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Vyleesi — Blue Cross Blue Shield of Texas

acquired, generalized hypoactive sexual desire disorder (HSDD) in premenopausal women

Initial criteria

  • ONE of the following: (A) ALL of the following: (1) The patient's benefit plan covers the requested agent AND (2) The patient is premenopausal AND (3) BOTH of the following: (A) ONE of the following: (1) The patient has a diagnosis of acquired, generalized HSDD OR (2) The patient has had a diagnosis of FSIAD AND (B) BOTH of the following: (1) The patient's HSDD is characterized by low sexual desire that causes marked distress or interpersonal difficulty AND (2) The patient's symptoms of low sexual desire have been present for at least 6 months AND (4) The HSDD is NOT due to ANY of the following: (A) A co-existing medical or psychiatric condition OR (B) Problems within the relationship OR (C) The effects of a medication or other drug substance OR (B) Both of the following: (1) The patient's benefit plan covers the requested agent AND (2) The patient has another FDA labeled or compendia supported indication for the requested agent and route of administration
  • The patient has tried and had an inadequate response to other treatment modalities (e.g., education, modification of contributing factors, and 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
  • Compendia Allowed: 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

BCBSIL: 12 months; BCBSMT/BCBSNM: 3 months; All other plans: 8 weeks; Renewal: 12 months