Benign Prostate Hypertrophy Drugs

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Current Drug Use Criteria New Drug Evaluation
doxazosin mesylate DOXAZOSIN MESYLATE TABLET Y    
doxazosin mesylate CARDURA TABLET Y    
finasteride FINASTERIDE TABLET Y PA Document  
finasteride PROSCAR TABLET Y    
tamsulosin HCl FLOMAX CAP ER 24H Y    
tamsulosin HCl TAMSULOSIN HCL CAP ER 24H Y    
alfuzosin HCl UROXATRAL TAB ER 24H N PA Document  
alfuzosin HCl ALFUZOSIN HCL ER TAB ER 24H N PA Document  
doxazosin mesylate CARDURA XL TAB ER 24 N PA Document  
dutasteride DUTASTERIDE CAPSULE N PA Document  
dutasteride AVODART CAPSULE N PA Document  
silodosin RAPAFLO CAPSULE N PA Document  
tadalafil CIALIS TABLET N PA Document  
dutasteride/tamsulosin HCl DUTASTERIDE-TAMSULOSIN CPMP 24HR    
dutasteride/tamsulosin HCl JALYN CPMP 24HR