Vyleesi — Blue Cross Blue Shield of Alabama

Initial criteria

• The patient’s benefit plan covers the requested agent
• The patient is premenopausal
• ONE of the following: • The patient has had a diagnosis of acquired, generalized hypoactive sexual desire disorder (HSDD) • The patient has had a diagnosis of female sexual interest/arousal disorder (FSIAD)
• BOTH of the following: • The patient’s diagnosis is characterized by low sexual desire that causes marked distress or interpersonal difficulty • The patient’s symptoms of low sexual desire have been present for at least 6 months
• The HSDD is NOT due to ANY of the following: • A co-existing medical or psychiatric condition • Problems within the relationship • The effects of a medication or other drug substance
• The patient has tried and had an inadequate response to other treatment modalities (e.g., education, modification factors thought to be contributing to HSDD/FSIAD, and sex therapy)
• The patient will NOT be using the requested agent in combination with another target agent in this program for the requested indication
• The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s prior authorization process
• The patient’s benefit plan covers the requested agent
• The patient is premenopausal
• The patient has had clinical benefit with the requested agent
• The patient will NOT be using the requested agent in combination with another target agent in this program for the requested indication
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 8 weeks; renewal 12 months