Oriahnn — Blue Cross Blue Shield of Illinois

Initial criteria

• Diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids)
• Diagnosis confirmed via imaging (e.g., ultrasound)
• Patient has NOT had a hysterectomy
• 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 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
• ONE of the following: (A) Patient is initiating therapy with requested agent OR (B) Patient not initiating therapy AND (1) Support confirming number of months patient has been on therapy AND (2) Total duration NOT exceeded 24 months per lifetime

Approval duration

Not explicitly stated in excerpt (likely 12 months similar to Myfembree)