MYFEMBREE (relugolix, estradiol hemihydrate, and norethindrone acetate)

Self-Administration-Oral

Indications for Prior Authorization:

Heavy Menstrual Bleeding Associated With Uterine Leiomyomas (Fibroids) - Indicated for the management of heavy menstrual bleeding associated with uterine leiomyomas (fibroids) in premenopausal women.

Pain Associated With Endometriosis - Indicated for the management of moderate to severe pain associated with endometriosis in premenopausal women. 

Limitation of Use:

  • Use should be limited to 24 months due to the risk of continued bone loss, which may not be reversible. 
Coverage Criteria:

For diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids):

  • Dose does not exceed 1 tablet (relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) daily, AND
  • Patient is 18 years of age or older, AND
  • Patient has a diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids), AND
  • Patient is premenopausal, AND
  • Prescribed by or in consultation with an obstetrics/gynecologist (OB/GYN) or reproductive endocrinologist, AND
  • History of inadequate control of bleeding following a trial of at least 3 months, or history of intolerance or contraindication to one of the following:
    • Combination (estrogen/progesterone) oral contraceptive, OR
    • Progestins, OR
    • Tranexamic acid, OR
  • Patient has had a previous interventional therapy to reduce bleeding (e.g., uterine-artery embolization and magnetic resonance-guided focused ultrasonography)

For diagnosis of pain associated with endometriosis: 

  • Dose does not exceed 1 tablet (relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) daily, AND
  • Patient is 18 years of age or older, AND
  • Patient has a diagnosis of moderate to severe pain associated with endometriosis, AND
  • Patient is premenopausal, AND
  • Prescribed by or in consultation with an obstetrics/gynecologist (OB/GYN) or reproductive endocrinologist, AND
  • History of inadequate control of bleeding following a trial of at least 3 months, or history of intolerance or contraindication to one of the following:
    • Danazol, OR
    • Combination (estrogen/progesterone) oral contraceptive, OR
    • Progestins, OR
    • Patient has had surgical ablation to prevent recurrence
       
Reauthorization Criteria:

For diagnosis of heavy menstrual bleeding associated with uterine leiomyomas (fibroids):

  • Dose does not exceed 1 tablet (relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) daily, AND
  • Patient has improvement in bleeding associated with uterine leiomyomas (fibroids) (e.g., significant/sustained reduction in menstrual blood loss per cycle, improved quality of life, etc.), AND
  • Treatment duration of therapy has not exceeded a total of 24 months

For diagnosis of pain associated with endometriosis: 

  • Dose does not exceed 1 tablet (relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) daily, AND
  • Patient has improvement in pain associated with endometriosis (e.g., improvement in dysmenorrhea and nonmenstrual pelvic pain), AND
  • Treatment duration of therapy has not exceeded a total of 24 months
Dosing:
  • 1 tablet (relugolix 40 mg, estradiol 1 mg, and norethindrone acetate 0.5 mg) orally once daily at approximately the same time.

  • Max duration of therapy: 24 months

Coverage Duration:
  • Initial: 1 year

  • Reauthorization: 1 year

Authorization is not covered for the following:

The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

Additional Information:
  • Recommended dose: one tablet orally once daily

  • Start Myfembree as early as possible after the onset of menses but no later than seven days after menses has started

  • The recommended total duration of treatment with Myfembree is 24 months due to the risk of continued bone loss which may not be reversible

  • Contraindications

    • High risk of arterial, venous thrombotic, or thromboembolic disorder

    • Pregnancy

    • Known osteoporosis

    • Current or history of breast cancer or other hormone-sensitive malignancies

    • Known hepatic impairment or disease

    • Undiagnosed abnormal uterine bleeding

    • Known hypersensitivity to components of Myfembree

  • Avoid use of Myfembree with oral P-gp inhibitors

  • Avoid use with combined P-gp and strong CYP3A inducers, as the exposure of the components of Myfembree may be decreased

Policy Updates:
  • 11/16/2021 – New policy approved by P&T

  • 05/16/2023 – Updated criteria.

References:
  • Myfembree Prescribing Information. Myovant Sciences, Inc. Brisbane, CA. August 2022.

  • De La Cruz MS, Buchanan EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician. 2017 Jan 15;95 (2): 100-107. Available by subscription at: https://www.aafp.org/afp/2017/0115/p100.html. Accessed June 8, 2021.

  • Stewart EA. Uterine Fibroids (Leiomyomas): Treatment Overview. UpToDate. Available by subscription at: https://www.uptodate.com. Accessed June 8, 2021.

  • Al-Hendy A, Lukes AS, Poindexter A, et al. LIBERTY: Long-term Extension Study Demonstrating One-year Efficacy and Safety of Relugolix Combination Therapy in Women with Symptomatic Uterine Fibroids. ASRM Scientific Congress & Expo. October

  • Nezhat, C., Vang, N. et al. Optimal Management of Endometriosis and Pain. Obstetrics & Gynecology: October 2019 - Vol. 134, Issue 4, p 834-839.

Last review date: September 22, 2023

Rite Aid Pharmacy Patients: All Rite Aid pharmacies nationwide are closing! Please be on the lookout for information from Rite Aid pharmacies about their bankruptcy and store closures. Call your Rite Aid pharmacy for questions about your prescriptions and new pharmacy options. WHA is here to help as well. Contact Us via Phone