estradiol 0.1% gel — Medical Mutual

Preferred products

• estrogen patches (generic)

Initial criteria

• Patient has tried a preferred product; OR
• Patient has tried brand Climara patches, brand Minivelle patches, or brand Vivelle-Dot patches; OR
• Step Therapy Exception Criteria met: Atypical diagnosis and/or unique patient characteristics prevent use of all preferred agents [documentation required]; OR
• Step Therapy Exception Criteria met: Patient has a contraindication to all preferred agents [documentation required]; OR
• Step Therapy Exception Criteria met: Patient is continuing therapy with the requested non-preferred agent after being stable for at least 90 days AND meets ONE of the following: 1) Patient has at least 130 days of prescription claims history on file supporting receipt of the requested agent for 90 days within a 130-day look-back period AND there is no generic equivalent available; OR 2) When 130-day claims history is unavailable, prescriber verifies patient has been receiving requested agent for 90 days via paid claims (no samples, coupons, or waivers) AND there is no generic equivalent available.

Reauthorization criteria

• Continuation of therapy approved when Step Therapy Exception criteria for continuation are met. All approvals for continuation of therapy are provided for 1 year.

Approval duration

initial 2 years; reauth 2 years; step therapy exception 1 year