Limited Coverage Drugs - Special Authority Criteria

Generic Name / Strength / Form
estradiol patches / transdermal gel

Criteria Approval Period
1. For indications of menopausal and post-menopausal symptoms
PLUS
extreme intolerance to oral preparations at the minimum dose required to control symptoms.

OR

2. For indications of menopausal and post-menopausal symptoms
PLUS
diagnosis of severe liver disease.

 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

  • Currently the following brands will be considered for coverage: Climara®, Estraderm®, Estracomb®, Estradot®, Estalis®, Estalis-Sequi®, Estrogel®, Oesclim®, and Vivelle®.

Online Forms (PDF)
Click on the link to complete a special authority request form.