Revatio oral suspension — Blue Cross Blue Shield of Montana

pulmonary arterial hypertension

Preferred products

The patient has been previously approved for the requested agent through the plan’s prior authorization process
The patient has had clinical benefit with the requested agent (e.g., stabilization, decreased disease progression)
If the requested agent is Tyvaso for pulmonary hypertension associated with interstitial lung disease, the patient continues ILD therapy
For one of the listed brand agents, one of the following applies: A) patient has stage four advanced, metastatic cancer and the agent is used to treat the cancer or an associated condition and use is consistent with best practices and FDA-approved, OR B) patient is currently treated and stable on the requested agent, OR C) patient has tried and had an inadequate response to the corresponding generic, OR D) generic was discontinued due to lack of efficacy/adverse event, OR E) patient has intolerance or hypersensitivity to the generic not expected with brand, OR F) FDA labeled contraindication to generic not expected with brand, OR G) generic expected to be ineffective or cause barrier/adverse reaction/worsen comorbidity per chart notes, OR H) generic not in best interest based on medical necessity, OR I) patient tried another in same class and discontinued for lack of efficacy/adverse event, OR J) support exists for using brand over generic
The prescriber is a specialist in the area of the patient’s diagnosis or consulted with one
The patient does NOT have any FDA labeled contraindications to the requested agent

12 months