ANNOVERA (segesterone acetate/ethinyl estradiol)
SELF ADMINISTRATION
Indications for Prior Authorization:
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Indicated for use by females of reproductive potential to prevent pregnancy
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Limitations: not adequately evaluated in females with a BMI >29 kg/m2
Patients must meet the following criteria for the indication(s) above:
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Prescribed for prevention of pregnancy, AND
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Trial and failure of two formulary contraceptive alternatives, unless contraindicated or adverse effects are experienced, AND
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Trial and failure of Nuvaring®, AND
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Patient does not have a contraindication to treatment:
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High risk of arterial or venous thrombotic diseases
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Current or history of breast cancer or other estrogen- or progestin-sensitive cancer
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Liver tumors, acute hepatitis, or severe (decompensated) cirrhosis
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Undiagnosed abnormal uterine bleeding
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Hypersensitivity to any of the components of Annovera™
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Use of Hepatitis C drug combinations containing ombitasvir/paritaprevir/ritonavir, with or without dasabuvir
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Dosing:
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Insert 1 Annovera™ ring and leave in place for 3 weeks, followed by a 1-week system-free interval
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One Annovera™ system provides contraception for 13 cycles
Approval:
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1 year (Max: 1 ring per year)
Last review date: October 15, 2019