Estrogen Replacement, Oral
PDL Reference Documents
Drug Use Review Documents
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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 | Carveout ‐ Bill FFS |
New Drug Evaluation & Updates |
|---|---|---|---|---|---|---|
| drospirenone/estradiol | ANGELIQ | TABLET | Y | N | ||
| estradiol | ESTRADIOL | TABLET | Y | N | ||
| estrogen,con/m-progest acet | PREMPHASE | TABLET | Y | N | ||
| estrogen,con/m-progest acet | PREMPRO | TABLET | Y | N | ||
| estrogens, conjugated | CONJUGATED ESTROGENS | TABLET | Y | N | ||
| estrogens, conjugated | PREMARIN | TABLET | Y | N | ||
| estrogens,conj.,synthetic A | CENESTIN | TABLET | Y | N | ||
| estropipate | OGEN | TABLET | Y | N | ||
| estropipate | ESTROPIPATE | TABLET | Y | N | ||
| estradiol/norethindrone acet | ABIGALE | TABLET | N | Age Restriction | N | |
| estradiol/norethindrone acet | ACTIVELLA | TABLET | N | Age Restriction | N | |
| estradiol/norethindrone acet | ABIGALE LO | TABLET | N | Age Restriction | N | |
| estradiol/norethindrone acet | ESTRADIOL-NORETHINDRONE ACETAT | TABLET | N | Age Restriction | N | |
| estradiol/norethindrone acet | MIMVEY | TABLET | N | Age Restriction | N | |
| estradiol/progesterone | BIJUVA | CAPSULE | N | Age Restriction | N | |
| estrogen,ester/me-testosterone | ESTROGEN-METHYLTESTOSTERONE | TABLET | N | Age Restriction | N | |
| estrogen,ester/me-testosterone | ESTRATEST H.S. | TABLET | N | Age Restriction | N | |
| estrogens,conj/bazedoxifene | DUAVEE | TABLET | N | Pharmacy PA | N | Nov 20, 2014 |
| estrogens,esterified | MENEST | TABLET | N | Age Restriction | N | |
| norethindrone ac/eth estradiol | NORETHINDRON-ETHINYL ESTRADIOL | TABLET | N | Age Restriction | N | |
| norethindrone ac/eth estradiol | JINTELI | TABLET | N | Age Restriction | N | |
| norethindrone ac/eth estradiol | FYAVOLV | TABLET | N | Age Restriction | N |