Addyi — Blue Cross Blue Shield of Montana

Initial criteria

• The patient's benefit plan covers the requested agent
• The patient is premenopausal
• Diagnosis of acquired, generalized hypoactive sexual desire disorder (HSDD) OR diagnosis of female sexual interest/arousal disorder (FSIAD)
• The HSDD is characterized by low sexual desire that causes marked distress or interpersonal difficulty AND symptoms have been present for ≥ 6 months
• The HSDD is NOT due to a co-existing medical or psychiatric condition, relationship problems, or the effects of a medication or drug substance
• The patient has tried and had an inadequate response to other treatment modalities (education, modification of contributing factors, 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
• For other indications: The patient's benefit plan covers the requested agent AND the requested use is FDA labeled or compendia supported (AHFS, DrugDex level 1, 2A, or 2B, or NCCN 1, 2A, or 2B recommended use)

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: 3 months (BCBSMT), 12 months (BCBSIL and others as stated); renewal: 12 months