HN Logo
Prior Authorization Protocol
AVODARTR (dutasteride), JALYNR(dutasteride and tamsulosin hydrochloride)

NATL
Coverage of drugs is first determined by the member’s pharmacy or medical benefit. Please consult with or refer to the Evidence of Coverage document.
  1. FDA Approved Indications:
    Avodart
    • Treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate to improve symptoms, reduce the risk of acute urinary retention, and reduce the risk of the need for BPH-related surgery
    • In combination with the alpha-blockeralpha-adrenergic antagonist, tamsulosin is indicated for the treatment of symptomatic BPH in men with an enlarged prostate
    Jalyn
    • For the treatment of symptomatic benign prostatic hyperplasia (BPH) in men with an enlarged prostate.
  2. Health Net Approved Indications and Usage Guidelines:
    • Diagnosis of symptomatic BPH
    AND
    • Failure or clinically significant adverse effects to ONE of the following: terazosin, doxazosin, tamsulosin or finasteride
  3. Coverage is Not Authorized For:
    • Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.
  4. General Information:
    • This section intentionally left blank
  5. Therapeutic Alternatives:
    Drug Dosing Regimen Dose Limit/ Maximum Dose

    doxazosin (CarduraR)

    1 mg PO QD, titrate to 2 mg QD and thereafter to 4 mg QD and 8 mg QD.
    Dosing range:
    1 - 8 mg

    8 mg/day

    finasteride (ProscarR)

    5 mg PO QD

    5 mg/day

    tamsulosin (FlomaxR)

    0.4 - 0.8 mg PO QD

    0.8 mg/day

    terazosin

    1 mg PO QD; increase the dose to 2 mg, 5 mg, or 10 mg QD in a stepwise fashion
    Dosing range:
    1 - 20 mg

    20 mg/day

    * Requires Prior Authorization
  6. Recommended Dosing Regimen and Authorization Limit:
    Drug Dosing Regimen Authorization Limit

    AvodartR

    One capsule (0.5 mg) PO QD

    Length of Benefit

    JalynR

    One capsule PO QD

    Length of Benefit

  7. Product Availability:
    Avodart: Capsule (0.5 mg)
    Jalyn: Capsule (0.5 mg dutasteride and 0.4 mg tamsulosin hydrochloride)
  8. References:

    1. Avodart. [Prescribing information] Research Triangle Park, NC: GSK; September 2014.
    2. Jalyn [Prescribing information] Research Triangle Park, NC: GSK; January 2015.
    3. MicromedexR Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed July 9, 2015.

The material provided to you are guidelines used by this plan to authorize, modify or determine coverage for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.