Pharmacy Prior Authorization Criteria

Tadalafil

Indications for Prior Authorization

Generic tadalafil

• For diagnosis of Benign Prostatic Hyperplasia (BPH) and Erectile Dysfunction (ED)
  Indicated for the treatment of the signs and symptoms of benign prostatic hyperplasia (BPH) and for the treatment of erectile dysfunction (ED) and the signs and symptoms of BPH (ED/BPH).

  Limitation of use: If tadalafil is used with finasteride to initiate BPH treatment, such 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 of tadalafil beyond 26 weeks is unknown.

Criteria

Generic tadalafil 2.5 mg or generic tadalafil 5 mg

Quantity limit: Cialis (tadalafil) 2.5 mg and 5 mg tablets will be subject to a quantity limit of 1 tablet per day.

Prior Authorization

Length of Approval: 12 Month(s)

• Diagnosis of benign prostatic hyperplasia (BPH)

P & T Revisions

2024-07-03, 2023-07-28, 2022-08-12, 2021-06-22, 2021-06-07, 2021-05-26, 2021-05-25, 2020-06-08

References

1. Tadalafil Prescribing Information. Ajanta Pharma USA Inc. Bridgewater, NJ. May 2023.

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Revision History

• 2024-07-03: 2024 Annual Review. No criteria changes. Background updates.
• 2023-07-28: Annual Review
• 2022-08-12: Annual review - no changes.
• 2021-06-22: Annual review - updated references.
• 2021-06-07: update name
• 2021-05-26: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-25: Addition of EHB formulary to guideline, no changes to criteria
• 2020-06-08: Annual review - no changes.

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