Addyi (flibanserin) prior authorization and reauthorization form
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This document is a prior authorization and reauthorization request form for Addyi (flibanserin) used to treat hypoactive sexual desire disorder (HSDD) in premenopausal females. It governs requirements providers must submit to Highmark BlueShield for coverage consideration.
No material clinical or coverage changes in this revision.
Coverage Criteria & Screening
Authorization criteria
Covered when ALL of the following are provided on the form and documented:
These items are captured by yes/no questions on the form.
The Addyi prior authorization form includes a specific clinical screening item asking whether the member has a current issue with alcohol or substance abuse. A positive response to this item would preclude safe use of flibanserin because of known interaction and safety concerns; therefore the form requires documentation of a yes/no response to this screening question before coverage can be considered.
Initial Authorization Requirements
Initial therapy criteria
Initial authorization documents baseline diagnostic and therapy consideration.
Captured by Clinical Information questions 1–4d on the form.
Reauthorization / Continuation Requirements
Reauthorization
Reauthorization requires documentation of tolerability and benefit.
Captured as two yes/no questions in the Reauthorization section of the form.
Provider Actions & Submission Instructions
Prior Authorization Required
Prior authorization requires completion of the Addyi PA form including patient, provider, medication, clinical information and signature. A separate, fully completed form must be submitted for each medication with the prescribing physician's signature.
- Submit a separate completed form for each medication.
- Fax completed form and all clinical documentation to 1-866-240-8123 or mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
Required Clinical Information
Complete all required clinical information on the form: medication information (drug name, strength, requested quantity, requested day supply, directions), diagnosis and/or ICD-10 code(s), and answers to the clinical questions below. The prescribing physician (PCP or Specialist) should, in most cases, complete and sign the form.
- Medication information: Drug name, Drug strength, Requested quantity, Requested day supply (30, 90, Other), Directions.
- Diagnosis and/or ICD-10 code(s).
- Clinical questionnaire answers (see clinical information callout).
Behavioral Therapy Consideration & Clinical Questions
The form asks whether the member is a premenopausal female; whether there is current alcohol or substance abuse; whether the member has been educated on Addyi administration and the alcohol-related adverse effects; and whether the member has a diagnosis of HSDD. If HSDD is present, the form queries whether the diagnosis is related to medical/psychiatric conditions, substance abuse, or relationship issues, and it asks about behavioral therapy candidacy, current enrollment, and prior therapeutic failure.
- Is the member a premenopausal female? (Yes/No)
- Does the member have a current issue with alcohol or substance abuse? (Yes/No)
- Has the member been educated on Addyi administration including potential adverse effects of alcohol consumption with Addyi? (Yes/No)
- Does the member have a diagnosis of HSDD (hypoactive sexual desire disorder)? (Yes/No)
- If HSDD: Is diagnosis related to co-existing medical/psychiatric condition, substance abuse, or relationship issue? (Yes/No)
- If HSDD: Is the member a candidate for behavioral therapy? (Yes/No)
- If HSDD: Is the member currently enrolled in behavioral therapy? (Yes/No)
- If HSDD: Has the member experienced therapeutic failure of behavioral therapy? (Yes/No)
Payment and Authorization Notice
The submitting provider certifies that the information provided is true, accurate and complete and that the requested services are medically indicated and necessary to the health of the member. Note: Payment is subject to member eligibility. Authorization does not guarantee payment.
Diagnosis & Billing Codes
| ICD-10 | Diagnosis and/or ICD-10 code(s) (specific codes to be provided by prescriber) |
Step Therapy / Behavioral Therapy Trial
| Requirement | Documentation on form |
|---|---|
| Document whether the member is a candidate for behavioral therapy for HSDD (yes/no) | |
| Document whether the member is currently enrolled in behavioral therapy for HSDD (yes/no) | |
| Document whether the member has experienced therapeutic failure of behavioral therapy for HSDD (yes/no) | |
| If not appropriate, provide reason behavioral therapy is not appropriate (documented on form) |
Clinical Background
Flibanserin (Addyi) is indicated for treatment of hypoactive sexual desire disorder (HSDD) in premenopausal females. The PA form captures premenopausal status, confirmation of an HSDD diagnosis, and related clinical details including whether the HSDD is attributable to co-existing medical/psychiatric conditions, substance abuse, or relationship issues; it also documents behavioral therapy candidacy, enrollment, or therapeutic failure and whether the member has been educated about alcohol-related adverse effects with Addyi.
Key Definitions
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