Pharmacy Prior Authorization Criteria

Femring (estradiol acetate ring)

Indications for Prior Authorization

Femring (estradiol acetate vaginal ring)

• For diagnosis of Moderate to Severe Vasomotor Symptoms
  Indicated for the treatment of moderate to severe vasomotor symptoms due to menopause.

• For diagnosis of Moderate to Severe Vulvar and Vaginal Atrophy
  Indicated for the treatment of moderate to severe vulvar and vaginal atrophy due to menopause.

Criteria

Femring

Step Therapy

Length of Approval: 12 Month(s)

• Both of the following:
• Diagnosis of vulvar and vaginal atrophy due to menopause
AND
• Trial and failure (of a minimum 28-day supply), contraindication or intolerance to one of the following:
• Premarin vaginal cream
• Imvexxy
• Osphena
OR
• Used for moderate to severe vasomotor symptoms due to menopause

P & T Revisions

2024-05-21, 2023-07-20, 2022-07-22, 2021-06-18, 2020-09-02

References

1. Femring Prescribing Information. Millicent U.S., Inc. East Hanover, NJ. November 2013.

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Revision History

• 2024-05-21: 2024 annual review - no criteria changes.
• 2023-07-20: Annual review - updated trial duration from 30 to 28 days.
• 2022-07-22: Annual review: added diagnosis of vulvar and vaginal atrophy due to menopause for criterion requiring step through alternative product.
• 2021-06-18: Annual Review
• 2020-09-02: New Program

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