bremelanotide — CareFirst (Caremark)

Initial criteria

• Patient has a diagnosis of acquired, generalized hypoactive sexual desire disorder (HSDD)
• Patient is premenopausal
• HSDD is NOT caused by a co-existing medical or psychiatric condition, problems with the relationship, or the effects of a medication or drug substance
• Diagnosis has been appropriately documented (evaluated by a complete clinical assessment using DSM and interviews/questionnaires)

Reauthorization criteria

• Patient has a diagnosis of acquired, generalized hypoactive sexual desire disorder (HSDD)
• Patient is premenopausal
• HSDD is NOT caused by a co-existing medical or psychiatric condition, problems with the relationship, or the effects of a medication or drug substance
• Patient has received at least an 8-week supply of the requested drug as a paid claim through a pharmacy benefit (excluding samples or vouchers/coupons)
• Patient has experienced an improvement in the symptoms of HSDD since starting this therapy

Approval duration

Initial: 3 months; Continuation: 12 months