[drug or class name]

Erectile Dysfunction Agents
Prior Authorization Criteria
NOTE: This prior authorization (PA) criteria contains a quantity limit of 8 tablets total for any combination of the 3 oral products (sildenafil, tadalafil, or vardenafil) or a quantity limit of 8 units total for any combination of the 3 non-oral alprostadil products (Caverject injection, Edex injection, Dosage Form

FDA APPROVED INDICATIONS1-6
The following information is taken from individual drug prescribing information and is provided here as background
information only. Not all FDA-approved indications may be considered medically necessary.
All criteria are found in the section “Prior Authorization Criteria for Approval.”

Cialis , Levitra , Viagra
Cialis (tadalafil), Levitra (vardenafil), and Viagra (sildenafil) are indicated for the treatment of erectile
dysfunction.
Caverject1
Caverject (alprostadil) is indicated for the treatment of erectile dysfunction due to neurogenic, vasculogenic,
psychogenic, or mixed etiology. Intracavernosal Caverject is also indicated as an adjunct to other diagnostic
tests in the diagnosis of erectile dysfunction.
Edex
Edex (alprostadil) is indicated for the treatment of erectile dysfunction due to neurogenic, vasculogenic,
psychogenic, or mixed etiology.
Muse
Muse (alprostadil) is indicated for the treatment of erectile dysfunction. Studies that established benefit
demonstrated improvements in success rates for sexual intercourse compared with similarly administered
placebo.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
Copyright Prime Therapeutics LLC. 04/2009 All Rights Reserved SUMMARY OF PRIOR AUTHORIZATION
The intent of the Erectile Dysfunction Prior Authorization (PA) Criteria is to appropriately select
patients for therapy according to product labeling and/or guidelines and/or clinical studies.
Patients meeting the selection requirements of the PA criteria will be approved for up to 8 units of
the requested erectile dysfunction (ED) agent per month for twelve months. For the oral
phosphodiesterase type 5 (PDE5) inhibitors (sildenafil, tadalafil, or vardenafil) the PA criteria will
approve a quantity of 8 tablets total for any combination of these 3 oral products. Similarly, for the
non-oral alprostadil products (Caverject injection, Edex injection, Muse urethral suppository) the
PA criteria will approve a quantity of 8 units total for any combination of these 3 products.
The claims adjudication system will reject ED agent claims when the agents are not a covered
benefit or for patients who are designated as female or less than eighteen years of age. These
claims will be directed to the health plans for determination of coverage.
Male patients eighteen years of age and older may be approved for up to eight units of an ED
agent if the following requirements are met:
 The primary diagnosis is erectile dysfunction or impotence (not a primary diagnosis of another sexual disorder) AND
 The diagnosis is erectile dysfunction or impotence secondary to an organic etiology (e.g., diabetes, prostate cancer, vascular insufficiency) that has persisted for a minimum of six
months. (NOTE: ED agents are not covered when impotency is an adverse effect of
prescription or recreational drug use or lifestyle enhancement) AND
 The patient has not been diagnosed with a bleeding disorder, an active peptic ulcer, or retinitis pigmentosa AND
 The patient does not have genital anatomical deformities that impair erection (e.g. angulation, cavernosal fibrosis, Peyronie’s disease) AND
 The patient is not concurrently prescribed an androgen (patients with hypogonadism may be prescribed testosterone and PDE5 agent concomitantly) AND
 Sildenafil, vardenafil, or tadalafil is not concurrently prescribed with a nitrate or nitric oxide AND
 The patient will not be receiving two ED agents concurrently
CLINICAL RATIONALE FOR PRIOR AUTHORIZATION
The Erectile Dysfunction PA criteria considers therapy with an ED agent appropriate when the
patient has been diagnosed with primary erectile dysfunction or impotence and if the erectile
dysfunction is secondary to an organic comorbidity such as hypertension, atherosclerosis or other
vascular insufficiency, hyperlipidemia, diabetes mellitus, or prostate cancer.
Once ED has been diagnosed and the underlying causes have been treated, the American
Urological Association (AUA) in a 2006 guideline recommends treatment with an oral
phosphodiesterase type 5 (PDE5) inhibitor (sildenafil, tadalafil, or vardenafil) as first-line therapy,
unless contraindicated.7 Other options include intra-urethral alprostadil, intracavernous
vasoactive drug injection, vacuum constriction devices, and penile prosthesis implantation.7 Use
of an ED agent for treatment of ED secondary to prescription or recreational drug use or for
lifestyle enhancement will not be considered approvable by this criteria.
The PDE5 inhibitors also have an inhibitory effect on PDE6, located in the rod and cone
photoreceptors of the eye. Studies in mice indicate that sildenafil has a significant impact on
retinal function and may have an impact on human carriers of retinosa pigmentosa.8 There is no
controlled clinical data evaluating the safety and efficacy of the PDE5 agents in patients with
retinitis pigmentosa.4,6 This group of patients has been excluded from PDE5 efficacy and safety
trials. Use in patients with known hereditary degenerative retinal disorders, including retinitis
pigmentosa, is not recommended.
Copyright Prime Therapeutics LLC. 04/2009 All Rights Reserved The PDE5 agents have not been evaluated in patients with bleeding disorders or significant
active peptic ulcers.2,4,6 Although these agents have not been shown to increase bleeding times in
healthy people, use in patients with bleeding disorders or significant peptic ulceration should be
based upon careful risk-benefit assessment and used with caution.2
The oral PDE5 ED medications are contraindicated in patients who are taking organic nitrates or
nitric oxide due to potentiation of hypotensive effects.2,4,6 Patients prescribed these agents are not
candidates for ED agent approval.
All three of the oral PDE5 agents interact with alpha blocking agents to some degree and
treatment with an alpha antagonist and all doses of vardenafil and tadalafil as well as 50 mg and
100 mg doses of sildenafil should be administered with caution.7 Prescribing information for
PDE5 agents do not list concomitant alpha-blocker use as a contraindication but do recommend
that for patients on alpha-blockers, the PDE5 agents should be started only when the patients are
stable on alpha-blocker therapy and that they should be started on the lowest PDE5 dose. In
those patients already taking an optimized dose of a PDE5 inhibitor, alpha-blocker therapy should
be initiated at the lowest dose. Safety of combined use of PDE5 inhibitors and alpha-blockers
may be affected by other variables, including intravascular volume depletion and other anti-
hypertensive drugs.2,4,6
Current AUA guidelines do not recommend the use of testosterone or other androgens for the
treatment of erectile dysfunction in patients with normal testosterone levels. However, men with
hypogonadism have a reduced response to PDE5 inhibitors and treatment with testosterone has
been shown to improve the response to sildenafil in men with erectile dysfunction with initially low
serum testosterone levels.9-10 The PA criteria will allow concomitant use of testosterone and an
ED agent when there is evidence if hypogonadism.
The use of alprostadil is contraindicated in patients with anatomical deformation of the penis,
such as angulation, cavernosal fibrosis, or Peyronie’s disease.1-6 Alprostadil is contraindicated for
patients with penile implants also.1,5,6 Use of alprostadil urethral suppositories has not been
evaluated in patients with implants.5 If used, the PDE5 inhibitors should be used with caution in
patients with anatomical deformation of the penis.2,4,6
The safety and efficacy of erectile dysfunction agent combinations has not been extensively
studied.1-6,12,13 Small studies evaluating alprostadil combined with a PDE5 agent report response
rates of ninety-two to one hundred percent in patients who did not respond to oral sildenafil
alone.11 Double blind randomized controlled clinical trials are needed to establish benefits,
optimal dosage, and possible adverse effects before combination therapy can be recommended.
PRIOR AUTHORIZATION CRITERIA FOR APPROVAL
Erectile Dysfunction Agents
Initial and Renewal Evaluation
1. Is the patient at least 18 years of age and male, and the requested agent is covered under their benefit plan? If yes to all requirements, continue to 2. If no to any requirement, forward to plan for benefit determination. 2. Does the patient have a diagnosis of primary erectile dysfunction or impotence (not If yes, continue to 4. If no, continue to 3. 3. Does the patient have a diagnosis of erectile dysfunction or impotence secondary to an organic (not medication) etiology (e.g., diabetes, prostate cancer, vascular insufficiency) that has persisted for a minimum of 6 month? Copyright Prime Therapeutics LLC. 04/2009 All Rights Reserved 4. Does the patient have a genital anatomical deformity (e.g., angulation, cavernosal fibrosis, Peyronie’s disease) that significantly impairs erection or does the patient have a penile implant? If yes, deny. If no, continue to 5. 5. Is the patient prescribed sildenafil, vardenafil, or tadalafil and also being treated with an If yes, continue to 6. If no, continue to 7. 6. Is the androgen agent being prescribed to treat a patient diagnosed with hypogonadism? 7. Is the patient prescribed sildenafil, vardenafil, or tadalafil and also being treated with a 8. Has the patient been diagnosed with one of the following: 9. Is the patient currently receiving another ED agent? If yes, discontinue previous ED agent and approve for a quantity of 8 units per month for 12 months. If no, approve for a quantity of 8 units per month for 12 months. NOTE: The PA criteria will approve a quantity of 8 tablets total for any combination of the 3 oral
products (sildenafil, tadalafil, or vardenafil) or a quantity of 8 units total for any combination of the
3 non-oral alprostadil products (Caverject injection, Edex injection, Muse urethral suppository).
SUMMARY
The use of an ED agent is appropriate when the patient has been diagnosed with primary erectile
dysfunction or impotence and if the erectile dysfunction is secondary to an organic comorbidity
such as hypertension, atherosclerosis or other vascular insufficiency, hyperlipidemia, diabetes
mellitus, or prostate cancer. Use of an ED agent for treatment of ED secondary to prescription or
recreational drug use or for lifestyle enhancement will not be considered approvable by these
criteria. The PA criteria for Cialis, Levitra, Viagra, Caverject, Edex, and Muse provide an approval
mechanism for patients for whom ED agents are appropriate. Patients meeting the selection
requirements of the PA criteria will be approved for up to 8 units of the requested ED agent per
month for twelve months. When ED agents are not a covered benefit, when members are
designated as female, or when members are less than eighteen years of age, requests will be
directed to the health plans for determination of coverage.
REFERENCES
1. Caverject prescribing information. Pfizer. September 2003. 2. Cialis prescribing information. Lilly ICOS, LLC. August 2008. 3. Edex prescribing information. Schwarz Pharma. January 2006. 4. Levitra prescribing information. Schering Corporation. December 2008. 5. Muse prescribing information. Vivus, Inc. August 2003. 6. Viagra prescribing information. Pfizer Labs. February 2008. 7. AUA guideline on the management of erectile dysfunction: Diagnosis and treatment recommendations. 2006 Update (confirmed 2008). Available at Accessed March 10, 2009. Copyright Prime Therapeutics LLC. 04/2009 All Rights Reserved Behn D, Potter MJ. Sildenafil-mediated reduction in retinal function in heterozygous mice lacking the γ-subunit. Invest Ophthamol Vis Sci 2001;42(2):523-527. Aversa A, Isidori AM, Spera G, Lenzi A, Fabbri A. Androgens improve cavernous vasodilatation and response to sildenafil in patients with erectile dysfunction. Clin Endocrinol 2003;58:636-638. Kalinchenko SY, Koslow GU, Gontchorov NP, Katsiya GV. Oral testosterone undecanoate reverses erectile dysfunction associated with diabetes mellitus in patients failing on sildenafil citrate therapy alone. Aging Male 2003;6:94-99. McMahon CN, Smith CJ, Shabsigh R. Treating erectile dysfunction when PDE5 inhibitors fail. BMJ 2006;332:589-592. Beckman TJ, Abu-Lebdeh HA, Mynderse LA.Evaluation and medical management of erectile dysfunction. Mayo Clin Proc. 2006;81(3):385-90. Rosenberg MT. Diagnosis and management of erectile dysfunction in the primary care setting. Int J Clin Pract. 2007;61(7):1198-1208.
Document History
Original Client Specific Criteria approved by HCSC Corporate Clinical Committee 08/2006
Annual Review Client Specific criteria approved by HCSC Corporate Clinical Committee 12/2007
Annual Review Client Specific criteria approved by HCSC Corporate Clinical Committee 04/2009
Copyright Prime Therapeutics LLC. 04/2009 All Rights Reserved

Source: http://www.bcbsil.com/pdf/pharmacy/rx_criteria/erectile_dysfunction.pdf