Sildenafil injection (Revatio)

Evicore covers Revatio (sildenafil) IV injection only for the FDA‑approved indication of pulmonary arterial hypertension (WHO Group 1) to improve exercise capacity; requests that do not meet the criteria are non‑covered. Coverage requires PAH confirmed by right‑heart catheterization, documented inability to take an oral PDE5 inhibitor, prescription by or consultation with a pulmonologist or cardiologist, documentation of ongoing medical necessity for up to 12 months, and dosing of 2.5 mg or 10 mg IV bolus three times daily (or clinical justification for deviation).

"Revatio injection is indicated for the treatment of pulmonary arterial hypertension (PAH) (WHO Group 1) to improve exercise ability."

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