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
Status
Current Drug Use Criteria New Drug Evaluation
DOXAZOSIN MESYLATE CARDURA TABLET Y    
DOXAZOSIN MESYLATE DOXAZOSIN MESYLATE TABLET Y    
FINASTERIDE FINASTERIDE TABLET Y PA Document  
FINASTERIDE PROSCAR TABLET Y    
TAMSULOSIN HCL TAMSULOSIN HCL CAP ER 24H Y    
TAMSULOSIN HCL FLOMAX CAP ER 24H Y    
TERAZOSIN HCL TERAZOSIN HCL CAPSULE 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 AVODART CAPSULE N PA Document  
DUTASTERIDE DUTASTERIDE 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