Estrogens, Parenteral

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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.
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.

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NDC Brand Name Generic Name Form Strength PDL
Status		 Rebate Current Drug Use Criteria
00026813120 STILPHOSTROL diethylstilbestrol diphosphate AMPUL 50 mg/mL Y  
50261011008 IMVEXXY estradiol INSERT 10 mcg Y  
68308074808 IMVEXXY estradiol INSERT 10 mcg Y  
68308074708 IMVEXXY estradiol INSERT 4 mcg Y  
50261011018 IMVEXXY estradiol INSR DS PK 10 mcg Y  
68308074818 IMVEXXY estradiol INSR DS PK 10 mcg Y  
68308074718 IMVEXXY estradiol INSR DS PK 4 mcg Y  
00009027101 DEPO-ESTRADIOL estradiol cypionate VIAL 5 mg/mL Y  
42023011001 DELESTROGEN estradiol valerate VIAL 10 mg/mL Y  
00143928901 ESTRADIOL VALERATE estradiol valerate VIAL 10 mg/mL Y  
70700027322 ESTRADIOL VALERATE estradiol valerate VIAL 10 mg/mL Y  
42023011101 DELESTROGEN estradiol valerate VIAL 20 mg/mL Y  
00143929001 ESTRADIOL VALERATE estradiol valerate VIAL 20 mg/mL Y  
00517042001 ESTRADIOL VALERATE estradiol valerate VIAL 20 mg/mL Y  
70700027422 ESTRADIOL VALERATE estradiol valerate VIAL 20 mg/mL Y  
00143929101 ESTRADIOL VALERATE estradiol valerate VIAL 40 mg/mL Y  
00517044001 ESTRADIOL VALERATE estradiol valerate VIAL 40 mg/mL Y  
70700027522 ESTRADIOL VALERATE estradiol valerate VIAL 40 mg/mL Y  
00046074905 PREMARIN estrogens, conjugated VIAL 25 mg Y  
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