Tadalafil Prior Authorization Criteria - Medicare Part D

Prior Authorization Criteria for Approval

Tadalafil 2.5 mg and 5 mg tablets will be approved when ALL of the following are met:

1. The requested medication will NOT be used to treat erectile dysfunction
   AND
2. The patient has a diagnosis of benign prostatic hyperplasia (BPH)
   AND
3. The patient has tried and had an insufficient response, intolerance or hypersensitivity, or FDA labeled contraindication to TWO alpha blocker medications (e.g., terazosin, doxazosin, tamsulosin)
   AND
4. The patient does NOT have any FDA labeled contraindications to the requested medication
   AND
5. ONE of the following:
   1. The requested quantity (dose) does NOT exceed the program quantity limit
      OR
   2. ALL of the following:
      1. The requested quantity (dose) is greater than the program quantity limit
         AND
      2. The requested quantity (dose) cannot be achieved with a lower quantity of a higher strength that does not exceed the program quantity limit
         AND
      3. The prescriber has provided information in support of therapy with a higher dose for the requested indication

Length of Approval: 12 months