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.

• Gender Dysphoria
  

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

Femring

Approval Length: N/A - Requests for gender transition or gender dysphoria should not be approved. Deny as a benefit exclusion.

Non Formulary

Length of Approval: N/A - Requests for non-approvable diagnoses should not be approved
For diagnosis of Gender Dysphoria/Gender Incongruence (off-label)

• Requests for coverage for diagnoses of gender transition or gender dysphoria are not authorized and will not be approved

P & T Revisions

2025-12-05, 2025-05-19, 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 2023.

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Revision History

• 2025-12-05: Add Gender Dysphoria Exclusion Criteria
• 2025-05-19: 2025 annual review - no criteria changes.
• 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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