Pharmacy Prior Authorization Criteria

Orgovyx (relugolix)

Indications for Prior Authorization

Orgovyx (relugolix)

• For diagnosis of Prostate Cancer
  Indicated for the treatment of adult patients with advanced prostate cancer.

Criteria

Orgovyx

Prior Authorization (Initial Authorization)

Length of Approval: 12 Month(s)

• Diagnosis of advanced prostate cancer
AND
• Disease is one of the following:
• Evidence of biochemical or clinical relapse following local primary intervention with curative intent
• Newly diagnosed androgen-sensitive metastatic disease
• Advanced localized disease unlikely to be cured by local primary intervention with curative intent

Orgovyx

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)

• Patient does not show evidence of progressive disease while on therapy
AND
• Documentation of serum testosterone level less than 50 ng/dL

P & T Revisions

2025-01-08, 2023-12-29, 2023-02-27, 2022-01-14, 2021-09-27, 2021-05-21, 2021-03-03, 2021-02-11

References

1. Orgovyx Prescribing Information. Myovant Sciences, Inc. Brisbane, CA. October 2024.

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Revision History

• 2025-01-08: 2025 UM Annual Review. No criteria changes. Background updates
• 2023-12-29: 2024 UM Annual Review. Removal of prescriber requirement. Background updates
• 2023-02-27: 2023 UM Annual Review. No changes to criteria. Updated references.
• 2022-01-14: 2022 UM Annual Review.
• 2021-09-27: Addition of EHB formulary to guideline, no changes to criteria
• 2021-05-21: Addition of EHB formulary to guideline, no changes to criteria
• 2021-03-03: Removed criterion of patient requiring least one year of androgen deprivation therapy.
• 2021-02-11: New program.

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