Pharmacy Prior Authorization Criteria

Healthcare Reform Copay Waiver Review - Contraceptives

Indications for Prior Authorization

Criteria

Contraceptives [A]

*Zero cost share contraceptive coverage lists are available at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document. FDA Contraceptive Methods available at: https://www.fda.gov/consumers/free-publications-women/birth-control. **Benefit exclusion if not for contraception. ***Any justification of medical necessity/appropriateness provided by the prescriber is adequate to approve access of a preferred product at $0 cost share, in accordance with the ACA’s contraceptive mandate.

Administrative

Length of Approval: 12 Month(s)

For medical necessity requests, to waive cost-sharing for a medication not included on a zero cost-sharing coverage list* BOTH of the following must be met:

Patient is using the prescribed drug for contraception**

AND

The requested product is medically necessary***

Guideline ID
GL-150032
Formulary
EHB
Effective date
Aug 1, 2024
P&T approval date
Nov 14, 2019

P & T Revisions

2024-07-19, 2024-06-20, 2023-09-19, 2023-08-24, 2023-07-21, 2023-01-05, 2023-01-05, 2022-12-15, 2022-10-13, 2022-09-07, 2022-07-22, 2022-03-29, 2022-01-19, 2021-09-28, 2021-07-07, 2021-05-20, 2021-05-04, 2021-04-15, 2020-10-12, 2020-09-30, 2020-06-30, 2020-05-18, 2020-05-15, 2020-05-14, 2020-02-11, 2019-12-17, 2019-11-26, 2019-10-25

References

End Notes

Oral Contraceptives: In order to receive an oral contraceptive at zero cost-share, a woman must be of childbearing potential and must be requesting an oral contraceptive for contraception (and not for another use) or if provider states medical necessity (as well as meeting the other criteria noted at the beginning of the policy). In addition, the 21 or 28 day oral contraceptive packs should not be approved for continuous use because there are continuous use products already on the Healthcare Reform Preventative Drug List posted at: https://uhgazure.sharepoint.com/sites/CST/CSDM/Shared%20Documents/UMCS%20Guidelines/Healthcare%20Reform%20Supporting%20Document.

Revision History

2024-07-19: Updated operational note's format per PA request.
2024-06-20: 2024 annual review: no criteria changes.
2023-09-19: Moved HCR Contraceptives criteria to its own guideline. No changes to criteria.
2023-08-24: Updated to remove VARENICLINE STARTING MONTH BOX from HIV Prep criteria box.
2023-07-21: Annual review - no updates.
2023-01-05: Update to change aspirins strength from 325 MG to 81 MG
2023-01-05: Consolidated multiple active guidelines to one guideline, combined changes from GL-118432 with GL-114810.
2022-12-15: Annual Review
2022-10-13: GPI Reclassification
2022-09-07: Updated background
2022-07-22: Revised contraceptive criteria to allow approval pathway if medically necessary. Minor update to "Generic Statins" criteria changing "i.e." to "e.g."
2022-03-29: Updated criteria and background
2022-01-19: Added Apo-Varenicline and updated smoking cessation products criteria.
2021-09-28: TSK003774440
2021-07-07: Annual review - updated criteria for Immunizations section per formulary strategy team request.
2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
2021-05-04: Reformatted criteria for HIV PrEP for additional clarity, no change to clinical intent
2021-04-15: Updated criteria for HIV PrEP per formulary request.
2020-10-12: updated criteria for HIV PrEp section per formulary request
2020-09-30: copied previous guideline as generic generic emtricitabine-tenofovir disoproxil fumarate is not yet available
2020-06-30: Revised language to "Smoking Cessation Products" vs. "Tobacco Cessation Products". Added age limits for influenza vaccines.
2020-05-18: Per PA request, added pravastatin, fluvastatin, pitavastatin, and rosuvastatin into product list.
2020-05-15: Per PA request, removed "e.g." from the list of statins that are not covered.
2020-05-14: Removed non-statin products from the statin criteria per PA request. SL 05/14/20
2020-02-11: Updated criteria and notes, and added Aromasin and Arimidex (brand, generic) to guideline.
2019-12-17: Updated guideline name to "Healthcare Reform Copay Waiver Review"
2019-11-26: Added GON prophylaxis (erythromycin) criteria and PrEP (Truvada, generic tenofovir, Descovy) criteria.
2019-10-25: Updated background info and statin criteria.