Veozah — Blue Cross Blue Shield of Montana

Initial criteria

• 1. ONE of the following: A. 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:
•   • 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 regarding menopausal hormone therapy:
•     A. Tried and had inadequate response to ≥1 menopausal hormone therapy (ET or EPT) OR
•     B. Intolerance or hypersensitivity to ≥1 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
•   • ONE of the following regarding nonhormonal therapy used to treat vasomotor symptoms (paroxetine, escitalopram, citalopram, venlafaxine, desvenlafaxine, duloxetine, gabapentin, oxybutynin):
•     A. Tried and had inadequate response to ≥1 nonhormonal therapy OR
•     B. Therapy discontinued due to lack of efficacy, diminished effect, or adverse event OR
•     C. Intolerance or hypersensitivity to ≥1 nonhormonal therapy OR
•     D. FDA-labeled contraindication to ALL nonhormonal therapies OR
•     E. Nonhormonal therapy expected to be ineffective or inappropriate based on clinical characteristics, adherence concerns, comorbidities, functional ability, or adverse reactions OR
•     F. Nonhormonal therapy not in patient's best interest based on medical necessity OR
•     G. Tried another agent with same mechanism/class as a nonhormonal therapy and it was discontinued due to lack of efficacy, diminished effect, or adverse event
•   • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• 1. Patient previously approved for the requested agent through the plan’s Prior Authorization process
• 2. Patient has had clinical benefit with the requested agent
• 3. BOTH:
•   A. Hepatic function (ALT, AST, serum bilirubin [total and direct]) evaluated since starting the requested agent AND
•   B. Hepatic transaminases < 2 × ULN and total bilirubin is normal
• 4. Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

initial 3 months; renewal 12 months