Veozah — Blue Cross Blue Shield of Oklahoma

Initial criteria

• 1. ONE of the following: (A) Prescriber states patient has been treated with the requested agent (not samples) within past 90 days and is at risk if therapy is changed OR (B) Diagnosis of vasomotor symptoms AND ALL of the following: patient is menopausal; symptoms are moderate to severe (≥7/day or ≥50/week); baseline hepatic function (ALT, AST, total and direct bilirubin) evaluated; hepatic transaminases <2× ULN and total bilirubin normal; AND ONE of the following: has tried and had inadequate response to ≥1 menopausal hormone therapy (ET or EPT) OR has intolerance/hypersensitivity to ≥1 menopausal hormone therapy OR has FDA labeled contraindication to ALL menopausal hormone therapies OR patient is age >60 years or onset of menopause ≥10 years prior.
• 2. ONE of the following regarding nonhormonal therapy: (A) Currently being treated and stable on requested agent OR (B) Tried and had inadequate response to ≥1 nonhormonal therapy (paroxetine, escitalopram, citalopram, venlafaxine, desvenlafaxine, duloxetine, gabapentin, oxybutynin) OR (C) One nonhormonal therapy discontinued due to lack of efficacy, diminished effect, or adverse event OR (D) Intolerance or hypersensitivity to ≥1 nonhormonal therapy OR (E) FDA labeled contraindication to ALL nonhormonal therapies OR (F) One nonhormonal therapy expected to be ineffective or cause significant barrier/adverse impact OR (G) One nonhormonal therapy not in patient’s best interest based on medical necessity OR (H) One prescription drug in same pharmacologic class/mechanism of action tried and discontinued due to lack of efficacy/effectiveness/adverse event.
• 3. Patient does NOT have any FDA labeled contraindications to the requested agent.
• 4. For Ohio residents: If plan is Fully Insured or HIM Shop (SG), approval also when ALL: patient has no contraindications AND has another FDA labeled indication OR compendia-supported indication OR prescriber submits two peer-reviewed articles supporting proposed use.

Reauthorization criteria

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

Approval duration

Initial 3 months (BCBSIL 12 months); Renewal 12 months