Genitourinary System
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 |
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Tier 1 products are covered with no authorization necessary.
Tier 2 authorization criteria
- Trials of all 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:
- Trials 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.
- For use of Myrbetriq® (mirabegron) in combination with VESIcare® (solifenacin), the member must have failed monotherapy with either mirabegron or solifenacin (minimum 4-week trial) defined by continued symptoms of urge urinary incontinence, urgency, and urinary frequency. Current tier structure rules will also apply.
desmopressin acetate sublingual tablets (Nocdurna®) Approval Criteria:
- An FDA approved diagnosis of nocturia due to nocturnal polyuria in adults who awaken at least 2 times per night to void; AND
- All other causes of nocturia have been ruled out or adequately treated [e.g., benign prostatic hyperplasia (BPH), overactive bladder (OAB), obstructive sleep apnea (OSA)]; AND
- The prescriber must confirm the member has a 6-month history of at least two nocturic episodes per night; AND
- Member has failed behavior modifications including reducing caffeine intake, alcohol intake, and nighttime fluid intake; AND
- Member must have failed a trial of DDAVP® (desmopressin acetate tablets) or have a patient-specific, clinically significant reason why the standard tablet formulation cannot be used; AND
- The prescriber must be willing to measure serum sodium levels prior to starting treatment and document levels are acceptable; AND
- The prescriber must agree to monitor serum sodium levels within the first week and approximately one month after starting treatment, and periodically during treatment; AND
- The prescriber must confirm the member is not taking loop diuretics; AND
- The prescriber must confirm the member does not have renal impairment with an estimated glomerular filtration rate (eGFR) <50mL/min/1.73m2; AND
- Initial approvals will be for the duration of 3 months; for continued authorization the prescriber must provide the following:
- Documentation that serum sodium levels are acceptable to the prescriber; AND
- Documentation that the member is responding to treatment; AND
- Approvals will be limited to the 27.7mcg dose for female members; AND
- A quantity limit of 30 tablets per 30 days will apply.
desmopressin acetate (Noctiva™) Approval Criteria:
- An FDA approved diagnosis of nocturia due to nocturnal polyuria in adults; AND
- All other causes of nocturia have been ruled out or adequately treated [e.g., benign prostatic hyperplasia (BPH), overactive bladder (OAB), obstructive sleep apnea (OSA)]; AND
- The prescriber must confirm the member has a 6-month history of at least two nocturic episodes per night; AND
- Member has failed behavior modifications including reducing caffeine intake, alcohol intake, and nighttime fluid intake; AND
- Member must have failed a trial of DDAVP® (desmopressin) tablets or have a patient-specific, clinically significant reason why the tablet formulation cannot be used; AND
- The prescriber must be willing to measure serum sodium levels within seven days of anticipated start of treatment and document levels are acceptable; AND
- The prescriber must agree to monitor serum sodium levels within one month of starting treatment or increasing the dose; AND
- The prescriber must confirm the member is not taking any of the following:
- Other medications via the nasal route; OR
- Loop diuretics; AND
- The prescriber must confirm the member does not have renal impairment with estimated glomerular filtration rate (eGFR) below 50mL/min/1.73m2; AND
- Initial approvals will be for the duration of 3 months, and for continued authorization the prescriber must provide the following:
- Documentation that serum sodium levels are acceptable to the prescriber; AND
- Documentation that the member is responding to treatment; AND
- A quantity limit of one bottle (3.8g) per 30 days will apply.
- An FDA approved indication of overactive bladder (OAB) with symptoms of urge urinary incontinence, urgency, and urinary frequency; and
- Member must be 18 years of age or older; and
- A patient-specific, clinically significant reason why all lower tiered medications are not appropriate for the member must be provided; and
- A quantity limit of 30 tablets per 30 days will apply.
Oxytrol (oxybutynin 3.9mg/day patch) Special PA Tier approval criteria:
- An FDA approved diagnosis of overactive bladder; AND
- A patient-specific, clinically significant reason why all lower tiered medications are not appropriate for the member; AND
- A quantity limit of 8 patches every 30 days will apply.
Tier 1 | Tier 2 | Tier 3 | Special PA |
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ER = extended-release; PA = prior authorization; SL = sublingual; susp = suspension Tier structure based on supplemental rebate participation and/or National Average Drug Acquisition Costs (NADAC), Wholesale Acquisition Costs (WAC), or State Maximum Allowable Costs (SMAC). ΔUnique criteria specific to use of Myrbetriq® (mirabegron) in combination with VESIcare® (solifenacin) applies. αAn age restriction of 2 to 10 years of age will apply for VESIcare LS™. Members older than 10 years of age will require a patient-specific, clinically significant reason why the oral tablet formulation cannot be used. βThe Myrbetriq® granule formulation is covered for members 3 years of age or older weighing <35kg. Members weighing ≥35kg will require a patient-specific, clinically significant reason why the granule formulation is needed in place of the regular tablet formulation. Current Tier-3 criteria applies. |
If you have questions please call the Pharmacy Help Desk at (800) 522-0114 option 4 or (405) 522-6205 option 4.