Genitourinary System 2016 Archive

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 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.

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.