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relugolix — Blue Cross Blue Shield of Illinois

FDA labeled or compendia-supported indications; non-oncology or oncology settings (as specified)

Initial criteria

  • The member resides in Ohio AND The plan is Fully Insured or HIM Shop (SG)
  • The patient does NOT have any FDA labeled contraindications to the requested agent
  • ONE of the following: (1) The patient has another FDA labeled indication for the requested agent and route of administration OR (2) The patient has another indication supported in compendia for the agent and route OR (3) The prescriber submitted TWO peer-reviewed journal articles (e.g., JAMA, NEJM, Lancet) supporting safe and effective use (no case studies permitted)

Approval duration

12 months