Orilissa 150 mg (elagolix) — United Healthcare
moderate to severe pain associated with endometriosis
Initial criteria
- Diagnosis of moderate to severe pain associated with endometriosis
- Failure after a 3-month trial (e.g., inadequate pain relief), contraindication, or intolerance of two analgesics (e.g., ibuprofen, meloxicam, naproxen)
- Failure after a 3-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 Obstetrician/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 (initial and reauthorization) up to a maximum treatment duration of 24 months