Benign Prostate Hypertrophy Drugs
PDL Reference Documents
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.
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 & Updates |
|---|---|---|---|---|---|
| doxazosin mesylate | DOXAZOSIN MESYLATE | TABLET | Y | ||
| doxazosin mesylate | CARDURA | TABLET | Y | ||
| finasteride | FINASTERIDE | TABLET | Y | ||
| finasteride | PROSCAR | TABLET | Y | ||
| tamsulosin HCl | TAMSULOSIN HCL | CAPSULE | Y | ||
| tamsulosin HCl | FLOMAX | CAPSULE | Y | ||
| terazosin HCl | TERAZOSIN HCL | CAPSULE | Y | ||
| 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 | |
| dutasteride/tamsulosin HCl | DUTASTERIDE-TAMSULOSIN | CPMP 24HR | N | PA Document | |
| silodosin | RAPAFLO | CAPSULE | N | PA Document | |
| silodosin | SILODOSIN | CAPSULE | N | PA Document | |
| tadalafil | TADALAFIL | TABLET | N | PA Document | |
| tadalafil | CIALIS | TABLET | N | PA Document |