Contact your Express Scripts plan directly for the most up-to-date information. Prior authorization (PA) requirements vary significantly depending on your specific plan and coverage.
Generally, expect to need a PA if:
- You’re using Cialis for a condition other than benign prostatic hyperplasia (BPH) or erectile dysfunction (ED). You’re exceeding a dosage threshold defined by your plan. Your doctor hasn’t met certain criteria regarding documentation or treatment attempts.
To initiate the PA process:
Obtain a completed PA form from your physician or Express Scripts. This form usually requires detailed medical history and justification for Cialis use. Your doctor will submit the completed form electronically or by mail; follow the specific instructions on the form. Check the Express Scripts website or your member portal regularly for updates on your PA request. Allow adequate processing time, which can range from a few days to several weeks. Expect to provide additional information if requested by Express Scripts. This could include lab results or other supporting medical documentation.
Factors influencing PA approval include:
- Diagnosis: Clearly documented diagnosis of ED or BPH. Treatment history: Demonstrated failure of other therapies. Medical necessity: A compelling rationale that shows Cialis is the most appropriate treatment.
If your PA is denied, you can appeal the decision. Appeal instructions will be included in the denial notification; follow those instructions carefully. Be prepared to provide further justification for the use of Cialis in your particular case.
Remember to always check your specific plan’s formulary and contact your doctor or Express Scripts’ customer service for personalized guidance.
