Orgovyx (relugolix)
Indications for Prior Authorization
Orgovyx (relugolix)
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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
2023-12-29, 2023-02-27, 2022-01-14, 2021-09-27, 2021-05-21, 2021-03-03, 2021-02-11
References
- Orgovyx Prescribing Information. Myovant Sciences, Inc. Brisbane, CA. August 2023.
Revision History
- 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.
HEALTHY LIVING