Oriahnn — Blue Cross Blue Shield of Texas

Initial criteria

• Diagnosis confirmed via imaging (e.g., ultrasound)
• Patient has NOT had a hysterectomy
• Patient is premenopausal (less than 12 months since last menstrual period)
• Patient’s bone health assessed and allows initiating therapy
• ONE of: tried and inadequate response to ONE prerequisite agent (hormonal contraceptive or NSAID including COX-II inhibitors) OR intolerance/hypersensitivity to ONE prerequisite OR FDA labeled contraindication to ALL prerequisite therapies
• Not used in combination with another GnRH antagonist (e.g., elagolix, relugolix)
• 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

Approval duration

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