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.
  

• alfuzosin (Uroxatrol®)
• doxazosin (Cardura®)
• finasteride (Proscar®)
• tamsulosin (Flomax®)
• terazosin (Hytrin®)

• doxazosin (Cardura XL®)
• dutasteride (Avodart®)
• dutasteride/tamsulosin (Jalyn®)
• silodosin (Rapaflo®)

• tadalafil (Cialis®)

Tier 1 products are covered with no authorization necessary.

Tier 2 Prior 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 Prior 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.

• 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®)

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

• Urogesic Blue®, and
• Utira-C®, Utrona-C®, or Darcalma®