CurrentBlue Cross Blue Shield - South CarolinaPolicy N/A

Oriahnn prior authorization request form — coverage criteria and submission instructions

This document is a prior authorization request form for Oriahnn for prescribers and pharmacies to request coverage from OptumRx/Blue Cross Blue Shield - South Carolina. It outlines required provider, medication, clinical, and quantity-limit information needed to process a PA.

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOriahnn prior authorization request form — coverage criteria and submission instructions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Oriahnn prior authorization form via fax to 844-403-1029 or via CoverMyMeds at go.covermymeds.com/OptumRx for processing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2 pagesform length

844-403-1029fax

CoverMyMedsonline PA portal

855-811-2218phone

Coverage Criteria

Policy Summary

PayerBlue Cross Blue Shield - South Carolina

PolicyOriahnn prior authorization request form — coverage criteria and submission instructions

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed Oriahnn prior authorization form via fax to 844-403-1029 or via CoverMyMeds at go.covermymeds.com/OptumRx for processing.

SourceLink

On This Page

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Core required documentation: Completed provider information, medication details, prescriber signature, and answers to all applicable clinical questions on the form.

Required for submission; request may be denied unless all required information is received.

Contraceptive trial requirement: Patient has tried and had inadequate response to hormonal contraceptives OR has documented intolerance, FDA‑labeled contraindication, or hypersensitivity to hormonal contraceptives.

One of these must be documented for approval.

Bone safety assessment when osteoporosis risk present: If patient has osteoporosis or history of low‑trauma fracture/other risk for bone loss, prescriber must have assessed bone mineral density and state the patient can continue therapy, and patient must not have had a fragility fracture since starting Oriahnn.

Both conditions required when osteoporosis/bone‑loss risk is present.

Indication: Patient has heavy menstrual bleeding associated with uterine leiomyomas (fibroids) and is premenopausal.

Indication and premenopausal status must be documented.

Duration and prior‑use consideration: Document whether patient has received 24 or more months of therapy with Oriahnn; prior Oriahnn use and duration should be reported.>=24 months

Prior duration may affect continuation/approval and should be provided when applicable.

Quantity limits and titration: If requesting titration quantity, indicate authorization for a 90‑day titration period; if requested dose/quantity exceeds the maximum FDA‑labeled or manufacturer's studied dose, prescriber must submit supporting documentation (medical records or completed form reflecting medical record documentation) showing length of time higher dose used and prior medications/doses tried and failed.

Documentation required for doses above studied/FDA‑labeled limits.

The prior authorization form does not list any explicit coverage exclusions. Instead, the clinical questions on the form function as screening items that may affect authorization decisions. In particular, the form asks whether the patient has a documented intolerance, FDA-labeled contraindication, or hypersensitivity to hormonal contraceptives, and whether the patient has osteoporosis or a history of low-trauma fracture or other risk for bone loss; these responses are used to identify safety concerns or contraindications that could preclude use.

Providers must complete all required clinical fields on the form, including documentation of prior trials of hormonal contraceptives or reasons they are not appropriate, and bone health assessments when risk factors are present. The form’s questions (e.g., prior contraceptive trial, osteoporosis history, fragility fracture since starting therapy) are intended to capture contraindications and safety considerations rather than to provide a separate exclusion list.

Initial Therapy Criteria

Initial therapy

Initial therapy authorization considerations include prior contraceptive therapy, osteoporosis risk assessment, premenopausal status, and quantity/titration rationale.

Initial therapy documentation: Document that patient is premenopausal with heavy menstrual bleeding associated with uterine leiomyomas (fibroids); document trial and inadequate response to hormonal contraceptives OR documented intolerance/ FDA‑labeled contraindication/hypersensitivity to hormonal contraceptives; assess and document bone health if osteoporosis risk factors are present; provide dosing/titration rationale if requesting a titration quantity or nonstandard dose.

Required for initial authorization.

Contraceptive step requirement: Patient has tried and had an inadequate response to hormonal contraceptives OR has documented intolerance/contraindication to hormonal contraceptives.

One must be present to satisfy step therapy question on the form.

Bone risk assessment: If patient has osteoporosis or history of low‑trauma fracture/other bone‑loss risk, prescriber must assess bone mineral density and state patient can continue therapy; patient must not have had a fragility fracture since starting Oriahnn.

Required when osteoporosis or bone‑loss risk is indicated.

Titration and dosing rationale: If requesting quantity for a 90‑day titration period, indicate as such; if the requested dose exceeds the maximum FDA‑labeled or manufacturer's studied dose, prescriber must submit supporting documentation (medical records or form reflecting medical record documentation) showing duration of higher‑dose use and prior medications/doses tried and failed.

Documentation needed for nonstandard dosing or higher doses.

Continuation Therapy Criteria

Continuation therapy

Continuation considerations captured by asking prior Oriahnn use and duration.

Prior Oriahnn use: Form asks whether patient has used Oriahnn previously and requests documentation of how long the patient has been on therapy if yes.

Used to assess cumulative duration and inform continuation decisions.

Duration threshold: Document whether the patient has received 24 or more months of therapy with Oriahnn.>=24 months

Durations at or above this threshold are specifically captured on the form and may affect continued authorization.

Provider Actions & Submission Instructions

Prior Authorization

Provider Action Required — Complete Form and Provide Supporting Documentation

Prior authorization is required and this request may be denied unless all required information is received. Complete provider information, medication details, and answers to the clinical questions (including prior contraceptive therapy, osteoporosis history and assessments, prior Oriahnn use and duration, and titration/quantity rationale) must be provided.

Complete provider information and medication details are required (member name, provider name, insurance ID, NPI, specialty, contact information).
Answer all clinical questions on the form, including prior contraceptive therapy, documented intolerance/contraindication to hormonal contraceptives, osteoporosis history, prior Oriahnn use and duration, and whether the patient is premenopausal and has heavy menstrual bleeding associated with fibroids.
If requesting a quantity above the FDA-labeled or manufacturer's studied dose, the prescriber must submit supporting documentation (medical records or completion of the form fields documenting length of time the higher dose has been used and prior medications/doses tried and failed).
Requests may be denied unless all required information and supporting documentation are received.

Note

How to Submit the Prior Authorization Request

The prior authorization form may be faxed to 844-403-1029. Requests can also be submitted via CoverMyMeds where applicable. For questions about the prior authorization process, contact 855-811-2218 (Mon–Fri 8 a.m.–1 a.m. ET; Sat 9 a.m.–6 p.m. ET).

Fax submissions: 844-403-1029
CoverMyMeds submission supported where applicable
Prior authorization inquiries: 855-811-2218

Documentation Required

Quantity Above Labeled/Studied Dose Requires Documentation

When a quantity that exceeds the FDA-labeled or manufacturer's studied dose is requested, the prescriber must document the clinical rationale and submit supporting records. Acceptable supporting documentation includes medical records or completing the form fields that document duration of higher-dose use and prior therapies and doses attempted.

If question 3 in the Quantity Limit section is marked Yes, submit medical records OR the form fields showing length of time the requested dose has been used and what other medications and doses have been tried and failed.
Requests for higher-than-labeled doses without supporting documentation may be denied.

Denial Risk

Complete Required Form Fields to Avoid Denial

Complete all required sections of the form (provider information, medication information, clinical questions, quantity limit questions) and sign/date the prescriber section. Incomplete requests increase the risk of denial.

Ensure prescriber's signature and date are included.
Provide any additional comments, diagnoses, or supporting information in the comments area as needed.

Definitions & Indications

Indication

IndicationHeavy menstrual bleeding associated with uterine leiomyomas (fibroids).

Premenopausal status requiredForm asks whether the patient is premenopausal (Yes/No).

Clinical confirmationIndication must be documented on the form to support authorization.

Titration quantity

Titration periodQuantity (dose) requested for documented titration purposes at initiation of therapy — authorization may allow a 90‑day titration period.

Form questionIs the quantity (dose) requested for documented titration purposes at the initiation of therapy? (Yes/No).

Documentation implicationIf marked as titration, authorization is for a 90‑day titration period per form instructions.

Step	Requirement
1	Document that the patient has tried and had an inadequate response to therapy with hormonal contraceptives OR document a documented intolerance, FDA‑labeled contraindication, or hypersensitivity to hormonal contraceptives.

Quantity Limits & Dosing

Oriahnn quantity limits and documentation

Titration authorizationAuthorization may allow a 90‑day titration period when quantity is requested for initiation/titration purposes.

Higher-than-labeled doseIf requested quantity exceeds the maximum FDA‑labeled or manufacturer's studied dose, prescriber must submit supporting documentation (medical records or completed form reflecting medical record documentation) showing length of time the higher dose has been used and prior medications/doses tried and failed.

Form requirementForm includes specific questions to capture titration intent and whether requested dose exceeds studied/FDA limits.

Background

Oriahnn is intended for premenopausal patients with heavy menstrual bleeding associated with uterine leiomyomas (fibroids); the prior authorization form explicitly asks the provider to confirm that the patient has this indication and is premenopausal. The form also collects clinical context needed to support an authorization decision, including whether the patient has tried and had an inadequate response to hormonal contraceptives or has a documented contraindication to them, prior use of Oriahnn and duration of use, and whether the patient has osteoporosis or other bone‑loss risk factors.

Completing these indication and clinical fields ensures the reviewer can verify that the request aligns with the labeled indication and assess safety (for example, bone mineral density evaluation and absence of fragility fractures if osteoporosis risk is present) before approving therapy.

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