Estrogen Replacement, Topical
PDL Reference Documents
Drug Use Review Documents
Newsletters
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.
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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| estradiol | ESTRADIOL (TWICE WEEKLY) | PATCH TDSW | Y | N | ||
| estradiol | ESTRADIOL (ONCE WEEKLY) | PATCH TDWK | Y | N | ||
| estradiol | ESTRADIOL | GEL MD PMP | N | Age Restriction | N | |
| estradiol | DIVIGEL | GEL PACKET | N | Age Restriction | N | |
| estradiol | MENOSTAR | PATCH TDWK | N | Age Restriction | N | |
| estradiol | EVAMIST | SPRAY | N | Age Restriction | N | |
| estradiol/levonorgestrel | CLIMARA PRO | PATCH TDWK | N | Age Restriction | N | |
| estradiol/norethindrone acet | COMBIPATCH | PATCH TDSW | N | Age Restriction | N |