Brand Hormonal Contraceptives — Point32Health

Initial criteria

• Documentation of one (1) of the following: (a) Treatment failure of two (2) or more formulary alternatives within same therapeutic class including therapeutically equivalent generic; OR (b) Allergy to an ingredient in the generic not contained in the brand; OR (c) Clinical justification that change to formulary alternative would cause instability; OR (d) Request due to drug shortage; OR (e) Clinical rationale that formulary alternative is not clinically appropriate