Vyleesi (bremelanotide subcutaneous injection) — Cigna

Initial criteria

• Patient is premenopausal; AND
• Patient’s symptoms of HSDD/FSIAD have persisted for a minimum of 6 months; AND
• Patient has had normal sexual desire in the past, prior to the diagnosis of HSDD/FSIAD; AND
• Patient has not been diagnosed or treated with depression within the previous 6 months; AND
• Other known causes of HSDD/FSIAD, such as co-existing medical or psychiatric conditions, problems within a relationship, effects of medications (e.g., antidepressants), or drug abuse have been ruled out by the prescriber

Reauthorization criteria

• Patient is premenopausal; AND
• The prescriber confirms that since initiating Vyleesi therapy, the patient reports a significant improvement in sexual desire and/or a decrease in sexual distress

Approval duration

8 weeks initial, 6 months reauth