Pulmonary Arterial Hypertension Oral and Inhaled Drugs
PDL Reference Documents
- Pulmonary Hypertension - Oct 07, 2021
- Pulmonary Hypertension Class Update - Sep 27, 2018
- Drugs for Pulmonary Arterial Hypertension - Mar 31, 2016
- Pulmonary Arterial Hypertension Class Update - Jul 31, 2014
- Abbreviated Class Review: Intraveneous/Subcutaneous Pulmonary Arterial Hypertension (PAH) Agents - Sep 27, 2012
- Class Scan: Pulmonary Arterial Hypertension Agents - Apr 26, 2012
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 | New Drug Evaluation |
---|---|---|---|---|---|
bosentan | BOSENTAN | TABLET | Y | ||
bosentan | TRACLEER | TABLET | Y | ||
sildenafil citrate | SILDENAFIL CITRATE | TABLET | Y | ||
sildenafil citrate | REVATIO | TABLET | Y | ||
ambrisentan | AMBRISENTAN | TABLET | N | PA Document | |
ambrisentan | LETAIRIS | TABLET | N | PA Document | |
bosentan | TRACLEER | TAB SUSP | 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 | LIQREV | ORAL SUSP | N | PA Document | |
sildenafil citrate | SILDENAFIL CITRATE | SUSP RECON | N | PA Document | |
sildenafil citrate | REVATIO | SUSP RECON | N | PA Document | |
sildenafil citrate | SILDENAFIL CITRATE | TABLET | N | PA Document | |
sildenafil citrate | VIAGRA | TABLET | N | PA Document | |
tadalafil | TADLIQ | ORAL SUSP | N | PA Document | |
tadalafil | ADCIRCA | TABLET | N | PA Document | |
tadalafil | ALYQ | TABLET | N | PA Document | |
tadalafil | TADALAFIL | TABLET | N | PA Document | |
treprostinil | TYVASO | AMPUL-NEB | N | PA Document | |
treprostinil | TYVASO DPI | CART INHAL | N | PA Document | |
treprostinil diolamine | ORENITRAM ER | TABLET ER | N | PA Document | |
treprostinil diolamine | ORENITRAM MONTH 1 TITRATION KT | TB ER DSPK | N | PA Document | |
treprostinil diolamine | ORENITRAM MONTH 2 TITRATION KT | TB ER DSPK | N | PA Document | |
treprostinil diolamine | ORENITRAM MONTH 3 TITRATION KT | TB ER DSPK | 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 |