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The Policy VaultThe Policy Vault

Veozah — Blue Cross Blue Shield of Illinois

vasomotor symptoms

Initial criteria

  • ONE of the following: A. The prescriber states the patient has been treated with the requested agent within the past 90 days and is at risk if therapy is changed OR B. The patient has a diagnosis of vasomotor symptoms AND ALL of the following:
  • The patient is menopausal
  • The patient's symptoms are moderate to severe (7 or more episodes per day or 50 or more episodes per week)
  • Baseline hepatic function (ALT, AST, serum bilirubin [total and direct]) has been evaluated
  • Hepatic transaminases < 2× ULN and total bilirubin is normal
  • ONE of the following for menopausal hormone therapy: A. Tried and inadequate response to at least one menopausal hormone therapy (ET or EPT) OR B. Intolerance or hypersensitivity to at least one menopausal hormone therapy OR C. FDA labeled contraindication to all menopausal hormone therapies OR D. Patient age ≥ 60 years or onset of menopause ≥ 10 years prior
  • AND ONE of the following for nonhormonal therapy: A. Tried and inadequate response to at least one nonhormonal vasomotor symptom therapy (paroxetine, escitalopram, citalopram, venlafaxine, desvenlafaxine, duloxetine, gabapentin, oxybutynin) OR B. Discontinued one such therapy due to lack of efficacy or adverse event OR C. Intolerance or hypersensitivity to at least one nonhormonal therapy OR D. FDA labeled contraindication to all nonhormonal therapies OR E. One nonhormonal therapy expected to be ineffective, unsafe, or detrimental based on clinical characteristics OR F. One nonhormonal therapy is not in the best interest of the patient based on medical necessity OR G. Tried another prescription drug in the same pharmacologic class or mechanism and discontinued due to lack of efficacy or adverse event
  • The patient does not have any FDA labeled contraindications to the requested agent

Reauthorization criteria

  • Patient previously approved for the requested agent through plan’s prior authorization process
  • Patient has had clinical benefit with the requested agent
  • Hepatic function (ALT, AST, serum bilirubin [total and direct]) evaluated since starting therapy
  • Hepatic transaminases < 2× ULN and total bilirubin is normal
  • Patient does not have any FDA labeled contraindications to the requested agent

Approval duration

12 months