norelgestromin/ethinyl estradiol (OrthoEvra) — United Healthcare
Polycystic Ovarian Syndrome (PCO or PCOS)
Initial criteria
- Patient is using the medication for non-contraception purposes (see listed examples)
Reauthorization criteria
- Reauthorization may be based on previous claim/medication history, diagnosis codes (ICD10) and/or claim logic per program rules
Approval duration
12 months