Health Net
Orilissa (elagolix)
Hormones : Drugs for Women
  • Step Therapy: Endometriosis:
    ST Single Generic

  • 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): Positive response to therapy
    Excluded Condition(s): Osteoporosis
    Documented Diagnosis: Yes

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