Pharmacy Prior Authorization Criteria

Intrarosa (prasterone)

Indications for Prior Authorization

Intrarosa (prasterone insert)

• 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 two of the following:
• Premarin vaginal cream
• Imvexxy
• Osphena

P & T Revisions

2024-06-20, 2023-05-10, 2022-06-17, 2021-05-06, 2020-09-02

References

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

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Revision History

• 2024-06-20: 2024 UM Annual Review. No criteria changes
• 2023-05-10: 2023 UM Annual Review. Updated trial duration to minimum 28 days
• 2022-06-17: Annual review: added criterion “Requested drug is being used for a Food and Drug Administration (FDA)-approved indication”.
• 2021-05-06: Annual Review
• 2020-09-02: New Program

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