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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.
POLICY GUIDELINESInvestigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
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.
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.