Limited Coverage Drug - Dienogest

Generic Name / Strength / Form

dienogest / 2 mg / tablets

Special Authority Criteria

Approval Period

For the management of pelvic pain associated with endometriosis for patients who have failed or who are unable to use combined hormonal contraceptives. Indefinite

Practitioner Exemptions

  • No practitioner exceptions

Special Notes

  • None

Special Authority Request Form(s)