Prior Authorization : Preferred Drug List

BPH Agents, Alpha Reductase Inhibitors

Note: The Preferred Drug List Quick Reference provides the most current list of preferred and non-preferred drugs in this drug class.

Entadfi

Entadfi requires clinical PA.

PA requests for Entadfi must be completed, signed, and dated by the prescriber. PA requests for Entadfi must be submitted using Section VI (Clinical Information for Drugs With Specific Criteria Addressed in the ForwardHealth Online Handbook) of the PA/DGA form.

The PA form must be sent to the pharmacy where the prescription will be filled. The prescriber may send the PA form to the pharmacy, or the member may carry the PA form with the prescription to the pharmacy. The pharmacy provider will use the completed PA form to submit a PA request to ForwardHealth. Prescribers should not submit the PA form to ForwardHealth.

Pharmacy providers are required to submit the completed PA/DGA form and a completed PA/RF to ForwardHealth.

PA requests for Entadfi may be submitted on the Portal, by fax, or by mail (but not using the STAT-PA system).

Clinical Criteria for Entadfi

Clinical criteria that must be documented for approval of a PA request for Entadfi are all of the following:

• The member has BPH with lower urinary tract symptoms.
• The member has taken dutasteride and experienced an unsatisfactory therapeutic response or experienced a clinically significant adverse drug reaction.
• The member has taken finasteride for at least two consecutive months and experienced a partial response.

Supporting clinical information and a copy of the member's current medical records must be submitted with all PA requests for Entadfi. The supporting clinical information and medical records must document the following:

• The member's medical condition being treated
• Details regarding previous medication use
• The member's current treatment plan

If the clinical criteria for Entadfi are met, PA requests may be approved for up to 182 days (26 weeks).

ForwardHealth allows only one Entadfi PA approval during a member's lifetime. Additional PA requests will not be approved.