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Erectile Dysfunction -Phosphodiesterase Type 5 Inhibitors, Quantity Limit Program Summary
Policy Number: PH-1089
This program applies to Blue Partner, Commercial, NetResults A series, SourceRx, and Health Insurance Marketplace formularies.
Self-funded groups may exclude this class of medications from coverage or have varying age and/or quantity limitations. Group specific policies will supersede this general policy when applicable. Refer to member’s benefit plan for further details regarding erectile dysfunction medications (may be referred to as Impotence Drugs).
POLICY REVIEW CYCLE
Effective Date |
Date of Origin |
07-01-2024 |
|
FDA LABELED INDICATIONS AND DOSAGE
See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm
POLICY AGENT SUMMARY QUANTITY LIMIT
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
QL Amount |
Dose Form |
Day Supply |
Duration |
Addtl QL Info |
Allowed Exceptions |
Targeted NDCs When Exclusions Exist |
|
|||||||||
|
vardenafil hcl orally disintegrating tab |
10 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
|
Vardenafil HCl Orally Disintegrating Tab 10 MG |
10 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Cialis |
Tadalafil Tab 10 MG |
10 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Cialis |
Tadalafil Tab 2.5 MG |
2.5 MG |
30 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 6 doses per month. The quantity of 6 doses per month is cumulative. |
|
Cialis |
Tadalafil Tab 20 MG |
20 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Cialis |
Tadalafil Tab 5 MG |
5 MG |
30 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 6 doses per month. The quantity of 6 doses per month is cumulative. |
|
Levitra |
vardenafil hcl tab |
10 MG ; 2.5 MG ; 20 MG ; 5 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Stendra |
avanafil tab |
100 MG ; 200 MG ; 50 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Viagra |
sildenafil citrate tab |
100 ; 100 MG ; 25 MG ; 50 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Viagra |
Sildenafil Citrate Tab 100 MG |
100 ; 100 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Viagra |
Sildenafil Citrate Tab 25 MG |
25 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
Viagra |
Sildenafil Citrate Tab 50 MG |
50 MG |
8 |
Tablets |
30 |
DAYS |
|
Quantity of 30 tablets per month is cumulative for Cialis/tadalafil 2.5 mg and 5 mg. All agents (except for Cialis/tadalafil 2.5 mg and 5 mg) are limited to 8 doses per month. The quantity of 8 doses per month is cumulative. Some groups cover less than or more than 8 tablets per month. Group specific policies will supersede this policy when applicable. Please refer to member's benefit plan. Only 1 oral agent will be covered per month. |
|
CLIENT SUMMARY – QUANTITY LIMITS
Target Brand Agent Name(s) |
Target Generic Agent Name(s) |
Strength |
Client Formulary |
|
vardenafil hcl orally disintegrating tab |
10 MG |
|
|
Vardenafil HCl Orally Disintegrating Tab 10 MG |
10 MG |
|
Cialis |
Tadalafil Tab 10 MG |
10 MG |
|
Cialis |
Tadalafil Tab 2.5 MG |
2.5 MG |
|
Cialis |
Tadalafil Tab 20 MG |
20 MG |
|
Cialis |
Tadalafil Tab 5 MG |
5 MG |
|
Levitra |
vardenafil hcl tab |
10 MG ; 2.5 MG ; 20 MG ; 5 MG |
|
Stendra |
avanafil tab |
100 MG ; 200 MG ; 50 MG |
|
Viagra |
sildenafil citrate tab |
100 ; 100 MG ; 25 MG ; 50 MG |
|
Viagra |
Sildenafil Citrate Tab 100 MG |
100 ; 100 MG |
|
Viagra |
Sildenafil Citrate Tab 25 MG |
25 MG |
|
Viagra |
Sildenafil Citrate Tab 50 MG |
50 MG |
|
QUANTITY LIMIT CLINICAL CRITERIA FOR APPROVAL
Module |
Clinical Criteria for Approval |
QL |
Quantity Limit for the Target Agent(s) will be approved when ALL of the following are met:
Length of Approval: Preservation of erectile function following a radical retropubic prostatectomy: 30 tablets per month for 12 months |
This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment
ALBP _ Commercial _ CS _ ED_Phosphodiesterase_Type_5_Inhibitors_Topical_Prostaglandin_QL _ProgSum_ 07-01-2024 _ © Copyright Prime Therapeutics LLC. May 2024 All Rights Reserved