Osphena — CareFirst (Caremark)

Initial criteria

• Authorization may be granted when the requested drug is being prescribed for the treatment of moderate to severe dyspareunia (pain during sexual intercourse) due to menopause.
• Authorization may be granted when the requested drug is being prescribed for the treatment of moderate to severe vaginal dryness due to menopause.

Reauthorization criteria

• Authorization may be granted when the requested drug is being prescribed for the treatment of moderate to severe dyspareunia (pain during sexual intercourse) due to menopause when ALL of the following criteria are met:
• The patient has achieved or maintained a positive clinical response to the requested drug.
• The patient has been re-evaluated periodically to determine if treatment is still medically necessary.
• Authorization may be granted when the requested drug is being prescribed for the treatment of moderate to severe vaginal dryness due to menopause when ALL of the following criteria are met:
• The patient has achieved or maintained a positive clinical response to the requested drug.
• The patient has been re-evaluated periodically to determine if treatment is still medically necessary.

Approval duration

12 months