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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.
 

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

  • 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.

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 
  • oxybutynin (Ditropan®)
  • oxybutynin ER tabs (Ditropan XL®)
 
  • tolterodine (Detrol®)
  • trospium (Sanctura™)
  • tolterodine ER tabs (Detrol LA®)
  • darifenacin (Enablex®)
  • oxybutynin Gel (Gelnique™)
  • mirabegron (Myrbetriq™)
  • trospium ER (Sanctura XR™)
  • fesoterodine (Toviaz™)
  • solifenacin (VESIcare®)
 
  • oxybutynin patch (Oxytrol®)                                                       

*Tier-1 products are available without a prior authorization for all members.  Hyoscyamine is available without prior authorization and can be used as adjunctive therapy, but does not count as a Tier-1 trial.

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

Last Modified on Dec 21, 2020
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