Benign Prostatic Hyperplasia (BPH) Agents Prior Authorization
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Defines prior authorization criteria, covered strengths, and exceptions for BPH medications for Georgia Medicaid Fee-for-Service members and guidance for prescribers and pharmacies.
No material clinical or coverage changes in this revision.
Covered Agents and Criteria
Cardura XL
Covered when ALL of the following are met
Cialis 5 mg / Tadalafil 2.5 mg
Covered when ALL of the following are met
Dutasteride/Tamsulosin generic
Covered when ALL of the following are met
Silodosin generic
Covered when ALL of the following are met
Tezruly (terazosin oral solution)
Covered when ALL of the following are met
Requests for Cialis/tadalafil 10 mg and 20 mg will not be covered. These strengths are explicitly excluded from coverage and prior authorization requests for these strengths will be denied.
Prescriber and Pharmacy Requirements
Prior authorization required for tadalafil 2.5 mg / Cialis 5 mg
Prior authorization is required for tadalafil 2.5 mg (generic) and Cialis 5 mg for BPH; approvals are limited to adults (≥18) with a BPH diagnosis and no current or past history of erectile dysfunction within the past 5 years. PA may be approvable for members <18 only for pulmonary arterial hypertension when prescribed by or in consultation with a cardiologist or pulmonologist.
- Only generic tadalafil 2.5 mg and brand Cialis 5 mg are covered with prior authorization.
- Member must be ≥18 with a diagnosis of BPH and no ED history within the past 5 years for BPH approvals.
- PA exception: members <18 may be approvable for PAH with appropriate specialist involvement.
Step therapy and prior‑trial requirements
Step therapy requires either prior trial and failure of an alpha blocker given in combination with a 5-alpha reductase inhibitor, or documented allergies/contraindications/drug interactions or intolerable side effects to all listed alpha blockers and 5-alpha reductase inhibitors; silodosin specifically requires inadequate response or intolerance to at least two preferred alpha blockers.
- EITHER: trial and inadequate therapeutic benefit from an alpha blocker (alfuzosin, doxazosin, silodosin, tamsulosin, terazosin) combined with finasteride or dutasteride.
- OR: allergies/contraindications/drug-drug interactions or intolerable side effects to alfuzosin, doxazosin, silodosin, tamsulosin, terazosin, finasteride and dutasteride.
- For silodosin: inadequate response, allergy/contraindication, drug interaction, or intolerable side effects to at least two preferred alpha blockers (alfuzosin, doxazosin, tamsulosin, terazosin).
Letter of medical necessity required for non‑preferred products
A written letter of medical necessity must be submitted when requesting Cardura XL, dutasteride/tamsulosin combination, or Tezruly to explain why the preferred alternatives are not appropriate for the member.
- Cardura XL: letter must state why preferred products (doxazosin and either alfuzosin, tamsulosin or terazosin) are not appropriate.
- Dutasteride/tamsulosin: letter must state why separate preferred products (dutasteride and tamsulosin) are not appropriate.
- Tezruly: letter required if member can take solid oral formulations; otherwise document inability to swallow solids as the reason for approvability.
10 mg and 20 mg tadalafil/Cialis strengths are not covered
Requests for tadalafil/Cialis strengths 10 mg and 20 mg will be denied because those strengths are not covered under this policy.
- Only generic tadalafil 2.5 mg and brand Cialis 5 mg are covered with prior authorization; 10 mg and 20 mg strengths are excluded.
Key Definitions and Exclusions
Clinical Background
Benign prostatic hyperplasia (BPH) is managed medically with agents such as alpha blockers and 5-alpha reductase inhibitors; combination therapy is frequently used for symptom control and prostate size reduction. This policy establishes prior authorization requirements and specifies covered strengths for tadalafil/Cialis in Georgia Medicaid Fee-for-Service.
For BPH, only generic tadalafil 2.5 mg and brand Cialis 5 mg are eligible for coverage with prior authorization. Cialis/tadalafil 10 mg and 20 mg strengths are not covered and will be denied if requested.
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