Revatio tablet — Blue Cross Blue Shield of Texas

pulmonary arterial hypertension

Preferred products

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
ONE of the following: A. patient has stage four advanced metastatic cancer and use is consistent with evidence-based best practices; OR B. patient is currently being treated and stable on requested agent; OR C. patient has tried and had inadequate response to the corresponding generic; OR D. generic discontinued due to lack of efficacy, diminished effect, or adverse event; OR E. intolerance or hypersensitivity to generic not expected with brand; OR F. FDA labeled contraindication to generic not expected with brand; OR G. generic expected ineffective or causes barrier/adverse reaction; OR H. generic not in best interest based on medical necessity; OR I. patient has tried another agent in same class discontinued for lack of efficacy/adverse event; OR J. there is support for use of requested brand over generic
Prescriber is a specialist in the area of the patient’s diagnosis or has consulted with one
Patient does NOT have any FDA labeled contraindications to the requested agent

12 months