Pulmonary Arterial Hypertension Oral and Inhaled Drugs

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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.

Alternate detailed view >

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria Carveout
‐ Bill FFS
New Drug Evaluation & Updates
bosentan TRACLEER TABLET Y   N  
bosentan BOSENTAN TABLET Y   N  
sildenafil citrate SILDENAFIL CITRATE TABLET Y Pharmacy PA N  
sildenafil citrate REVATIO TABLET Y Pharmacy PA N  
tadalafil ADCIRCA TABLET Y Pharmacy PA N  
tadalafil ALYQ TABLET Y Pharmacy PA N  
tadalafil TADALAFIL TABLET Y Pharmacy PA N  
ambrisentan AMBRISENTAN TABLET N Pharmacy PA N  
ambrisentan LETAIRIS TABLET N Pharmacy PA N  
bosentan BOSENTAN TAB SUSP N Pharmacy PA N  
bosentan TRACLEER TAB SUSP N Pharmacy PA N  
macitentan OPSUMIT TABLET N Pharmacy PA N  
riociguat ADEMPAS TABLET N Pharmacy PA N  
selexipag UPTRAVI TAB DS PK N Pharmacy PA N  
selexipag UPTRAVI TABLET 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  
sildenafil citrate SILDENAFIL CITRATE TABLET N Pharmacy PA N  
tadalafil TADLIQ ORAL SUSP N Pharmacy PA N  
treprostinil TYVASO AMPUL-NEB N Pharmacy PA N  
treprostinil TYVASO DPI CART INHAL N Pharmacy PA N  
treprostinil diolamine ORENITRAM ER TABLET ER N Pharmacy PA N  
treprostinil diolamine ORENITRAM MONTH 2 TITRATION KT TB ER DSPK N Pharmacy PA N  
treprostinil diolamine ORENITRAM MONTH 1 TITRATION KT TB ER DSPK N Pharmacy PA N  
treprostinil diolamine ORENITRAM MONTH 3 TITRATION KT TB ER DSPK N Pharmacy PA N  
treprostinil sodium YUTREPIA CAP W/DEV N Pharmacy PA N  
treprostinil/neb accessories TYVASO REFILL KIT AMPUL-NEB N Pharmacy PA N  
treprostinil/nebulizer/accesor TYVASO INSTITUTIONAL START KIT AMPUL-NEB N Pharmacy PA N  
treprostinil/nebulizer/accesor TYVASO STARTER KIT AMPUL-NEB N Pharmacy PA N