Prior Auth Protocol

FDA Approved Indications:

Use by females of reproductive age to prevent pregnancy

Health Net Approved Indications and Usage Guidelines:

Medical justification as to why the patient requires a chewable product

OR

Failure or clinically significant adverse effects to Lomedia^TM 24 Fe and one other generic oral contraception, e.g. Norethindrone Acetate 1 mg/Ethinyl Estradiol 0.02 mg and Ferrous Fumarate 75 mg, Junel Fe 24, Gildess 24 Fe, Microgestin

Coverage is Not Authorized For:

Non-FDA approved indications, which are not listed in the Health Net Approved Indications and Usage Guidelines section, unless there is sufficient documentation of efficacy and safety in the published literature.

General Information:

Lomedia 24 Fe is the generic equivalent to Loestrin 24 Fe
Black Box warning: cigarette smoking increases the risk of serious cardiovascular events from combination oral contraceptive use; smoking women over 35 years old should not use.

Therapeutic Alternatives:

Drug	Dosing Regimen	Dose Limit/ Maximum Dose
Norethindrone Acetate 1 mg/Ethinyl Estradiol 0.02 mg and Ferrous Fumarate 75 mg (Junel Fe 24, Gildess 24 Fe, Microgestin	Oral Contraceptive Day 1-24: 1 tablet PO QD Ferrous Fumarate Day 25-28: 1 tablet PO QD	Oral Contraceptive 1 tablet PO QD Ferrous Fumarate 1 tablet PO QD
Lomedia^TM 24 Fe	Oral Contraceptive Day 1-24: 1 tablet PO QD Ferrous Fumarate Day 25-28: 1 tablet PO QD	Oral Contraceptive 1 tablet PO QD Ferrous Fumarate 1 tablet PO QD

* Requires Prior Authorization

Recommended Dosing Regimen and Authorization Limit:

Drug	Dosing Regimen	Authorization Limit
Minastrin 24 FE	Oral Contraceptive Day 1-24: 1 tablet PO QD Ferrous Fumarate Day 25-28: 1 tablet PO QD	Length of Benefit

Product Availability:

Tablets: Each blister card contains 28 tablets in the following order: 24 white tablets each containing 1 mg norethindrone acetate and 20 mcg ethinyl estradiol, 4 brown tablets each containing 75 mg ferrous fumarate.

References:

Minastrin 24 Fe [Prescribing Information] Parsippany, NJ: Actavis Pharma, Inc; December 2014.
Lomedia 24 Fe [Prescribing Information]Glasgow, KY: Amneal Pharmaceuticals; October 2013.
Micromedex^R Healthcare Series [Internet database]. Greenwood Village, Colo: Thomson Healthcare. Updated periodically. Accessed June 9, 2015.
Estrogen-Progestin Combinations. American Hospital Formulary Service Drug Information. Available at: http://www.medicinescomplete.com/mc/ahfs/current/. Accessed June 9, 2015.
Clinical Pharmacology Web site. Available at http://www.clinicalpharmacology-ip.com/default.aspx. Accessed June 9, 2015.