Veozah — Blue Cross Blue Shield of Texas

Initial criteria

• 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 apply: (1) The patient is menopausal AND (2) The patient's symptoms are moderate to severe (≥7 episodes per day or ≥50 episodes per week) AND (3) Baseline hepatic function (ALT, AST, total and direct bilirubin) has been evaluated AND (4) Hepatic transaminases <2× ULN and total bilirubin normal AND (5) ONE of the following: (A) Tried and had inadequate response to ≥1 menopausal hormone therapy (ET or EPT; oral, transdermal patches, sprays, gels, vaginal ring) 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 menopause onset ≥10 years prior AND (6) ONE of the following: (A) Currently treated and stable on requested agent OR (B) Tried and inadequate response to ≥1 nonhormonal therapy for vasomotor symptoms (paroxetine, escitalopram, citalopram, venlafaxine, desvenlafaxine, duloxetine, gabapentin, oxybutynin) OR (C) Nonhormonal therapy discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event OR (D) Intolerance or hypersensitivity to ≥1 nonhormonal therapy OR (E) FDA labeled contraindication to ALL nonhormonal therapies OR (F) Nonhormonal therapy expected to be ineffective, cause adherence barrier, worsen comorbidity, decrease functional ability, or cause harm OR (G) Nonhormonal therapy not in best interest of patient based on medical necessity OR (H) Tried another agent in same class or mechanism as ≥1 nonhormonal therapy and discontinued due to lack of efficacy/effectiveness/diminished effect/adverse event OR (C) The patient has another FDA labeled indication for the agent and route AND (2) No FDA labeled contraindications to requested agent.

Reauthorization criteria

• ALL of the following: (1) Patient previously approved through plan’s prior authorization process AND (2) Patient has had clinical benefit with the requested agent AND (3) BOTH of the following: (A) Hepatic function (ALT, AST, total and direct bilirubin) evaluated since starting therapy AND (B) Hepatic transaminases <2× ULN and total bilirubin normal AND (4) No FDA labeled contraindications to requested agent.

Approval duration

3 months initial; 12 months renewal (12 months BCBSIL)