Intrarosa — Medical Mutual

Initial criteria

• Patient is a post-menopausal woman with a diagnosis of moderate-to-severe dyspareunia due to vulvar and vaginal atrophy; AND
• Patient has tried and failed a low dose estrogen preparation (e.g., generic estradiol vaginal cream, generic estradiol vaginal insert, Yuvafem, Premarin vaginal cream, Estrace vaginal cream, Estring, Vagifem); OR
• According to the prescriber, the patient is at an increased risk of endometrial cancer, stroke, and/or deep vein thrombosis (DVT); AND
• Patient does not have any of the following contraindications to Intrarosa: undiagnosed abnormal genital bleeding, pregnant or breastfeeding, current or past history of breast cancer; AND
• Patient does not have renal or hepatic impairment; AND
• Use of Intrarosa will be for the shortest duration consistent with treatment goals and risks, with periodic re-evaluation

Reauthorization criteria

• Patient meets all of the criteria for new starts; AND
• Patient has been evaluated and seen improvement on Intrarosa, as determined by the prescriber

Approval duration

initial 3 months; reauth 1 year