MyFembree — United Healthcare
Moderate to severe pain associated with endometriosis
Preferred products
- analgesics (e.g., ibuprofen, meloxicam, naproxen)
- hormonal contraceptives
- progestins [e.g., norethindrone (generic Aygestin)]
Initial criteria
- Diagnosis of moderate to severe pain associated with endometriosis
- Failure after a three-month trial (inadequate pain relief), contraindication, or intolerance of TWO analgesics (e.g., ibuprofen, meloxicam, naproxen)
- Failure after a three-month trial, contraindication, or intolerance to ONE of the following: hormonal contraceptives OR progestins [e.g., norethindrone (generic Aygestin)]
- Prescribed by or in consultation with an Obstetrics/Gynecologist (OB/GYN) OR reproductive endocrinologist
Reauthorization criteria
- Documentation of positive clinical response to therapy
- Impact to bone mineral density has been considered
- Treatment duration has not exceeded a total of 24 months
Approval duration
12 months (up to a maximum total treatment duration of 24 months)