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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.
PDF Format
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Last Revised: June 21, 2006
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