sildenafil citrate — Blue Cross Blue Shield of Alabama

Initial criteria

• The patient will NOT be using the requested agent in combination with another phosphodiesterase type 5 (PDE5) inhibitor for the requested indication
• The requested agent has been prescribed for preservation of erectile function following radical retropubic prostatectomy
• The quantity requested is less than or equal to 30 tablets per month

Reauthorization criteria

• Same criteria as initial authorization

Approval duration

12 months