Myfembree — Blue Cross Blue Shield of Texas

Initial criteria

• Diagnosis confirmed via imaging for uterine fibroids OR diagnosis of moderate to severe endometriosis pain
• Patient has NOT had a hysterectomy if uterine fibroid indication
• Patient is premenopausal (less than 12 months since last menstrual period)
• Patient’s bone health has been assessed and allows initiating therapy
• ONE of: tried and inadequate response to ONE prerequisite agent (hormonal contraceptive or NSAID including COX-II inhibitor) OR intolerance/hypersensitivity to ONE prerequisite OR FDA labeled contraindication to ALL prerequisite therapies
• Patient will NOT use requested agent in combination with another GnRH antagonist (e.g., elagolix, relugolix)
• Patient has no FDA labeled contraindications to requested agent
• ONE of: initiating therapy OR continuing therapy with documentation of months on therapy AND total duration has NOT exceeded 24 months per lifetime

Reauthorization criteria

• Patient previously approved through plan’s PA process
• Patient is premenopausal (less than 12 months since last menstrual period)
• Patient has had clinical benefit with requested agent
• Bone health assessed and allows continued therapy
• No fragility fracture since starting therapy
• Not using in combination with another GnRH antagonist agent (e.g., elagolix, relugolix)
• No FDA labeled contraindications to requested agent
• Documentation confirming number of months on therapy AND total duration has NOT exceeded 24 months per lifetime

Approval duration

12 months (BCBSIL and BCBSTX) or up to 6 months (others); lifetime max 24 months