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Drug Category: Men’s Health

Medication Class/Individual Agents: Alpha-1 Blockers, 5-Alpha-Reductase Inhibitors, & Phosphodiesterase Inhibitors

I. Prior-Authorization Requirements

 Benign Prostatic Hyperplasia (BPH) Agents – 5-Alpha-Reductase Inhibitors

Clinical Notes

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

dutasteride Avodart PA  
finasteride Proscar PA  

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

 

FDA-approved indications:

  • Hypertension: doxazosin, prazosin, terazosin
  • BPH: alfuzosin, doxazosin, dutasteride, finasteride, silodosin, tadalafil, tamsulosin, terazosin

Dose and administration:

  • Doxazosin, prazosin, and terazosin: take first dose and subsequent first increased dose at bedtime to minimize lightheadedness and syncope.
  • Titrate to therapeutic maintenance doses to minimize dizziness and orthostatic hypotension.
  • If therapy is discontinued or interrupted for two or more days, reinstitute therapy cautiously.
 

 Benign Prostatic Hyperplasia (BPH) Agents – Alpha-1 Blockers

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

alfuzosin extended-release Uroxatral # test  
doxazosin extended-release Cardura XL PA  
doxazosin immediate-release Cardura # test  
prazosin Minipress # test  
silodosin Rapaflo BP PA  
tamsulosin Flomax # test  
terazosin test  

 Benign Prostatic Hyperplasia (BPH) Agents – Combination Products

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

dutasteride / tamsulosin Jalyn PA  

 Benign Prostatic Hyperplasia (BPH) Agents – Phosphodiesterase Inhibitors

Drug Details

Drug Generic Name

Drug Brand Name

PA
Status

tadalafil-Cialis Cialis PA  
Table Footnotes
# This designates a brand-name drug with FDA “A”-rated generic equivalents. Prior authorization is required for the brand, unless a particular form of that drug (for example, tablet, capsule, or liquid) does not have an FDA “A”-rated generic equivalent.
 
BP Brand Preferred over generic equivalents. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing the non-preferred drug generic equivalent.
 

II. Therapeutic Uses

FDA-approved, for example:

  • BPH
  • status post-transurethral resection of the prostate (TURP) with persistent urinary symptoms
  • hypertension (doxazosin immediate-release, prazosin, and terazosin only)

Note: The above list may not include all FDA-approved indications.

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III.  Evaluation Criteria for Approval

Please note: In the case where the prior authorization (PA) status column indicates PA, both the brand and generic (if available) require PA. Typically, the generic is preferred when available unless the brand-name drug appears on the MassHealth Brand Name Preferred Over Generic Drug List. In general, when requesting the non-preferred version, whether the brand or generic, the prescriber must provide medical records documenting an inadequate response or adverse reaction to the preferred version, in addition to satisfying the criteria for the drug itself.

  • All PA requests must include clinical diagnosis, drug name, dose, and frequency.
  • A preferred drug may be designated for this therapeutic class. In general, MassHealth requires a trial of the preferred drug or clinical rationale for prescribing a non-preferred drug within a therapeutic class. Additional information about these agents, including PA requirements and preferred products, can be found within the MassHealth Drug List at www.mass.gov/druglist.
  • For recertification requests, approval may require submission of additional documentation including, but not limited to, documentation of: some or all criteria for the original approval; response to therapy; clinical rationale for continuation of use; status of member’s condition; appropriate diagnosis; appropriate age; appropriate dose, frequency, and duration of use for requested medication; complete treatment plan; current laboratory values; and member’s current weight.
  • Additional criteria may apply, depending upon requested medication (see below).

   

Cardura XL

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • medical records documenting an adverse reaction or inadequate response to doxazosin immediate-release; and
    • medical records documenting an adverse reaction, inadequate response, or contraindication to tamsulosin.

 

dutasteride and finasteride

  • Documentation of the following is required:  
    • appropriate diagnosis; and
    • member is ≥ 18 years of age.

SmartPA: Claims for dutasteride or finasteride will usually process at the pharmacy without a PA request if the member is ≥ 18 years of age and has a history of MassHealth medical claims for BPH or status post TURP.

 

dutasteride/tamsulosin

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • adverse reaction, inadequate response (defined as ≥ 90 days of therapy), or contraindication to finasteride; and
    • adverse reaction, inadequate response, or contraindication to alfuzosin, doxazosin, tamsulosin, or terazosin; or
    • an enlarged prostate.

SmartPA: Claims for dutasteride/tamsulosin will usually process at the pharmacy without a PA request if the member is ≥ 18 years of age, has a history of MassHealth medical claims for BPH or status post TURP, has a history of paid MassHealth pharmacy claims for alfuzosin, doxazosin, terazosin, or tamsulosin, and has a history of paid MassHealth pharmacy claims for ≥ 90 days of therapy with finasteride.

      

silodosin

  • Documentation of the following is required:
    • appropriate diagnosis; and
    • member is ≥ 18 years of age; and
    • adverse reaction, inadequate response, or contraindication to tamsulosin; and
    • adverse reaction, inadequate response, or contraindication to alfuzosin; and
    • quantity requested is ≤ 30 units/month.

 

SmartPA: Claims for silodosin at a quantity of ≤ 30 units/month will usually process at the pharmacy without a PA request if the member is ≥ 18 years of age, has a history of MassHealth medical claims for BPH or status post TURP, and has a history of paid MassHealth pharmacy claims for alfuzosin and tamsulosin.

 

tadalafil

  • Documentation of the following is required:
    • diagnosis of BPH; and
    • strength requested is 5 mg daily; and
    • member is ≥ 18 years of age; and
    • medical records documenting an adverse reaction, inadequate response, or contraindication to tamsulosin, alfuzosin, silodosin, and dutasteride or finasteride; and
    • medical records documenting an adverse reaction, inadequate response, or contraindication to combination therapy with an alpha-1 blocker and 5-alpha-reductase inhibitor.

 

 

Please Note: The MassHealth agency does not pay for any drug when used for the treatment of male or female sexual dysfunction as described in 130 CMR 406.413(B) “Limitations on Coverage of Drugs – Drug Exclusions” (see link below).

 

 https://www.mass.gov/regulations/130-CMR-406000-pharmacy-services

 

Note: The decision on whether PA is required is based upon information available in the MassHealth medical claim and pharmacy claim databases. The MassHealth database contains member information exclusive to MassHealth, and no other health plans.


Original Effective Date: 04/2003

Last Revised Date: 08/2019


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Last updated 11/25/19