Myfembree — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following: (A) Diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) AND (1) Diagnosis confirmed via imaging (e.g., ultrasound) AND (2) Patient has NOT had a hysterectomy OR (B) 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: (A) Tried and had an inadequate response to ONE prerequisite agent (hormonal contraceptive, NSAID [including COX-II inhibitors]) OR (B) Intolerance or hypersensitivity to ONE prerequisite agent (hormonal contraceptive, NSAID [including COX-II inhibitors]) OR (C) FDA labeled contraindication to ALL prerequisite therapies (hormonal contraceptives, NSAIDs [including COX-II inhibitors])
• Patient will NOT use the requested agent in combination with another GnRH antagonist agent targeted in this program (e.g., elagolix, relugolix) for the requested indication
• Patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: (A) Patient is initiating therapy with the requested agent OR (B) Patient is not initiating therapy with the requested agent AND (1) Support confirming number of months patient has been on therapy AND (2) Total duration of treatment has NOT exceeded 24 months per lifetime

Reauthorization criteria

• Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• Patient is premenopausal (e.g., less than 12 months since last menstrual period)
• Patient has had clinical benefit with the requested agent
• Patient’s bone health has been assessed and allows for continued therapy
• Patient has NOT had a fragility fracture since starting therapy with the requested agent
• Patient will NOT be using the requested agent in combination with another GnRH antagonist agent targeted in this program (e.g., elagolix, relugolix) for the requested indication
• Patient does NOT have any FDA labeled contraindications to the requested agent
• (A) Support confirming number of months patient has been on therapy AND (B) Total duration of treatment with the requested agent has NOT exceeded 24 months per lifetime

Approval duration

12 months (BCBSIL/BCBSTX); up to 6 months (others) with lifetime maximum 24 months