Annovera®
Drug - Annovera® (segesterone acetate and ethinyl estradiol ring) [Therapeutics MD, Inc.]
July 2020
Therapeutic area - Contraceptives
Approval criteria
- Prescribed for pregnancy prevention; AND
- Patient’s body mass index (BMI) ≤ 29 kg/m2 and be provided at time of request; AND
- Prescriber attests that prescriber has reviewed and determined that the patient is not a candidate for the short-acting hormonal methods listed below:
- Estrogen-progestin pill
- Patch
- 28-day cycle vaginal system
AND
- Patient was adherent to other short-acting hormonal methods, if applicable; AND
- Prescriber attests to ALL of the following:
- Patient has been instructed on how to use Annovera; AND
- Both prescriber and patient understand that early refill coverage request due to lost, stolen, damaged or destroyed Annovera may be approved once every 12 months.
Quantity limits
- One vaginal system per thirteen 28-day cycles (1 year)
Background information
- Early refill request may be approved once every 12 months consistent with MHCP policy on Pharmacy Overrides
Questions?
MHCP Provider Call Center 651-431-2700 or 800-366-5411