Pulmonary Arterial Hypertension Oral and Inhaled Drugs
PDL Reference Documents
Drug Use Review Documents
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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| bosentan | BOSENTAN | TABLET | Y | N | ||
| sildenafil citrate | SILDENAFIL CITRATE | TABLET | Y | Pharmacy PA | N | |
| tadalafil | ALYQ | TABLET | Y | Pharmacy PA | N | |
| ambrisentan | LETAIRIS | TABLET | N | Pharmacy PA | N | |
| macitentan | OPSUMIT | TABLET | N | Pharmacy PA | N | |
| selexipag | UPTRAVI | TAB DS PK | N | Pharmacy PA | N | |
| sildenafil citrate | REVATIO | SUSP RECON | N | Pharmacy PA | N | |
| sildenafil citrate | SILDENAFIL CITRATE | SUSP RECON | N | Pharmacy PA | N | |
| sildenafil citrate | VIAGRA | TABLET | N | Pharmacy PA | N | |
| treprostinil | TYVASO | AMPUL-NEB | N | Pharmacy PA | N | |
| treprostinil | TYVASO DPI | CART INHAL | N | Pharmacy PA | N | |
| treprostinil diolamine | ORENITRAM MONTH 1 TITRATION KT | TB ER DSPK | N | Pharmacy PA | N | |
| treprostinil diolamine | ORENITRAM MONTH 2 TITRATION KT | TB ER DSPK | N | Pharmacy PA | N | |
| treprostinil/neb accessories | TYVASO REFILL KIT | AMPUL-NEB | N | Pharmacy PA | N | |
| treprostinil/nebulizer/accesor | TYVASO STARTER KIT | AMPUL-NEB | N | Pharmacy PA | N |