Caverject Impulse — Cigna

Initial criteria

• Erectile Dysfunction: Approve for FDA-approved indication.
• History of Radical Prostatectomy: Approve if BOTH of the following (A and B) are met: A) Patient was started on therapy post-operatively; AND B) Patient is currently continuing therapy with an alprostadil product.
• Prophylaxis after Radical Prostatectomy (Early Penile Rehabilitation): Approve if ALL of the following (A, B, and C) are met: A) Patient is treatment-naïve; AND B) Therapy will be started within 6 months of surgery; AND C) The medication is prescribed by or in consultation with a urologist.

Approval duration

1 year