CurrentCignaPolicy N/A

Sildenafil (Revatio) prior authorization for pulmonary arterial hypertension

Prior authorization form and requirements for prescribing sildenafil (Revatio) for pulmonary arterial hypertension (WHO Group 1) for Cigna members; intended for prescribers (including cardiology/pulmonology) and dispensing facilities.

Policy Summary

PayerCigna

PolicySildenafil (Revatio) prior authorization for pulmonary arterial hypertension

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with indication, ICD-10, dose/frequency/duration, and attach right heart catheterization documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

Accredonationally preferred specialty pharmacy identifier

WHO Group 1diagnosis checkbox explicitly listed for PAH

Coverage criteria and required information

Information required for prior authorization

Authorization will be processed when the request includes the following required information and supporting documentation:

Diagnosis and confirmation: Diagnosis of WHO Group 1 pulmonary arterial hypertension (PAH) confirmed by right heart catheterization

Form asks whether diagnosis was confirmed by right heart catheterization and requests attachment of the right heart catheterization report/medical documentation

Prescriber information and specialty: Indicate whether medication is prescribed by or in consultation with a cardiologist or pulmonologist; provide prescriber identifiers (DEA, NPI or TIN) and prescriber signature/date

Form includes a checkbox for prescriber specialty and requires attestation/signature

Current therapy and oral medication status: State whether patient is established on oral sildenafil/Revatio and whether patient is temporarily unable to take oral medication

Policy Summary

PayerCigna

PolicySildenafil (Revatio) prior authorization for pulmonary arterial hypertension

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization with indication, ICD-10, dose/frequency/duration, and attach right heart catheterization documentation.

SourceLink

On This Page

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The form itself does not list additional coverage criteria beyond the fields it requests; it functions as a prior authorization questionnaire to collect the information needed to evaluate a request for sildenafil (Revatio) for pulmonary arterial hypertension (WHO Group 1). Key data requested on the form include confirmation of WHO Group 1 PAH by right heart catheterization, whether the prescriber is a cardiologist or pulmonologist, current therapy status with oral sildenafil/Revatio (and whether the patient is temporarily unable to take oral medication), concurrent use with a guanylate cyclase stimulator, intolerance to sildenafil injection, and space for additional pertinent information and attestation.

What the prescriber or facility must do

Prior Authorization

Prior Authorization Required

Prior authorization is required for sildenafil (Revatio). Submit a completed prior authorization request that includes the indication, relevant ICD-10 code(s), dose, frequency, duration of therapy, and the J-code if an injectable formulation is requested.

Indication and ICD-10 code(s)
Dose, frequency, and duration of therapy
J-code if requesting an injectable formulation
Specify product: Revatio or Sildenafil

Note

Assessment of Current Therapy

Provide documentation of current therapy status. Indicate whether the patient is established on oral sildenafil/Revatio. If the patient is established on oral therapy but is temporarily unable to take oral medication, note the reason and expected duration of inability to take oral medications.

Is the patient established on oral sildenafil/Revatio? (Yes/No)
If Yes, is there a temporary inability to take oral medication? (Yes/No) — include reason and expected duration

Documentation Required

Required Clinical Documentation

Attach required clinical documentation. Right heart catheterization confirmation demonstrating WHO Group 1 PAH diagnosis must be provided when requested. Include supporting records such as chart notes, laboratory tests, and any relevant claims records. Requests lacking required clinical documentation may be denied.

Right heart catheterization report confirming WHO Group 1 PAH (attach)
Supporting clinical records (chart notes, labs, imaging, claims) as applicable
Documentation must be attached to the prior authorization request

Documentation Required

Administrative Documentation

Provide complete administrative and facility/prescriber identifiers to enable processing and dispensing/administration. Incomplete administrative information may delay review or result in denial.

Patient: Cigna ID, full name, date of birth, street address, phone
Prescriber: name, specialty, DEA / NPI / TIN, office contact, phone, fax, office address
Facility (if dispensing/administration): facility name, state, tax ID
For injectable products, include billing information and any applicable J-code

Denial Risk

Documentation-Dependent Denial Risk

Requests may be denied if required medical documentation (for example, the right heart catheterization report confirming WHO Group 1 PAH) or required administrative identifiers are not attached. Ensure all requested attachments are submitted with the prior authorization to avoid denial.

Missing right heart catheterization report may result in denial
Missing patient or prescriber identifiers (Cigna ID, DOB, DEA/NPI/TIN) may result in denial
Attach all supporting clinical records and facility/tax ID for injectable administration

Policy background and scope

This prior authorization form is used to support coverage decisions for sildenafil (Revatio) when prescribed for WHO Group 1 pulmonary arterial hypertension (PAH). The form requires confirmation that the diagnosis was confirmed by right heart catheterization, asks whether the prescriber is a cardiologist or pulmonologist, and documents current therapy with oral sildenafil/Revatio and any temporary inability to take oral medication. The form also instructs providers to attach medical documentation (for example, chart notes, laboratory tests, or claims records) and warns that requests may be denied if those documents are not supplied; routine processing time is 5 business days for prescription drug coverage requests.

OpenPayer

Sildenafil (Revatio) prior authorization for pulmonary arterial hypertension

Coverage criteria and required information

Billing and coding information to provide

What the prescriber or facility must do

Policy background and scope

Key definitions