CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Orilissa

Defines clinical criteria, duration limits, and quantity limits for coverage of Orilissa (elagolix) for treatment of moderate to severe endometriosis-related pain under a Medicaid scope.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyOrilissa

Policy CodePolicy N/A

Change TypeRevised (references updated)

Effective DateJan 1, 2019

Next Review Date

Key ActionSubmit documentation that Orilissa is for moderate to severe endometriosis-related pain and evidence of trial and failure or contraindication to two of: norethindrone 5 mg, danazol, zoladex injection; include prior elagolix/relugolix treatment history to confirm cumulative exposure limits are not exceeded.

SourceLink

POLICY UPDATE CHANGES

Policy reviewed on 3/2026 with references updated (Orilissa package insert cited Dec 2025).

3Required prior therapies (options)

6 / 24Key duration limits (short/long)

B/CHepatic impairment restrictions

Coverage Summary

Coverage stance: covered_with_criteria for Orilissa (elagolix) for endometriosis-related pain. Scope: Medicaid; this policy defines clinical criteria requiring Orilissa to be used for moderate-to-severe endometriosis-related pain and subjects coverage to prior hormonal therapy trials, hepatic-function restrictions, and cumulative exposure/duration limits.

Duration and Exposure Limits

Maximum cumulative elagolix/relugolix exposure> 24 months

Maximum Orilissa 200 mg twice daily exposure> 6 months

Orilissa 150 mg daily — standard patients (duration limit)24 months

Orilissa 150 mg daily — Moderate Hepatic Impairment (Child-Pugh B)6 months

Orilissa 200 mg twice daily — for dyspareunia (duration limit)6 months