CIALIS, Tadalafil Form

Tadalafil (Cialis®) is a phosphodiesterase-5 (PDE-5) inhibitor.
____ *For Health Insurance Marketplace (HIM), tadalafil 2.5 mg, 10 mg, and 20 mg tablets are non-formulary and cannot be approved using these criteria; refer to the formulary exception policy, HIM.PA.103.
FDA Approved Indication(s) Cialis is indicated for the treatment of: • Erectile dysfunction (ED)
• The signs and symptoms of benign prostatic hyperplasia (BPH)
• ED and the signs and symptoms of BPH (ED/BPH) Limitation(s) of use: If Cialis is used with finasteride to initiate BPH treatment, such use is recommended for up to 26 weeks because the incremental benefit of Cialis decreases from 4 weeks until 26 weeks, and the incremental benefit of Cialis beyond 26 weeks is unknown. Policy/Criteria Provider must submit documentation (such as office chart notes, lab results or other clinical information) supporting that member has met all approval criteria.
It is the policy of health plans affiliated with Centene Corporation® that Cialis is medically necessary when the following criteria are met:
I. Initial Approval Criteria
A. Benign Prostatic Hyperplasia (must meet all):

1. Diagnosis of BPH;
   2. Age ≥ 18 years;
   3. Failure of one alpha blocker (e.g., alfuzosin, doxazosin, prazosin, tamsulosin or terazosin) and one 5-alpha reductase inhibitor (finasteride or dutasteride), at up to maximally indicated doses, unless clinically significant adverse effects are experienced or all are contraindicated;
2. If request is for brand Cialis, member must use generic tadalafil, unless contraindicated or clinically significant adverse effects are experienced;
3. Cialis is not prescribed concurrently with nitrates (e.g., Nitrodur, Nitrobid, Nitrostat, Isordil, Ismo);

4. Cialis is not prescribed concurrently with guanylate cyclase stimulator, such as riociguat (Adempas);
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   CLINICAL POLICY Tadalafil BPH - ED

5. Dose does not exceed 5 mg (1 tablet) per day. Approval duration: Medicaid/HIM – 12 months Commercial – 12 months or duration of request, whichever is less B. Erectile Dysfunction (must meet all): *Cialis is not covered for this diagnosis for HIM and Medicaid.
   1. Diagnosis of ED;
   2. Age ≥ 18 years;
   3. Failure of generic Viagra® (sildenafil 25 mg, 50 mg, 100 mg) unless contraindicated or clinically significant adverse effects are experienced;
6. If request is for brand Cialis, member must use generic tadalafil, unless contraindicated or clinically significant adverse effects are experienced;
   
   5. Cialis is not prescribed concurrently with concomitant nitrates (e.g., Nitrodur, Nitrobid, Nitrostat, Isordil, Ismo);
7. Cialis is not prescribed concurrently with guanylate cyclase stimulators, such as riociguat (Adempas).
8. Dose does not exceed 20 mg per day and the health plan-approved quantity limit.
   Approval duration:
   Medicaid – Not covered
   HIM – Not covered, use Stendra or generic Viagra (prior authorization is required for these agents) Commercial – Benefit Renewal Date (quantity limits are plan specific) C. Other diagnoses/indications (must meet 1 or 2):
9. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b): a. For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace, and CP.PMN.255 for Medicaid; or b. For drugs NOT on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace, and CP.PMN.16 for Medicaid; or

10. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid.
    II. Continued Therapy A. Benign Prostatic Hyperplasia (must meet all):

    1. Member meets one of the following (a or b): a. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; Page 2 of 7

    CLINICAL POLICY Tadalafil BPH - ED b. Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations (refer to state specific addendums for CC.PHARM.03A and CC.PHARM.03B);

    2. Member is responding positively to therapy;
    3. If request is for brand Cialis, member must use generic tadalafil, unless contraindicated or clinically significant adverse effects are experienced;
11. If request is for a dose increase, new dose does not exceed 5 mg (1 tablet) per day.
    Approval duration:
    Medicaid/HIM – 12 months Commercial – 12 months or duration of request, whichever is less
    B. Erectile Dysfunction (must meet all): *Cialis is not covered for this diagnosis for HIM and Medicaid.
    1. Member meets one of the following (a or b): a. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; b. Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations (refer to state specific addendums for CC.PHARM.03A and CC.PHARM.03B);
    2. Member is responding positively to therapy;
    3. If request is for brand Cialis, member must use generic tadalafil, unless contraindicated or clinically significant adverse effects are experienced;
12. If request is for a dose increase, new dose does not exceed 20 mg per day and the health plan-approved quantity limit. Approval duration:
    Medicaid – Not covered
    HIM – Not covered, use Stendra or generic Viagra (prior authorization is required for these agents) Commercial – Benefit Renewal Date (quantity limits are plan specific)
    C. Other diagnoses/indications (must meet 1 or 2):
13. If this drug has recently (within the last 6 months) undergone a label change (e.g., newly approved indication, age expansion, new dosing regimen) that is not yet reflected in this policy, refer to one of the following policies (a or b): a. For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the no coverage criteria policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.33 for health insurance marketplace, and CP.PMN.255 for Medicaid; or b. For drugs NOT on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), the non-formulary policy for the relevant line of business: CP.CPA.190 for commercial, HIM.PA.103 for health insurance marketplace, and CP.PMN.16 for Medicaid; or

14. If the requested use (e.g., diagnosis, age, dosing regimen) is NOT specifically listed under section III (Diagnoses/Indications for which coverage is NOT authorized) AND criterion 1 above does not apply, refer to the off-label use policy for the relevant line of business: CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid.
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    CLINICAL POLICY Tadalafil BPH - ED III. Diagnoses/Indications for which coverage is NOT authorized:
    A. Non-FDA approved indications, which are not addressed in this policy, unless there is sufficient documentation of efficacy and safety according to the off label use policies – CP.CPA.09 for commercial, HIM.PHAR.154 for health insurance marketplace, and CP.PMN.53 for Medicaid, or evidence of coverage documents.
    IV. Appendices/General Information Appendix A: Abbreviation/Acronym Key BPH: benign prostatic hyperplasia ED: erectile dysfunction
    FDA: Food and Drug Administration GC: guanylate cyclase PDE-5: phosphodiesterase-5 Appendix B: Therapeutic Alternatives
    This table provides a listing of preferred alternative therapy recommended in the approval criteria. The drugs listed here may not be a formulary agent for all relevant lines of business and may require prior authorization.
    Drug Name Dosing Regimen BPH: 1 to 8 mg PO QD doxazosin (Cardura, Cardura XL®) dutasteride (Avodart ®) BPH: 0.5 mg PO QD finasteride (Proscar) BPH: 5 mg PO QD prazosin (Minipress) BPH: 2 mg PO BID tamsulosin (Flomax) BPH: 0.4 mg PO QD terazosin (Hytrin) sildenafil (Viagra) BPH: 5 to 10 mg PO QD ED: 50 mg PO 1 hour (0.5 - 4 hours) before sexual activity Dose Limit/ Maximum Dose 8 mg/day 0.5 mg/day 5 mg/day 9 mg/day 0.8 mg/day 20 mg/day 100 mg/day Therapeutic alternatives are listed as Brand name® (generic) when the drug is available by brand name only and generic (Brand name®) when the drug is available by both brand and generic. Appendix C: Contraindications/Boxed Warnings
    • Contraindication(s): o Cialis is contraindicated in patients using nitric oxide donors, such as organic nitrates or organic nitrites in any form. Cialis was shown to potentiate the hypotensive effect of nitrates (e.g., Nitrodur, Nitrobid, Nitrostat, Isordil, Ismo). o Cialis is contraindicated with administration of guanylate cyclase (GC) stimulators, such adempas (Riociguat). o History of known serious hypersensitivity reaction to Cialis or Adcirca®. • Boxed warning(s): none reported Appendix D: General Information
    • Cialis should not be used in conjunction with other PDE-5 inhibitors, such as sildenafil.
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    CLINICAL POLICY Tadalafil BPH - ED V. Dosage and Administration
    Indication Dosing Regimen 2.5 - 5 mg PO QD BPH 10 - 20 mg PO as needed prior to ED sexual activity or 2.5 mg once daily, without regard to timing of sexual activity Maximum Dose 5 mg/day 5 mg/day for ED for once daily use; 20 mg/dose for ED for as needed use, not to exceed 1 dose/24 hours
    VI. Product Availability
    Tablets: 2.5 mg, 5 mg, 10 mg, 20 mg VII.