CurrentCignaPolicy N/A

Erectile Dysfunction - Alprostadil Products Prior Authorization Policy

Prior authorization requirements for Caverject, Caverject Impulse, Edex (intracavernosal alprostadil) and MUSE (transurethral alprostadil) for treatment of erectile dysfunction and select post-prostatectomy uses under Cigna-administered benefit plans.

Policy Summary

PayerCigna

PolicyErectile Dysfunction - Alprostadil Products Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateNov 6, 2024

Key ActionObtain prior authorization for intracavernosal and transurethral alprostadil products; approvals are typically for 1 year and limited to specified indications.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4alprostadil formulations covered

1 yrtypical approval duration

≤6 mostart therapy window

Not coveredother uses

Coverage Criteria for Alprostadil Products

FDA-Approved Indication

Covered when ALL of the following are met:

Erectile Dysfunction (FDA-approved): Approval for treatment of erectile dysfunction (FDA-approved indication).Approve for 1 year

Post-Radical Prostatectomy (continuing therapy)

Covered when ALL of the following are met:

History of Radical Prostatectomy - continuing therapy: Patient was started on therapy post-operatively AND patient is currently continuing therapy with an alprostadil product.Approve for 1 year

Applicable products: Caverject, Caverject Impulse, Edex, MUSE.

Policy Summary

PayerCigna

PolicyErectile Dysfunction - Alprostadil Products Prior Authorization Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateNov 6, 2024

Key ActionObtain prior authorization for intracavernosal and transurethral alprostadil products; approvals are typically for 1 year and limited to specified indications.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Prophylaxis after Radical Prostatectomy (Early Penile Rehabilitation)

Covered when ALL of the following are met:

Early penile rehabilitation after radical prostatectomy: Patient is treatment-naïve AND therapy will be started within 6 months of surgery AND the medication is prescribed by or in consultation with a urologist.Approve for 1 year

Alprostadil products (including intracavernosal injections and the transurethral suppository) are considered experimental, investigational or unproven for any uses other than the FDA‑approved indication and the listed post‑radical prostatectomy uses. Criteria will be updated if new published data become available.

Any requests for alprostadil products for indications not specified in this policy — i.e., uses other than the FDA‑approved treatment of erectile dysfunction and the supportive post‑radical prostatectomy indications described here — are considered not medically necessary / not covered under this policy.

Drug Products and Coding

Covered drug products by brandmixedCovered

Caverject	alprostadil intracavernosal injection - Pfizer
Caverject Impulse	alprostadil intracavernosal injection - Pfizer (single-dose dual chamber)
Edex	alprostadil intracavernosal injection - Endo
MUSE	alprostadil urethral suppository - MEDA

Not covered routes/usesmixedNot Covered

Other routes

Alprostadil given by intravenous (IV) or other routes

Provider Actions and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for listed alprostadil products when requested for coverage. Prescriptions should include documentation of the indication, relevant clinical history, and duration of therapy requested. Some approvals require the medication to be prescribed by or in consultation with a specialist experienced in treating the condition (e.g., urologist for post‑prostatectomy or early penile rehabilitation).

Affected products: Caverject, Caverject Impulse, Edex, MUSE
Approvals are typically for 1 year
Specialty/consult requirement applies for certain indications (see policy criteria)

Step Therapy

No step therapy (fail-first) requirements are specified for alprostadil products in this policy.

Documentation Required

Prescriber Specialty / Consultation Requirement

For some indications (for example: prophylaxis/early penile rehabilitation after radical prostatectomy), the drug must be prescribed by or in consultation with a specialist (urologist). Documentation of the specialist consultation or prescriber specialty should be submitted with the prior authorization request.

Specialist example: urologist for post‑radical prostatectomy indications
Include consult notes or prescriber specialty on PA submission

Denial Risk

Not Covered Uses

Requests for alprostadil products for indications other than the FDA‑approved indication (erectile dysfunction) or the specified supportive‑evidence uses (post‑radical prostatectomy and prophylaxis/early penile rehabilitation) are considered not covered (experimental, investigational or unproven).

Not covered: any use outside the FDA‑approved indication and the listed supportive‑evidence uses
Policy will be updated if new published data become available

Background

Alprostadil (prostaglandin E1) is available as intracavernosal injections (Caverject, Caverject Impulse, Edex) and as a transurethral suppository system (MUSE) for treatment of erectile dysfunction. The injectable and urethral formulations deliver prostaglandin directly to the corpora cavernosa or urethra to promote cavernosal oxygenation and support erectile function. In addition to the FDA‑approved erectile dysfunction indication, alprostadil formulations have been studied and are covered in this policy for certain post‑radical prostatectomy uses: continuation of therapy when started post‑operatively, and early penile rehabilitation when initiated within 6 months of surgery and prescribed by or in consultation with a urologist. Approvals for covered indications are typically authorized for 1 year.

Definitions

MUSE (transurethral alprostadil)

DefinitionMUSE is a single-use, medicated transurethral system for delivery of alprostadil directly into the urethra.

AdministrationAdministered by inserting the applicator stem into the urethra after urination.

UseIndicated for treatment of erectile dysfunction due to neurogenic, vasculogenic, psychogenic, or mixed etiologies.

FormulationAvailable as a single-use urethral suppository system (medicated transurethral applicator).