I recently received some updates from Natacha Graham at the AUA regarding insurance coverage for ED care that I wanted to share with all of you:
1. COVERAGE OF ED DRUGS
Blue Cross Blue Shield (BCBS) New York has updated its medical policy for Erectile Dysfunction Agents with the following changes to applicable medications, criteria, and supporting information. They have added generic tadalafil, sildenafil and vardenafil to the policy as plan-preferred.
Coverage is provided in accordance with the following:
* For Viagra/sildenafil, Levitra/vardenafil, Cialis/tadalafil, Staxyn, Stendra, Muse, Caverject, or Edex for the treatment of erectile dysfunction.
* For Cialis/tadalafil 2.5mg or 5mg tablets for the treatment of benign prostatic hyperplasia
* Phosphodiesterase (PDE) inhibitors are not covered for the preservation of penile function after radical prostatectomy, as this is considered investigational.
* BCBS NY has changed Cialis from plan-preferred to non-preferred status. Coverage of Cialis, Viagra, Levitra, Staxyn, Stendra, Muse, Caverject, or Edex is available if there is a documented trial (resulting in intolerance or treatment failure) with ONE of the plan-preferred medications (sildenafil, tadalafil, or vardenafil) OR when at least ONE of the following criteria have been met:
* The plan-preferred medications are contraindicated or will likely cause an adverse reaction by or physical or mental harm to the member.
* The plan-preferred medications are expected to be ineffective based on the known clinical history and conditions of the member and the member’s prescription drug regimen.
* The member has tried the plan-preferred medications or another prescription drug in the same pharmacologic class or with the same mechanism of action and such prescription drug was discontinued due to lack of efficacy or effectiveness, diminished effect, or an adverse event.
* The member is stable on the medication selected by their healthcare professional for the medical condition under consideration (where “stable” is defined as receiving the medication for an adequate period of time, have achieved optimal response, and continued favorable outcomes are expected UNLESS the medication was initially selected due to the availability of a drug sample or a coupon card and the member does not otherwise meet the definition of “stable”).
* The plan-preferred medication is not in the best interest of the member because it will likely cause a significant barrier to the member’s adherence or to compliance with the member’s plan of care, will likely worsen a comorbid condition of the member, or will likely decrease the member’s ability to achieve or maintain reasonable functional ability in performing daily activities.
2. TIBIAL NERVE STIMULATION
Health Now Blue Cross Blue Shield of New York has revised their Percutaneous Tibial Nerve Stimulation medical policy with the following changes to the criteria:
* Changed coverage decision from investigational to medically necessary for percutaneous tibial nerve stimulation for members with non-neurogenic urinary dysfunction when criteria are met;
* Added position statement indicating medical necessity for maintenance therapy using monthly percutaneous tibial nerve stimulation for members whose urinary dysfunction improved following initial treatment;
* Revised indications for which percutaneous nerve stimulation is considered investigational, removing all indications aside from neurogenic bladder dysfunction and fecal incontinence.
* Changed prior authorization status from recommended to not required.
Emblem Health of New York has revised its Jevtana medical policy with the following changes to criteria:
* Updated initial approval criteria for the use of Jevtana in the treatment of prostate cancer to revise the requirement that the medication will be used in combination, changing the specification of prednisone into any steroid.
* Revised criterion regarding metastatic disease to change “hormone-refractory” to “castration-resistant.”
John Phillips, MD, FACS, President, New York State Urological Society