PAH AGENTS: ORAL AND INHALED | Vendor Drug Program

Brand Name/Generic Name	NDC/Manufacturer	FFS Clinical Prior Auth Required	PDL Prior Auth Required	Programs
ADCIRCA 20 MG TABLET tadalafil	66302046760 ELI LILLY & CO.	Yes	No	Medicaid CHIP CSHCN
LETAIRIS 10 MG TABLET ambrisentan	61958080201 GILEAD SCIENCES	Yes	No	Medicaid CHIP CSHCN
LETAIRIS 10 MG TABLET ambrisentan	61958080205 GILEAD SCIENCES	Yes	No	Medicaid CHIP CSHCN
LETAIRIS 5 MG TABLET ambrisentan	61958080101 GILEAD SCIENCES	Yes	No	Medicaid CHIP CSHCN
LETAIRIS 5 MG TABLET ambrisentan	61958080105 GILEAD SCIENCES	Yes	No	Medicaid CHIP CSHCN
REVATIO 10 MG/ML ORAL SUSP sildenafil citrate	00069033621 PFIZER/VIATRIS	Yes	No	Medicaid CHIP CSHCN
REVATIO 20 MG TABLET sildenafil citrate	00069419068 PFIZER/VIATRIS	Yes	No	Medicaid CHIP CSHCN
TRACLEER 125 MG TABLET bosentan	66215010206 ACTELION PHARMA	Yes	No	Medicaid CHIP CSHCN
TRACLEER 62.5 MG TABLET bosentan	66215010106 ACTELION PHARMA	Yes	No	Medicaid CHIP CSHCN
ADEMPAS 0.5 MG TABLET riociguat	50419025001 BAYER,PHARM DIV	Yes	Yes	Medicaid CHIP CSHCN