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NYS Medicaid Pharmacy Prior Authorization Programs

Providers • CDRP • PDP Classes subject to CDRP • Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH

Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH

Prior Authorization Call Line: 1-877-309-9493

Prior Authorization Fax Line: 1-800-268-2990

Prior authorization for sildenafil citrate (Revatio®) and tadalafil (Adcirca®) has been implemented to reinforce appropriate use and ensure utilization consistent with approved indications. Only prescribers, not their authorized agents, can initiate the prior authorization process for Revatio® and Adcirca®. An authorized agent is an employee of the prescribing practitioner and has access to the patient's medical records (i.e. nurse, medical assistant).

The following is general information about Revatio® and Adcirca® prior authorization requirements:

  • All prescriptions for Adcirca® must be prior authorized effective January 12, 2010.
  • All prescriptions for Revatio® must be prior authorized effective October 18, 2006.
  • Prescribers are required to respond to a series of questions that identify the prescriber, the patient and the reason for prescribing this drug.
  • Please be prepared to fax clinical documentation upon request.
  • Prescriptions can be written for a 30-day supply with up to 5 refills.
  • The CDRP Phosphodiesterase type-5 (PDE-5) Inhibitors for PAH Prescriber Worksheet and Instructions provides step-by-step assistance in completing the prior authorization process.