Limited Coverage Drugs - Estradiol

Generic Name / Strength / Form

estradiol patches / transdermal gel

Special Authority Criteria

Approval Period
For indications of menopausal and post-menopausal symptoms

PLUS

extreme intolerance to oral preparations at the minimum dose required to control symptoms

OR

diagnosis of severe liver disease.

 Indefinite

Practitioner Exemptions

  • No practitioner exemptions

Special Notes

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

Special Authority Request Form(s)