Pharmacy Prior Authorization Criteria

Intrarosa (prasterone)

Indications for Prior Authorization

Intrarosa (prasterone)

• For diagnosis of Moderate to Severe Dyspareunia
  Indicated for the treatment of moderate to severe dyspareunia, a symptom of vulvar and vaginal atrophy, due to menopause.

Criteria

Intrarosa

Step Therapy

Length of Approval: 12 Month(s)

• Requested drug is being used for a Food and Drug Administration (FDA)-approved indication
AND
• Trial and failure (of a minimum 28-day supply), contraindication, or intolerance to one of the following:
• Premarin vaginal cream
• Osphena

P & T Revisions

2025-06-04, 2024-06-20, 2023-05-10, 2022-06-02, 2021-07-07, 2020-09-02

References

1. Intrarosa Prescribing Information. Millicent U.S. Inc. East Hanover, NJ. November 2020.

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Revision History

• 2025-06-04: 2025 UM Annual Review. No criteria changes. Updated references.
• 2024-06-20: 2024 UM Annual Review. No criteria changes
• 2023-05-10: 2023 UM Annual Review. Updated trial duration to 28 days supply
• 2022-06-02: Updated criteria.
• 2021-07-07: New program
• 2020-09-02: New Program

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