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  
estrogens,conj.,synthetic A CENESTIN TABLET Y Age Restriction  
estropipate OGEN TABLET Y Age Restriction  
estropipate ESTROPIPATE TABLET Y Age Restriction  
drospirenone/estradiol ANGELIQ TABLET N Age Restriction  
estradiol/norethindrone acet LOPREEZA TABLET N Age Restriction  
estradiol/norethindrone acet ACTIVELLA TABLET N Age Restriction  
estradiol/norethindrone acet MIMVEY LO TABLET N Age Restriction  
estradiol/norethindrone acet AMABELZ TABLET N Age Restriction  
estradiol/norethindrone acet ESTRADIOL-NORETHINDRONE ACETAT TABLET N Age Restriction  
estradiol/norethindrone acet MIMVEY 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  
estrogens, conjugated PREMARIN TABLET N Age Restriction  
estrogens,conj.,synthetic B ENJUVIA 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 JINTELI TABLET N Age Restriction  
norethindrone ac-eth estradiol JEVANTIQUE LO TABLET N Age Restriction  
norethindrone ac-eth estradiol FYAVOLV TABLET N Age Restriction  
norethindrone ac-eth estradiol FEMHRT TABLET N Age Restriction  
norethindrone ac-eth estradiol NORETHINDRON-ETHINYL ESTRADIOL TABLET N Age Restriction