Oriahnn (elagolix-estradiol-norethindrone) — Blue Cross Blue Shield of New Mexico

Initial criteria

• Diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids)
• Diagnosis of uterine fibroids 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
• 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

Approval duration

6-12 months (lifetime max 24 months)