Addyi — Blue Cross Blue Shield of Illinois

Initial criteria

• Patient’s benefit plan covers the requested agent AND
• Patient is premenopausal AND
• Diagnosis of acquired, generalized HSDD OR female sexual interest/arousal disorder (FSIAD) AND
• HSDD characterized by low sexual desire that causes marked distress or interpersonal difficulty AND symptoms present for at least 6 months AND
• HSDD is NOT due to a co-existing medical or psychiatric condition, problems within the relationship, or effects of a medication or other drug substance AND
• Patient has tried and had an inadequate response to other treatment modalities (e.g., education, modification of contributing factors, and sex therapy) AND
• Patient will NOT be using the requested agent in combination with another target agent in this program for the requested indication AND
• Patient does NOT have any FDA labeled contraindications to the requested agent
• Compendia allowed: AHFS, DrugDex 1, 2A, 2B; NCCN 1, 2A, or 2B recommended use
• The requested agent will also be approved for Ohio Fully Insured or HIM Shop members when: no contraindications AND (FDA labeled indication OR compendia supported indication OR two peer-reviewed journal articles demonstrating safety and efficacy)

Reauthorization criteria

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

Approval duration

12 months (BCBSIL); 3 months (BCBSMT/BCBSNM); 8 weeks (all other plans); 12 months (renewal)