Myfembree — Blue Cross Blue Shield of Alabama

Initial criteria

• Diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) confirmed via imaging (e.g., ultrasound) AND patient has NOT had a hysterectomy OR diagnosis of moderate to severe pain associated with endometriosis
• Patient is premenopausal (e.g., less than 12 months since last menstrual period)
• Patient’s bone health has been assessed AND allows for initiating therapy with the requested agent
• ONE of the following: patient has tried and had an inadequate response to ONE prerequisite agent (hormonal contraceptive or NSAID including COX-II inhibitors) OR patient has intolerance or hypersensitivity to ONE prerequisite agent OR patient has an FDA labeled contraindication to ALL prerequisite therapies (hormonal contraceptives including oral, topical patches, implants, injections, IUD, NSAIDs including COX-II inhibitors)
• Patient will NOT be using the requested agent in combination with another GnRH antagonist agent targeted in this program (e.g., elagolix, relugolix)
• Patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: patient is initiating therapy with the requested agent OR patient is not initiating therapy and BOTH of the following: (a) there is support confirming the number of months the patient has been on therapy AND (b) total duration of treatment with the requested agent has NOT exceeded 24 months per lifetime

Approval duration

6 months (lifetime maximum 24 months)