Subject: Osphena PA Policy 961-A 01-2022
Policy:
FDA-approved Indications
Osphena is indicated for:
• The treatment of moderate to severe dyspareunia, a
symptom of vulvar and vaginal atrophy, due to
menopause.
• The treatment of moderate to severe vaginal
dryness, a symptom of vulvar and vaginal atrophy,
due to menopause.
COVERAGE CRITERIA
The requested drug will be covered with prior authorization when the following criteria are met:
• The requested drug is being prescribed for the
treatment of any of the following: A) Moderate to
severe dyspareunia (pain during sexual intercourse)
due to menopause, B) Moderate to severe vaginal
dryness due to menopause
Place of Service:
Outpatient
The above policy is based on the following references:
- Osphena [package insert]. Florham Park, NJ: Shionogi Inc.; January 2019.
- Lexicomp Online, AHFS DI (Adult and Pediatric) Online, Hudson, Ohio: UpToDate, Inc.; 2021; Accessed December 2, 2021.
- Micromedex (electronic version). IBM Watson Health, Greenwood Village, Colorado, USA. Available at: https://www.micromedexsolutions.com. Accessed December 2, 2021.
Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
June 12, 2022
