CurrentNeighborhood Health Plan of Rhode IslandPolicy 865-C

Tadalafil chewable and low‑dose tablets (Chewtadzy, Cialis) for BPH and ED — Prior authorization with quantity limit

Prior authorization with quantity limits for Chewtadzy 5 mg (tadalafil chewable) and Cialis 2.5 mg and 5 mg when prescribed for daily use to treat benign prostatic hyperplasia (BPH) and/or erectile dysfunction (ED) in adult males.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyTadalafil chewable and low‑dose tablets (Chewtadzy, Cialis) for BPH and ED — Prior authorization with quantity limit

Policy CodePolicy 865-C

Change TypeNo material change

Effective Date

Next Review Date

Key ActionObtain prior authorization with specified quantity limits and document daily use for symptomatic BPH and evidence of a positive or maintained clinical response to approve coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

36Duration of approval (DOA)

30Quantity limit (30-day fill)

90Quantity limit (90-day fill)

Authorization Criteria

Authorization criteria for Benign Prostatic Hyperplasia (BPH)

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ALL of the following

The requested drug (Chewtadzy 5 mg or Cialis 2.5 mg or 5 mg) is being prescribed for daily use for symptomatic benign prostatic hyperplasia (BPH).
Examples of signs and symptoms include incomplete emptying, weak stream, straining, urinary frequency, intermittency, or urgency.
The patient has achieved or maintained a positive clinical response to the requested drug.

What Providers Must Do

Prior Authorization

Prior authorization required

Initial prior authorization is required for Chewtadzy 5 mg and Cialis 2.5 mg and 5 mg when used for daily treatment of symptomatic benign prostatic hyperplasia (BPH); approvals are subject to the stated quantity limits and are only granted when daily use for symptomatic BPH is documented and the patient has achieved or maintained a positive clinical response.

Chewtadzy 5 mg
Cialis 2.5 mg
Cialis 5 mg

Documentation Required

Documentation of symptoms and response

Provider must document the patient’s signs and symptoms of BPH and evidence of a positive clinical response or maintenance of response to the requested drug when prescribing Chewtadzy or Cialis for daily use.

Incomplete emptying
Weak stream
Straining
Urinary frequency
Intermittency
Urgency

Clinical Background

Tadalafil (brand examples Chewtadzy and Cialis) is indicated for the treatment of erectile dysfunction (ED), benign prostatic hyperplasia (BPH), and the combination of ED/BPH in adult males. When tadalafil is used in combination with finasteride to initiate BPH treatment, use is recommended for up to 26 weeks because the incremental benefit of tadalafil decreases from 4 weeks until 26 weeks, and the incremental benefit beyond 26 weeks is unknown.

Policy Scope and References

This policy establishes prior authorization with quantity limits for Chewtadzy 5 mg (tadalafil chewable) and Cialis 2.5 mg and 5 mg when prescribed for daily use to treat benign prostatic hyperplasia (BPH) and/or erectile dysfunction (ED) in adult males; initial prior authorization is required and quantity limits apply as specified.

Chewtadzy [package insert]. ANI Pharmaceuticals, Inc. June 2024.

Cialis [package insert]. Eli Lilly and Company; April 2023.

Lexicomp Online. Accessed March 27, 2024.

Micromedex (electronic version). Cited March 27, 2024.

AUA Guideline amendment 2023: Management of lower urinary tract symptoms attributed to BPH.