Sildenafil (Revatio, Liqrev)
Clinical policy governing medical necessity criteria, dosing limits, prior authorization and continuation criteria for sildenafil (Revatio, Liqrev) for treatment of pulmonary arterial hypertension (PAH) across Commercial, HIM, and Medicaid lines of business.
RT4: updated PAH criteria to include newly FDA approved pediatric age expansion and updated adult PAH dosing per revised PI; updated HCPCS codes and Appendix B (03.08.23).
1Q 2025 annual review clarified criteria also applies to brand Revatio and Liqrev and updated Appendix B per Clinical Pharmacology.
Coverage Summary
Background: Sildenafil (Revatio, Liqrev) is a phosphodiesterase-5 inhibitor indicated for treatment of pulmonary arterial hypertension (PAH; WHO Group 1) in adults and in pediatric patients ages 1–17 years to improve exercise ability and, in younger pediatric patients, pulmonary hemodynamics; dosing varies by age, weight and formulation.