Genitourinary System 2017 Archive

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.

desmopressin acetate (Noctiva™) Approval Criteria:

• An FDA approved diagnosis of nocturia due to nocturnal polyuria in adults 50 years of age and older; 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; OR
• 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. 

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®)
• fesoterodine (Toviaz™)

• tolterodine (Detrol®)
• trospium (Sanctura™)

• tolterodine ER tabs (Detrol LA®)
• darifenacin (Enablex®)
• oxybutynin Gel (Gelnique™)
• mirabegron (Myrbetriq™)
• trospium ER (Sanctura XR™)
• solifenacin (VESIcare®)

• desmopressin acetate nasal spray (Noctiva™)+
• 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.