Orilissa (elagolix tablets) — Medica
Endometriosis
Preferred products
- combination oral contraceptives
- levonorgestrel-releasing intrauterine systems (Mirena, Liletta)
- depo-medroxyprogesterone injection
- oral progesterone (norethindrone tablets)
- Lupron Depot (leuprolide depot injection)
- Myfembree (relugolix, estradiol, norethindrone tablets)
Initial criteria
- Patient has tried ONE of the following, unless contraindicated (an exception to the requirement for a trial 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):
- i. A contraceptive (e.g., combination oral contraceptives, levonorgestrel-releasing intrauterine systems [e.g., Mirena, Liletta], a depo-medroxyprogesterone injection); OR
- ii. An oral progesterone (e.g., norethindrone tablets)
Reauthorization criteria
- Patient is currently receiving Orilissa
Approval duration
6 months