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Revatio suspension — Medica

pulmonary arterial hypertension (WHO Group I)

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 one Preferred Product (generic sildenafil tablets 20 mg)

Reauthorization criteria

  • Patient continues to meet the Pulmonary Arterial Hypertension – Phosphodiesterase Type 5 Inhibitors Prior Authorization Policy criteria

Approval duration

1 year