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®)
  • dutasteride (Avodart®)
  • finasteride (Proscar®)
  • tamsulosin (Flomax®)
  • terazosin (Hytrin®)
 
  • doxazosin (Cardura XL®)
  • dutasteride/tamsulosin (Jalyn®)
  • silodosin (Rapaflo®)
 
  • tadalafil (Cialis®)
 

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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.

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; AND 
  • 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

Special PA 
  • 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.

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