Estrogen Replacement, Topical
PDL Reference Documents
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 but eligible patients will encounter a co-pay at the pharmacy.
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 |
|---|---|---|---|---|---|
| estradiol | ESTRADIOL | PATCH TDSW | Y | Age Restriction | |
| estradiol | MINIVELLE | PATCH TDSW | Y | Age Restriction | |
| estradiol | ALORA | PATCH TDSW | Y | Age Restriction | |
| estradiol | VIVELLE-DOT | PATCH TDSW | Y | Age Restriction | |
| estradiol | CLIMARA | PATCH TDWK | Y | Age Restriction | |
| estradiol | ESTRADIOL | PATCH TDWK | Y | Age Restriction | |
| estradiol | ELESTRIN | GEL MD PMP | N | Age Restriction | |
| estradiol | DIVIGEL | GEL PACKET | N | Age Restriction | |
| estradiol | MENOSTAR | PATCH TDWK | N | Age Restriction | |
| estradiol | EVAMIST | SPRAY | N | Age Restriction | |
| estradiol/levonorgestrel | CLIMARA PRO | PATCH TDWK | N | Age Restriction | |
| estradiol/norethindrone acet | COMBIPATCH | PATCH TDSW | N | Age Restriction |