Genitourinary System

Benign Prostatic Hyperplasia (BPH) Medications
Tier 1 products are covered with no authorization necessary. Tier 2 Prior Authorization criteria FDA approved diagnosis. Recent 4-week trial of at least two Tier 1 medications from different pharmacological classes within the last 90 days. Documented adverse effect, drug interaction, or contraindication to all available Tier 1 products. Tier 3 Prior Authorization Criteria FDA approved diagnosis of BPH. Trial of at least two Tier 1 medications from different pharmacological classes. A 4-week trial of each Tier 2 medication within the past 5 months. Documented adverse effect, drug interaction, or contraindication, or lack of efficacy to all available Tier 1 and Tier 2 products. Authorizations for tadalafil (Cialis®) will be granted for 5mg tablets only.

Benign Prostatic Hyperplasia (BPH) Medications

Tier 1 products are covered with no authorization necessary.

Tier 2 Prior Authorization criteria

FDA approved diagnosis.
Recent 4-week trial of at least two Tier 1 medications from different pharmacological classes within the last 90 days.
Documented adverse effect, drug interaction, or contraindication to all available Tier 1 products.

Tier 3 Prior Authorization Criteria

FDA approved diagnosis of BPH.
Trial of at least two Tier 1 medications from different pharmacological classes.
A 4-week trial of each Tier 2 medication within the past 5 months.
Documented adverse effect, drug interaction, or contraindication, or lack of efficacy to all available Tier 1 and Tier 2 products.
Authorizations for tadalafil (Cialis®) will be granted for 5mg tablets only.

Tier 1	Tier 2	Tier 3
alfuzosin (Uroxatrol®) doxazosin (Cardura®) finasteride (Proscar®) tamsulosin (Flomax®) terazosin (Hytrin®)	doxazosin (Cardura XL®) dutasteride (Avodart®) dutasteride/tamsulosin (Jalyn®) silodosin (Rapaflo®)	tadalafil (Cialis®)

Bladder Control Drugs
Tier 1 products are covered with no authorization necessary. Tier 2 authorization criteria Trial of two Tier 1 medication that yielded inadequate clinical response or adverse effects, or A unique FDA approved indication not covered by Tier 1 products. Tier 3 Authorization Criteria: Trial of all Tier 2 medications that yielded inadequate clinical response or adverse effects, or A unique FDA approved indication not covered by lower Tiered products.

Bladder Control Drugs

Tier 1 products are covered with no authorization necessary.

Tier 2 authorization criteria

Trial of two Tier 1 medication that yielded inadequate clinical response or adverse effects, or
A unique FDA approved indication not covered by Tier 1 products.

Tier 3 Authorization Criteria:

Trial of all Tier 2 medications that yielded inadequate clinical response or adverse effects, or
A unique FDA approved indication not covered by lower Tiered products.

Tier 1	Tier 2	Tier 3
oxybutynin (Ditropan®) trospium ER (Sanctura XR™)	oxybutynin ER tabs (Ditropan XL®)	tolterodine (Detrol®) tolterodine ER tabs (Detrol LA®) darifenacin (Enablex®) oxybutynin Gel (Gelnique™) mirabegron (Myrbetriq™) oxybutynin patch (Oxytrol®) trospium (Sanctura™) fesoterodine (Toviaz™) flavoxate (Urispas®) solifenacin (VESIcare®)
*hyoscyamine can be used as adjuvant therapy only. By itself, it will not count as a tier 1 trial.

Miscellaneous Bladder Agents (Urelle®, Prosed DS®, Darpaz®)
Recent 14 day trials within the past 30-60 days of: Urogesic Blue®, and Utira-C®, Utrona-C®, or Darcalma®

Miscellaneous Bladder Agents (Urelle®, Prosed DS®, Darpaz®)

Recent 14 day trials within the past 30-60 days of:

If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.