Revatio tablets — Cigna

Preferred products

• generic sildenafil tablets (20 mg)

Initial criteria

• Patient meets the standard Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors Prior Authorization Policy criteria
• Patient has tried generic sildenafil 20 mg tablets [documentation required or verification of prescription claims history required]
• Patient cannot continue to use generic sildenafil 20 mg tablets due to a formulation difference in the inactive ingredient(s) (e.g., dyes, fillers, preservatives) between the Brand and the bioequivalent product which, per the prescriber, would result in a significant allergy or serious adverse reaction

Approval duration

1 year