Myfembree — Blue Cross Blue Shield of Montana

Initial criteria

• 1. ONE of the following: A. The patient has a diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) and BOTH of the following: 1. The diagnosis of uterine fibroids was confirmed via imaging (e.g., ultrasound) AND 2. The patient has NOT had a hysterectomy OR B. The patient has a diagnosis of moderate to severe pain associated with endometriosis
• 2. The patient is premenopausal (e.g., less than 12 months since last menstrual period)
• 3. The patient’s bone health has been assessed AND allows for initiating therapy with the requested agent
• 4. ONE of the following: A. The patient has tried and had an inadequate response to ONE prerequisite agent (i.e., hormonal contraceptive, NSAID [including COX-II inhibitors]) used in the treatment of the requested indication OR B. The patient has an intolerance or hypersensitivity to ONE prerequisite agent OR C. The patient has an FDA labeled contraindication to ALL prerequisite therapies (i.e., hormonal contraceptives, NSAIDs including COX-II inhibitors)
• 5. The patient will NOT be using the requested agent in combination with another GnRH antagonist agent targeted in this program (e.g., elagolix, relugolix)
• 6. The patient does NOT have any FDA labeled contraindications to the requested agent
• 7. ONE of the following: A. The patient is initiating therapy OR B. The patient is not initiating therapy and BOTH of the following: 1. There is support confirming the number of months the patient has been on therapy AND 2. The total duration of treatment with the requested agent has NOT exceeded 24 months per lifetime

Reauthorization criteria

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

Approval duration

BCBSIL and BCBSTX: 12 months; all other plans: up to 6 months (at least 3 months for MT/NM), lifetime maximum 24 months