flibanserin (Addyi®)

ORAL ADMINISTRATION

Indications for Prior Authorization:

Hypoactive sexual desire disorder

  • Treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD), as characterized by low sexual desire that causes marked distress or interpersonal difficulty and is not due to a coexisting medical or psychiatric condition, problems within the relationship, or the effects of a medication or other drug substance

Limitations of use

  • Flibanserin is not indicated for the treatment of HSDD in postmenopausal women or in men, or to enhance sexual performance

All of the following must be met as a condition(s) for coverage:

  • Treatment of premenopausal women with acquired, generalized hypoactive sexual desire disorder (HSDD), as characterized by low sexual desire that causes marked distress or interpersonal difficulty AND
  • Diagnosis is supported by medical record/chart note documentation AND
  • HSDD is not due to a coexisting medical or psychiatric condition, problems within the relationship, or the effects of a medication or other drug substance AND
  • patient is not taking a moderate or strong CYP3A4 Inhibitor (contraindication) concomitantly, is not using alcohol concomitantly, or does not have hepatic impairment

This Medication is Not Approvable for the following condition(s):

  • Any condition not listed above as an approved indication
  • Not approvable with concomitant use of alcohol or CYP3A4 inhibitors (contraindication), or for patients with hepatic impairment

Dosing:

  •  Females (premenopausal): 100 mg once daily at bedtime

 

Last review date: July 24, 2016

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