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

• 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 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

• 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.