NYRx, the Medicaid Pharmacy Program

Providers • CDRP • Drugs • sildenafil citrate (Revatio®)

sildenafil citrate (Revatio®)

Prior Authorization Call Line: 1-877-309-9493
Prior Authorization Fax Line: 1-800-268-2990

Prior authorization for sildenafil citrate (Revatio®) 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®.

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

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 sildenafil citrate (Revatio�) Prescriber Fax Form and Instructions provides step-by-step assistance in completing the prior authorization process.