Target Agent(s) — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient is age > 60 years OR onset of menopause was ≥ 10 years prior AND
• The patient has an FDA labeled contraindication to ALL non-hormonal therapies used to treat vasomotor symptoms of menopause (paroxetine, escitalopram, citalopram, venlafaxine, desvenlafaxine, duloxetine, gabapentin, oxybutynin) OR
• The patient has another FDA labeled indication for the requested agent and route of administration AND
• 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 has had clinical benefit with the requested agent
• Hepatic function (ALT, AST, serum bilirubin [total and direct]) has been evaluated since starting the requested agent AND hepatic transaminases are < 2 × ULN and total bilirubin is normal
• The patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

3 months initial, 12 months renewal