Myfembree — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient is premenopausal; AND
• Patient has previously tried one of the following, unless contraindicated (unless previously used a gonadotropin-releasing hormone agonist [e.g., Lupron Depot] or Orilissa):
• i. A contraceptive (e.g., combination oral contraceptives, levonorgestrel-releasing intrauterine systems [e.g., Mirena, Liletta], depo-medroxyprogesterone injection); OR
• ii. An oral progesterone (e.g., norethindrone tablets)

Reauthorization criteria

• Extended approval allowed if total therapy does not exceed 24 months

Approval duration

initial 12 months, reauth 12 months (up to 24 months total)