Estrogen Replacement, Oral
PDL Reference Documents
- Estrogens - Aug 04, 2022
- Hormone Replacement Therapy Class Update - Jan 26, 2017
- Cross-sex Hormones - Nov 19, 2015
- Hormone Replacement Therapy DERP Scan Summary - Nov 20, 2014
- Hormone Replacement Therapy Scan Summary - Jan 30, 2014
- Hormone Replacement Therapy DERP Scan - Jan 30, 2014
- Class Scan: Hormone Replacement Therapies (HRT) - Nov 29, 2012
Drug Use Review Documents
Newsletters
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| drospirenone/estradiol | ANGELIQ | TABLET | Y | ||
| estradiol | ESTRADIOL | TABLET | Y | ||
| estradiol | ESTRACE | TABLET | Y | ||
| estrogen,con/m-progest acet | PREMPRO | TABLET | Y | ||
| estrogen,con/m-progest acet | PREMPHASE | TABLET | Y | ||
| estrogens, conjugated | PREMARIN | TABLET | Y | ||
| estrogens,conj.,synthetic A | CENESTIN | TABLET | Y | ||
| estropipate | OGEN | TABLET | Y | ||
| estropipate | ESTROPIPATE | TABLET | Y | ||
| estradiol/norethindrone acet | AMABELZ | TABLET | N | Age Restriction | |
| estradiol/norethindrone acet | ACTIVELLA | TABLET | N | Age Restriction | |
| estradiol/norethindrone acet | ESTRADIOL-NORETHINDRONE ACETAT | TABLET | N | Age Restriction | |
| estradiol/norethindrone acet | MIMVEY | TABLET | N | Age Restriction | |
| estradiol/norgestimate | PREFEST | TABLET | N | Age Restriction | |
| estradiol/progesterone | BIJUVA | CAPSULE | N | Age Restriction | |
| estrogen,ester/me-testosterone | ESTROGEN-METHYLTESTOSTERONE | TABLET | N | Age Restriction | |
| estrogens,conj/bazedoxifene | DUAVEE | TABLET | N | PA Document | Nov 20, 2014 |
| estrogens,esterified | MENEST | TABLET | N | Age Restriction | |
| norethindrone ac-eth estradiol | JINTELI | TABLET | N | Age Restriction | |
| norethindrone ac-eth estradiol | FYAVOLV | TABLET | N | Age Restriction | |
| norethindrone ac-eth estradiol | NORETHINDRON-ETHINYL ESTRADIOL | TABLET | N | Age Restriction |