Skip to content
The Policy VaultThe Policy Vault

Myfembree (relugolix-estradiol-norethindrone acetate) — Blue Cross Blue Shield of New Mexico

moderate to severe pain associated with endometriosis

Initial criteria

  • ONE of the following: (A) Diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) and BOTH: diagnosis confirmed by imaging (e.g., ultrasound) AND no 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
  • ONE of the following: (A) Tried and had inadequate response to ONE prerequisite agent (hormonal contraceptive or NSAID including COX-II inhibitors) OR (B) Intolerance or hypersensitivity to ONE prerequisite agent 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)
  • Patient does NOT have any FDA labeled contraindications to the requested agent
  • ONE of the following: (A) Patient is initiating therapy OR (B) If not initiating, BOTH: support confirming number of months on therapy AND total duration 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
  • 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
  • BOTH of the following: support confirming number of months on therapy AND total duration of treatment has NOT exceeded 24 months per lifetime

Approval duration

6-12 months (lifetime max 24 months)