Pulmonary Arterial Hypertension Oral and Inhaled Drugs

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
BOSENTAN TRACLEER TABLET Y    
SILDENAFIL CITRATE REVATIO TABLET Y    
SILDENAFIL CITRATE SILDENAFIL TABLET Y    
AMBRISENTAN LETAIRIS TABLET N PA Document  
ILOPROST TROMETHAMINE VENTAVIS AMPUL-NEB N PA Document  
MACITENTAN OPSUMIT TABLET N PA Document  
RIOCIGUAT ADEMPAS TABLET N PA Document  
SELEXIPAG UPTRAVI TAB DS PK N PA Document  
SELEXIPAG UPTRAVI TABLET N PA Document  
SILDENAFIL CITRATE REVATIO SUSP RECON N PA Document  
SILDENAFIL CITRATE VIAGRA TABLET N PA Document  
TADALAFIL ADCIRCA TABLET N PA Document  
TREPROSTINIL TYVASO AMPUL-NEB N PA Document  
TREPROSTINIL DIOLAMINE ORENITRAM ER TABLET ER N PA Document  
TREPROSTINIL/NEB ACCESSORIES TYVASO REFILL KIT AMPUL-NEB N PA Document  
TREPROSTINIL/NEBULIZER/ACCESOR TYVASO INSTITUTIONAL START KIT AMPUL-NEB N PA Document  
TREPROSTINIL/NEBULIZER/ACCESOR TYVASO STARTER KIT AMPUL-NEB N PA Document