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)
- 5328 - General Special Authority Request (PDF, 523KB)