Prior Auth Protocol

FDA Approved Indications:

Health Net Approved Indications and Usage Guidelines:

AND

AND

Failure or clinically significant adverse effects to ONE oral Phosphodiesterase Type 5 (PDE5) inhibitor (e.g. Cialis^R) unless contraindicated (i.e. concomitant nitrate use)

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.
Members without sexual dysfunction coverage

General Information:

Muse is contraindicated in patients who have conditions that might predispose them to priapism, such as sickle cell anemia or trait, multiple myeloma, thrombocythemia or polycythemia, or in patients with abnormal penile anatomy.

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
Cialis^R(tadalafil)*	Daily: 2.5 - 5 mg PO QD PRN: 10 mg PO before sexual activity. Dosing range: 5 - 20 mg. The maximum recommended dosing frequency is ONCE per day.	QD dosing 5 mg/day PRN dosing 20 mg/day
Viagra^R(sildenafil)*	50 mg PO 1 hour (0.5-4 hours) before sexual activity. Dosing range: 25 -100 mg The maximum recommended dosing frequency is ONCE per day.	100 mg/day
Levitra^R (vardenafil)*	10 mg PO 60 minutes before sexual activity. Dosing range: 5 - 20 mg. The maximum recommended dosing frequency is ONCE per day.	20 mg/day
Staxyn^R (vardenafil)*	Place 1 tablet (10 mg) on the tongue 60 minutes before sexual activity. The maximum recommended dosing frequency is ONCE per day.	10 mg/day
Stendra^TM (avanafil)*	100 mg PO 30 minutes before sexual activity. Dosing range: 50 - 200 mg. The maximum recommended dosing frequency is ONCE per day.	200 mg/day

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Muse	125 -1,000 mcg inserted into the urethra as needed to achieve erection. The lowest effective dosage should be used. Maximum of two systems per 24 hours.	Limit 6 per month

Product Availability:

Muse: 125 mcg, 250 mcg, 500 mcg, 1000 mcg

References:

Muse [Prescribing Information]. Somerset, NJ: Meda Pharmaceuticals, Inc.; August 2014.
Micromedex^R Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed May 27, 2015.
Muse. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed May 27, 2015.