fezolinetant — Blue Cross Blue Shield of Kansas

Initial criteria

• The requested agent will be approved when BOTH of the following are met:
• 1. ONE of the following:
• A. The requested agent is eligible for continuation of therapy AND ONE of the following:
• • The patient has been treated with the requested agent (starting on samples is not approvable) within the past 90 days OR
• • The prescriber states the patient has been treated with the requested agent (starting on samples is not approvable) 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:
• 1. The patient is menopausal AND
• 2. The patient's symptoms are moderate to severe (i.e., 7 or more episodes per day or 50 or more episodes per week) AND
• 3. Baseline (prior to starting the requested agent) hepatic function (ALT, AST, serum bilirubin [total and direct]) has been evaluated AND
• 4. Hepatic transaminases are less than two times the upper limit of normal (ULN) and total bilirubin is normal AND
• 5. ONE of the following:
• A. The patient has tried and had an inadequate response to TWO therapies used to treat vasomotor symptoms of menopause (paroxetine, escitalopram, citalopram, venlafaxine, desvenlafaxine, duloxetine, gabapentin, oxybutynin, estrogen therapy [ET] or estrogen plus progesterone therapy [EPT] including oral, transdermal patches, sprays and gels, and vaginal ring agents) OR
• B. The patient has tried and had an inadequate response to ONE therapy used to treat vasomotor symptoms of menopause and an intolerance or hypersensitivity to ONE therapy used to treat vasomotor symptoms of menopause OR
• C. The patient has an intolerance or hypersensitivity to TWO therapies used to treat vasomotor symptoms of menopause OR
• D. The patient has an FDA labeled contraindication to ALL therapies used to treat vasomotor symptoms of menopause