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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


  • 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


MHCP Provider Call Center 651-431-2700 or 800-366-5411

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