Oriahnn — Blue Cross Blue Shield of Oklahoma

Initial criteria

• The patient has a diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids)
• The diagnosis of uterine fibroids was confirmed via imaging (e.g., ultrasound)
• The patient has NOT had a hysterectomy
• The patient is premenopausal (less than 12 months since last menstrual period)
• The 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 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 or NSAIDs including COX-II inhibitors)
• The patient will NOT be using the requested agent in combination with another GnRH antagonist (e.g., elagolix, relugolix)
• The patient does NOT have any FDA labeled contraindications to the requested agent
• ONE of the following: A. The patient is initiating therapy with the requested agent OR B. The patient is not initiating therapy and BOTH: 1. 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

Approval duration

6–12 months (lifetime maximum 24 months)