Estrogen Replacement, Topical

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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 MINIVELLE PATCH TDSW Y Age Restriction  
estradiol VIVELLE-DOT PATCH TDSW Y Age Restriction  
estradiol ESTRADIOL PATCH TDSW Y Age Restriction  
estradiol ALORA PATCH TDSW Y Age Restriction  
estradiol ESTRADIOL PATCH TDWK Y Age Restriction  
estradiol CLIMARA PATCH TDWK Y Age Restriction  
estradiol ELESTRIN GEL MD PMP N Age Restriction  
estradiol DIVIGEL GEL PACKET N Age Restriction  
estradiol MENOSTAR PATCH TDWK N Age Restriction  
estradiol EVAMIST SPRAY N Age Restriction  
estradiol/levonorgestrel CLIMARA PRO PATCH TDWK N Age Restriction  
estradiol/norethindrone acet COMBIPATCH PATCH TDSW N Age Restriction