersensitivity to the generic equivalent not expected with the brand • Patient has FDA labeled contraindication to the generic equivalent not expected with the brand • There is support for use of the requested brand over the generic equivalent
• - If request is for Tadliq, ONE of the following: • Patient has tried and had inadequate response to generic tadalafil tablets • Patient has intolerance or hypersensitivity to generic tadalafil tablets not expected with Tadliq • Patient has FDA labeled contraindication to generic tadalafil tablets not expected with Tadliq
• - If request is for Liqrev, ONE of the following: • Patient has tried and had inadequate response to generic sildenafil oral suspension • Patient has intolerance or hypersensitivity to generic sildenafil oral suspension not expected with Liqrev • Patient has FDA labeled contraindication to generic sildenafil oral suspension not expected with Liqrev
• - Prescriber is a specialist in the area of the patient’s diagnosis (e.g., cardiologist, pulmonologist) or has consulted with such a specialist
• - Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• - Patient has been previously approved for the requested agent through the plan’s prior authorization process
• - Patient has had clinical benefit with the requested agent (e.g., stabilization, decreased disease progression)
• - If Tyvaso for PH-ILD (WHO group 3), patient continues standard of care therapy for ILD
• - For brand agents with generic equivalents, same intolerance, contraindication, or support justifications apply
• - Specialist involvement continues
• - No FDA labeled contraindications

Approval duration

12 months