Synarel (nafarelin acetate) — Highmark

Preferred products

• Orilissa

Initial criteria

• Member is 18 years of age or older
• Member is female
• Diagnosis of endometriosis (ICD-10: N80)
• Provider attests member is not pregnant if of childbearing age
• Member has experienced therapeutic failure, contraindication, or intolerance to two standard of care treatments from: NSAIDs, combined hormonal contraceptive, progestin (e.g., medroxyprogesterone injection), GnRH agonist (leuprolide), danazol
• Member has experienced therapeutic failure, contraindication, or intolerance to plan-preferred Orilissa

Reauthorization criteria

• Reauthorizations will not be approved due to lack of safety data beyond 6 months of therapy

Approval duration

6 months