Health Net
Orilissa (elagolix)
Hormones : Drugs for Women
  • Prior Authorization: Endometriosis:
    Documented Diagnosis: Yes
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Endometriosis:
    Age Requirement: >= 18
    Duration: 12 Month(s)
    Specialist Required: Yes
    Medical Test Required: No
    Specialist Type(s): Gynecologist
    Reauthorization Required: Yes
    Duration of Reauthorization: <= 12 month(s)
    Surgical Ablation to Prevent Recurrence Required: No
    Reauthorization Requirement(s): 2 of Positive response to therapy;Treatment duration has not exceeded a total of 24 months
    Excluded Condition(s): 1 of Osteoporosis;Other excluded condition(s);Pregnancy or plan to become pregnant while taking medication;Receiving strong organic anion transporting polypeptide (OATP) 1B1 inhibitors;Severe hepatic impairment (Child Pugh C)
    Documented Diagnosis: Yes

  • Step Therapy: Endometriosis:
    ST Single Generic

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