Subject: Benign Prostatic Hyperplasia (BPH) Agents

Status	Drug	PR	PR-QL	PR-AL	ST	M EX‡
P	doxazosin
P	finasteride	X		X
P	terazosin
P	Avodart®  (dutasteride)	X
P	Flomax®  (tamsulosin)	X
P	Uroxatral®  (alfuzosin)	X
FE	Cardura® XL  (doxazosin)					X
FE	Proscar®  (finasteride)	X		X		X
FE	Rapaflo™  (silodosin)	X				X

Policy:

1. Precertification Criteria

Under some benefit plans, including plans that use an open or closed formulary, for Avodart, Flomax, finasteride, Proscar, Rapaflo and Uroxatral may be subject to precertification members who are female.* If precertification requirements apply, Aetna considers Avodart, Flomax, finasteride, Proscar, Rapaflo and Uroxatral to be medically necessary for those female members who meet the following criteria:

Member is male
A or B – Proscar, finasteride

A. Age > 50 yrs old

OR

B. Member has diagnosis of BPH (Benign Prostatic Hyperplasia)

NOTE: Avodart, Flomax, Rapaflo and Uroxatral do not require precertification for males; please see below for precertification criteria for females.

Member is female 
A AND (B OR E) – For Proscar, finasteride
A AND E - For Avodart
C OR D OR E – For Flomax
E – For Rapaflo, Uroxatral

A. Member is NOT pregnant

AND

B. Documented diagnosis of hirsutism secondary to ovarian or adrenal dysfunction (for example, polycystic ovary syndrome, adrenal or ovarian tumor)

OR

C. Documented diagnosis of Urethral syndrome (urinary hesitancy, frequency, and dysuria)

OR

D. Documented diagnosis of intractable micturition difficulties (difficulty passing urine)

OR

E. Member’s physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for medical use in females.


2. Medical Exception Criteria

Cardura XL, Proscar and Rapaflo are currently listed on the Aetna Formulary Exclusions List.* Therefore, Cardura XL, Proscar and Rapaflo are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is granted.  Aetna considers Cardura XL, Proscar and Rapaflo to be medically necessary for those members who meet any of the following criteria:

For  Proscar
Member is male - (A OR B) AND (C OR D)

A.  Age > 50 yrs old

OR

B. Documented diagnosis of BPH (Benign Prostatic Hyperplasia)

AND

C. Documented

• Contraindication to one preferred alternative indicated for the member's condition OR 
• Intolerance to one preferred alternative indicated for the member's condition OR 
• Allergy to one preferred alternative agent indicated for the member's condition OR 
• Failure of an adequate trial of one month of one preferred alternative indicated for the member's condition OR
• Member has a documented diagnosis of hypotension/low blood pressure (Proscar-only )

OR

D. Documentation of a prostate volume > 40 cm3


OR

Member is female - A AND (B OR C) For Proscar,


A.  Member is NOT pregnant

AND

B. Documented diagnosis of hirsutism secondary to ovarian or adrenal dysfunction (for example, polycystic ovary syndrome, adrenal or ovarian tumor)

OR

C. Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for medical use in females.

For Rapaflo
Member is male

A.  Documented

• Contraindication to one preferred alternative indicated for the member’s condition OR,
• Intolerance to one preferred alternative indicated for the member’s condition OR,
• Allergy to one preferred alternative agent indicated for the member’s condition OR
• Failure of an adequate trial of one month of one preferred alternative indicated for the member’s condition.

Member is female

Member’s physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for medical use in females.

For CARDURA XL

A.  A documented

• Contraindication to one preferred alternative indicated for the member's condition OR
• Intolerance to one preferred alternative indicated for the member's condition OR
• Allergy to one preferred alternative agent indicated for the member's condition OR
• Failure of an adequate trial of one month of one preferred alternative indicated for the member's condition.

Place of Service:

Outpatient

The above policy is based on the following references:

1. DrugPoints® System ( www.statref.com) Thomson Micromedex, Greenwood Village, CO. Updated periodically.
2. AHFS Drug Information® with AHFSfirstReleases®. ( www.statref.com), American Society Of Health-System Pharmacists®, Bethesda, MD. Updated periodically.
3. DRUGDEX® System [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
4. Drug Facts and Comparisons on-line. (www.drugfacts.com), Wolters Kluwer Health, St. Louis, MO. Updated periodically.
5. PDR® Electronic Library™ [Internet database]. Greenwood Village, Colo: Thomson Micromedex. Updated periodically.
6. Vaughan, E. Darracott. Medical Management of Benign Prostatic Hyperplasia- Are Two Drugs Better than One? The New England Journal of Medicine 2003; 349;25: 2449-2451
7. Mehik, Aare. Alfuzosin Treatment for Chronic Prostatitis/Chronic Pelvic Pain Syndrome: A Prospective, Randomized, Double-blind, Placebo-controlled, Pilot Study.  Urology 2003; 62 (3): 425-429.
8. Narayan, Perinchery. Long-term Safety and Efficacy of Tamsulosin for the Treatment of Lower Urinary Tract Symptoms Associated with Benign Prostatic Hyperplasia. The Journal of Urology 2003; 170 (2): 498-502.
9. Wilt, TJ. Terazosin for Treating Symptomatic Benign Prostatic Obstruction: A Systematic Review of Efficacy and Adverse Effects. BJU Int. 2002; 89 (3): 214-225
10. Vaughan, D. Long Term (7 to 8 year) Experience with Finasteride in Men with Benign Prostatic Hyperplasia. Urology 2002; 60 (6): 1040-1044
11. Marks,Leonard S. First dose efficacy of Alfuzosin Once Daily in Men with Symptomatic Benign Prostatic Hyperplasia. Adult Urology 2003; 62 (5): 888-893
12. AUA Practice Guidelines Committee. AUA Guideline Management of Benign Prostatic Hyperplasia: Chapter1: Diagnosis and Treatment Recommendations. The Journal of Urology 2003; 170(2): 530-547
13. Lowe FC. Role of the newer alpha, -adrenergic-receptor antagonists in the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Clin Ther. 2004;26(11):1701-13.
14. Milani S, Djavan B. Lower urinary tract symptoms suggestive of benign prostatic hyperplasia: latest update on alpha-adrenoceptor antagonists. BJU Int. 2005 Jun;95 Suppl 4:29-36.
15. Dolder CR. Dutasteride: a dual 5-alpha reductase inhibitor for the treatment of symptomatic benign prostatic hyperplasia. Ann Pharmacother. 2006;40(4):658-65.
16. Novara G, Galfano A, Ficarra V, Artibani W. Anticholinergic Drugs in Patients with Bladder Outlet Obstruction and Lower Urinary Tract Symptoms: A Systematic Review. Eur Urol. 2006 Jul 31; [Epub ahead of print].
17. Rapaflo™ Product Information, Watson Pharmaceuticals. Corona, California. February 2009.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 05, 2009