Orilissa (elagolix tablets – AbbVie) — Cigna

Initial criteria

• Patient has tried ONE of the following, unless contraindicated (i or ii):
• i. A contraceptive (e.g., combination oral contraceptives, levonorgestrel-releasing intrauterine systems [e.g., Mirena {levonorgestrel intrauterine system}, Liletta {levonorgestrel intrauterine system}], a depo-medroxyprogesterone injection); OR
• ii. An oral progesterone (e.g., norethindrone tablets);
• Note: An exception to the requirement for a trial of the above therapies can be made if the patient had previously used a gonadotropin-releasing hormone agonist (e.g., Lupron Depot [leuprolide depot injection]) or Myfembree (relugolix, estradiol, norethindrone tablets) for endometriosis.

Reauthorization criteria

• Patient is currently receiving Orilissa.

Approval duration

6 months