Estrogen Replacement, Oral

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PDL Status Values

Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the Non-Preferred Drugs in Select PDL Classes prior authorization criteria. New drugs will be listed as N until reviewed by the P&T Committee and are subject to the New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required but eligible patients will encounter a co-pay at the pharmacy.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.

To request a Prior Authorization, please use this form.

Generic Name Brand Name Form PDL
Status
Current Drug Use Criteria New Drug Evaluation
ESTRADIOL ESTRADIOL TABLET Y Age Restriction  
ESTRADIOL ESTRACE TABLET Y Age Restriction  
ESTROPIPATE ESTROPIPATE TABLET Y Age Restriction  
DROSPIRENONE/ESTRADIOL ANGELIQ TABLET N Age Restriction  
ESTRADIOL/NORETHINDRONE ACET ESTRADIOL-NORETHINDRONE ACETAT TABLET N Age Restriction  
ESTRADIOL/NORETHINDRONE ACET MIMVEY TABLET N Age Restriction  
ESTRADIOL/NORETHINDRONE ACET AMABELZ TABLET N Age Restriction  
ESTRADIOL/NORETHINDRONE ACET ACTIVELLA TABLET N Age Restriction  
ESTRADIOL/NORETHINDRONE ACET LOPREEZA TABLET N Age Restriction  
ESTRADIOL/NORETHINDRONE ACET MIMVEY LO TABLET N Age Restriction  
ESTRADIOL/NORGESTIMATE PREFEST TABLET N Age Restriction  
ESTROGEN,CON/M-PROGEST ACET PREMPHASE TABLET N Age Restriction  
ESTROGEN,CON/M-PROGEST ACET PREMPRO TABLET N Age Restriction  
ESTROGEN,ESTER/ME-TESTOSTERONE ESTROGEN-METHYLTESTOSTERONE TABLET N Age Restriction  
ESTROGEN,ESTER/ME-TESTOSTERONE EEMT H.S. TABLET N Age Restriction  
ESTROGEN,ESTER/ME-TESTOSTERONE EEMT TABLET N Age Restriction  
ESTROGEN,ESTER/ME-TESTOSTERONE COVARYX TABLET N Age Restriction  
ESTROGEN,ESTER/ME-TESTOSTERONE COVARYX H.S. TABLET N Age Restriction  
ESTROGENS, CONJUGATED PREMARIN TABLET N Age Restriction  
ESTROGENS,CONJ/BAZEDOXIFENE DUAVEE TABLET N PA Document Nov 20, 2014
ESTROGENS,ESTERIFIED MENEST TABLET N Age Restriction  
NORETHINDRONE AC-ETH ESTRADIOL FYAVOLV TABLET N Age Restriction  
NORETHINDRONE AC-ETH ESTRADIOL JEVANTIQUE LO TABLET N Age Restriction  
NORETHINDRONE AC-ETH ESTRADIOL JINTELI TABLET N Age Restriction  
NORETHINDRONE AC-ETH ESTRADIOL NORETHINDRON-ETHINYL ESTRADIOL TABLET N Age Restriction  
NORETHINDRONE AC-ETH ESTRADIOL FEMHRT TABLET N Age Restriction