UnitedHealthcare
Orilissa (elagolix)
Hormones : Drugs for Women
  • Step Therapy: Endometriosis:
    ST Multiple Generics

  • Prior Authorization: Endometriosis:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

  • Quantity Limit: Maximum quantity of 31 per 31 Day(s). Maximum quantity 1 tablet per day.
  • Endometriosis:
    Duration: 6 Month(s)
    Specialist Required: Yes
    Medical Test Required: No
    Specialist Type(s): 1 of Endocrinologist;Gynecologist;Obstetrician
    Reauthorization Required: Yes
    Duration of Reauthorization: = 6 month(s)
    Surgical Ablation to Prevent Recurrence Required: No
    Reauthorization Requirement(s): 2 of Bone mineral density within normal limits;Positive response to therapy
    Documented Diagnosis: Yes