Medication Prior Authorization Form — Addyi (flibanserin)
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This document is a medication prior authorization form used by Highmark Pennsylvania for requesting coverage of Addyi (flibanserin) and applies to prescribers submitting PA requests for members. It governs the information and clinical responses required to process initial and reauthorization requests.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy — Covered when ALL of the following are met and documented on the form
Covered when ALL of the following are met and documented on the form
All items correspond to checkboxes/questions and the medication history section on the form.
Continuation Therapy / Reauthorization — Reauthorization requires documentation that BOTH conditions are met
Reauthorization requires documentation that BOTH conditions are met
Both yes responses are requested on the reauthorization section of the form.
The form explicitly screens for current alcohol or substance abuse as part of the clinical information. A positive response to "Does the member have a current issue with alcohol or substance abuse?" indicates a contraindication or important caution for Addyi (flibanserin) and must be documented on the form. The form also requires documentation that the member has been educated about the risks of alcohol use with Addyi—providers must confirm whether the member "has been educated on Addyi administration including the potential adverse effects of alcohol consumption with Addyi."
When HSDD is documented, the form requests further clinical context that can affect appropriateness of therapy: whether the HSDD is related to co-existing medical or psychiatric conditions, substance abuse, or relationship issues. Behavioral therapy considerations are captured as well—providers must indicate if the member is a candidate for behavioral therapy, currently enrolled, or has experienced therapeutic failure of behavioral therapy. These items must be completed and signed by the prescriber to support an initial authorization.
Initial Therapy Requirements
Initial Therapy — Initial authorization requires clinical and medication history details
Initial authorization requires clinical and medication history details
These items are captured by the Clinical Information and Medication History sections on the form.
Continuation / Reauthorization Criteria
Reauthorization — Reauthorization questions to assess continued benefit and tolerability
Reauthorization questions to assess continued benefit and tolerability
Both reauthorization questions are required on the form; provider may include updated medication history in the Medication History section.
Provider Actions & Submission Requirements
Prior Authorization Required
Prior authorization is required before services will be considered for coverage. Complete the Medication Information and Clinical Information sections in full, including the diagnosis and applicable ICD-10 code(s), drug name, strength, requested quantity, day supply, directions, and whether this is a new request or reauthorization. Fax or mail the completed form and all supporting clinical documentation as instructed. Authorization does not guarantee payment; payment is subject to member eligibility.
- Complete Medication Information and Clinical Information sections including diagnosis / ICD-10 code(s).
- Include drug name, strength, requested quantity, requested day supply (e.g., 30 or 90 days), and directions.
- Fax completed form and clinical documentation to 1-866-240-8123 or mail to 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222.
Step / Prior Therapy Documentation
Provide a medication history documenting prior treatments tried and failed. For conditions where behavioral therapy is relevant, indicate whether the member is a candidate for behavioral therapy, currently enrolled, and whether behavioral therapy has failed. For reauthorization requests, document tolerance and clinical benefit compared to baseline.
- List other medications the member has tried and failed (include dates, doses, and reason for discontinuation where available).
- If applicable, answer behavioral therapy questions: candidate for behavioral therapy; currently enrolled; therapeutic failure of behavioral therapy.
- For reauthorization: document tolerance of therapy and improvement in symptoms from baseline.
Required Submission Documentation
Include complete member and provider identifying information, medication details, clinical answers to form questions, and the prescribing physician's signature and date. Ensure physician address and contact information are provided. Submit all supporting clinical documentation (chart notes, test results, specialty consults) with the form.
- Member information: subscriber ID, group number, member name, DOB, phone, address.
- Provider information: physician name, NPI, phone, fax, address, suite/building, physician signature and date.
- Medication details: drug name, strength, quantity, day supply, directions, diagnosis / ICD-10 code(s).
- Attach supporting documentation (clinical notes, test results, prior medication records).
Incomplete Information May Cause Denial
Incomplete, inaccurate, or missing information may delay review or result in denial. The submitting provider certifies the information is true, accurate, and complete. Remember: authorization approval does not guarantee payment; payment depends on member eligibility and plan benefits.
- Incomplete forms or missing clinical documentation may prevent payment or lead to denial.
- Provider certification statement must be included; signature and date required.
- Authorization is not a guarantee of payment — verify member eligibility and benefits.
Coding and Dispensing Details
| ICD-10 | Diagnosis and/or ICD-10 code(s) (specific code to be provided by prescriber) |
Step Therapy / Prior Medication History
| Requirement | Provider must document |
|---|---|
| {"text":"Prior medication therapy","status":""},{"text":"List other medications the member has tried and failed (medication history section).","status":""} | |
| {"text":"Behavioral therapy status (if applicable)","status":""},{"text":"Indicate whether the member is a candidate for behavioral therapy, currently enrolled, and whether behavioral therapy has failed (questions 3b–3d on the form).","status":""} | |
| {"text":"Alcohol/substance use screening","status":""},{"text":"Document whether the member has a current issue with alcohol or substance abuse (clinical question 1).","status":""} | |
| {"text":"Education on alcohol risks","status":""},{"text":"Confirm the member has been educated on Addyi administration and the potential adverse effects of alcohol consumption with Addyi (clinical question 2).","status":""} |
Quantity Limits
Site of Care and Submission Methods
Form Completion and Submission (Office)
The prescribing physician (PCP or specialist) should complete and sign the form; submit the completed form and all clinical documentation via fax or mail using the contact information on the form.
- Fax completed form and documentation to 1-866-240-8123
- Mail to: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
Background
This prior authorization form is specific to requests for Addyi (flibanserin) for the treatment of hypoactive sexual desire disorder (HSDD). The Clinical Information section collects confirmation of HSDD diagnosis and asks the prescriber to identify whether the diagnosis is related to comorbid medical/psychiatric conditions, substance abuse, or relationship issues.
The form requires documentation that the member has been educated about Addyi administration and the potential adverse effects of alcohol consumption when taking Addyi. It also captures behavioral therapy status (candidate, currently enrolled, or failed) to inform clinical appropriateness and prior-therapy considerations.
Definitions
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