Myfembree (relugolix, estradiol, and norethindrone acetate tablets) — Cigna

Initial criteria

• Patient is age ≥ 18 years AND
• Patient is premenopausal (before menopause) AND
• Patient is experiencing heavy menstrual bleeding associated with uterine fibroids AND
• Uterine fibroids have been confirmed by a pelvic ultrasound (including transvaginal ultrasonography or sonohysterography), hysteroscopy, or magnetic resonance imaging AND
• Patient has tried at least one other therapy for the medical management of heavy menstrual bleeding (examples include combination estrogen-progestin contraceptives [oral tablets, vaginal ring, transdermal patch], levonorgestrel-releasing intrauterine systems [e.g., Mirena, Liletta], oral progesterone [e.g., medroxyprogesterone acetate], depo-medroxyprogesterone injection, tranexamic acid tablets) AND
• Patient has not previously received a continuous regimen of 24 months or longer of therapy with Myfembree or Oriahnn AND
• Medication is prescribed by or in consultation with an obstetrician-gynecologist or a health care practitioner specializing in women’s health

Approval duration

up to 24 months