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Please perform a formulary drug search on your patient’s member ID to ensure the prescription drug is covered under their benefit plan. The medication(s) in this medical policy may not be covered under a specific member’s benefit plan.
DESCRIPTIONRapaflo® (silodosin) is indicated for the treatment of symptomatic benign prostatic hyperplasia (BPH). The recommended dosage of Rapaflo is 8 mg daily.
POLICYRapaflo will be approved based on both of the following criteria:
• Patient has been clinically diagnosed benign prostatic hyperplasia (BPH) AND
• Patient has a documented intolerance to, or treatment failure of Flomax (tamsulosin) or Uroxatral (alfuzosin).
If approved, the Plan will only reimburse for the same amount as generic tamsulosin on prescriptions for Rapaflo.
Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
01/01/2014: New policy added.
07/27/2015: Code Reference section updated for ICD-10.
05/31/2016: Policy number added. Investigative definition updated in Policy Guidelines section.
SOURCE(S)Rapaflo® Prescribing Information
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.
The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.