Rxedo cialis prior authorization form

SELF ADMINISTRATION - ORAL

Indications for Prior Authorization:

• Cialis® for daily use: Benign prostatic hyperplasia (BPH)

Patients must meet the following criteria for the indication(s) above:

• Cialis® for daily use:
  • Diagnosis of benign prostatic hyperplasia (BPH) and treatment failure on two or more of the following FDA-approved drug classes for BPH:
    • A 5 alpha-reductase inhibitor: Finasteride (Proscar®), dutasteride (Avodart®), AND
    • An alpha-blocker: terazosin (Hytrin), doxazosin (Cardura®), tamsulosin (Flomax®), alfuzosin (Uroxatral®), and silodosin (Rapaflo®)

    The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P&T Committee:

    • Peripheral vasoconstriction
    • Patients taking nitrates
    • All non-FDA approved uses not listed in the approved indications

    Dosing:

    • Cialis®: 5 mg daily for BPH
      • For male ED (erectile dysfunction), Cialis® is limited to 8 tablets per 30 day supply at a retail pharmacy or 24 tablets per 90 day supply at a mail order pharmacy

      Approval:

      • One year

      Last review date: August 10, 2020