Orilissa (elagolix) — CareFirst (Caremark)

Preferred products

• Lupron Depot
• Lupaneta Pack
• Synarel
• Zoladex

Initial criteria

• The requested drug is being prescribed for the management of moderate to severe pain associated with endometriosis.
• The patient has NOT received the maximum recommended treatment course of 12 months of Lupron Depot or Lupaneta Pack OR 6 months of Synarel or Zoladex.
• If the patient has not previously received treatment with an elagolix-containing product (e.g., Oriahnn, Orilissa) or a relugolix-containing product (e.g., Myfembree), the patient will receive 150 mg once daily of the requested drug OR 200 mg twice daily of the requested drug.
• If the patient has previously received treatment with an elagolix-containing product (e.g., Oriahnn, Orilissa) or a relugolix-containing product (e.g., Myfembree), the patient must not have already received any of the following: greater than or equal to 24 cumulative months of treatment with elagolix-containing products (e.g., Oriahnn, Orilissa) and/or relugolix-containing products (e.g., Myfembree), OR greater than or equal to 6 months of treatment with Orilissa 200 mg twice daily.

Approval duration

Up to a total additive duration of 24 months (based on cumulative prior treatment: 12 months if ≤12 months prior treatment; decreases by 1 month for each additional prior month up to 23)