Myfembree — Highmark
Endometriosis with moderate to severe pain
Initial criteria
- age ≥ 18 years
- diagnosis of endometriosis (ICD-10: N80) with documentation of moderate to severe pain
- premenopausal woman
- prescriber attests that the member is not pregnant if of childbearing age
- no diagnosis of osteoporosis
- therapeutic failure, contraindication, or intolerance to at least two of the following: generic NSAID, combined hormonal contraceptive, progestin (specifically medroxyprogesterone injection), GnRH agonist (for example, leuprolide)
- total combined treatment duration with Oriahnn, Orilissa, and Myfembree has not exceeded 24 months
Reauthorization criteria
- prescriber attests that the member has experienced a reduction in pain associated with endometriosis
- prescriber attests that the benefit of treatment exceeds the risk of bone loss
- total combined treatment duration with Oriahnn, Orilissa, and Myfembree has not exceeded 24 months
- prescriber attests that the member is not pregnant if of childbearing age
Approval duration
initial up to 6 months; reauthorization up to 18 months (total combined ≤ 24 months; Orilissa 200 mg cumulative ≤ 6 months)