Pharmacy Prior Authorization Criteria

Contraceptives for Non-Contraceptive Use

Indications for Prior Authorization

Criteria

Formulary and Non Formulary Contraceptives

*Examples of non-contraception uses: (1) Abnormal or excessive bleeding disorders (eg, amenorrhea, oligomenorrhea, menorrhagia, dysfunctional uterine bleeding); (2) Acne; (3) Decrease in bone mineral density; (4) Dysmennorrhea; (5) Endometriosis; (6) Hirsutism; (7) Irregular menses / cycles; (8) Ovarian cysts; (9) Perimenopausal symptoms; (10) History of Pelvic Inflammatory Disease (PID); (11) Polycystic Ovarian Syndrome (PCO or PCOS); (12) Premenstrual Syndrome (PMS); (13) Premenstrual Dysphoric Disorder (PMDD); (14) Prevention of endometrial and/or ovarian cancer; (15) Prevention of menstrual migraines; (16) Turner’s syndrome; (17) Uterine fibroids or adenomyosis. [1-7, 9-12]

Administrative

Length of Approval: 12 Month(s)

• Patient is using the medication for non-contraception purposes*

P & T Revisions

2024-08-19, 2023-08-02, 2022-08-02, 2021-07-23, 2021-05-20, 2021-04-19, 2021-02-02, 2021-01-07, 2020-12-21, 2020-07-18

References

1. Burkamn R, Schlesselman JJ, Zieman M. Safety concerns and health benefits associated with oral contraception. Am J Obstet Gynecol. 2004;190(4 Suppl):S5-22.
2. Dayal M, Barnhart KT. Noncontraceptive benefits and therapeutic uses of the oral contraceptive pill. Semin Repord Med. 2001;19(4):295-303
3. DRUGDEX System [Internet database]. Greenwood Village, Colo: Thomson Reuters (Healthcare) Inc. Updated periodically.
4. ESHRE Capri Workshop Group. Noncontraceptive health benefits of combined oral contraception. Hum Reprod Update. 2005;11(5):513-25. Epub 2005 Jul 8.
5. Kaunitz AM. Hormonal Contraception in women of older reproductive age. N Engl J Med. 2008; 358(12):1262-1270
6. Kaunitz AM. Menstruation: choosing whether…and when. Contraception. 2000;62:277-84.
7. Olive DL, Pritts EA. Treatment of endometriosis. N Engl J Med. 2001;345(4):266-75.
8. Pharmacist’s Letter Detail-Document, Comparison of Oral Contraceptives and Non-Oral Alternatives. Pharmacist’s Letter/Prescriber’s Letter. March 2013.
9. ACOG Practice Bulletin No. 110: noncontraceptive uses of hormonal contraceptives. Obstet Gynecol. 2010 Jan;115(1):206-18.
10. King, J. Noncontraceptive uses of hormonal contraception. J Midwifery Womens Health. 2011;56:628-635.
11. Livengood, CH. Pathogenesis of and risk factors for pelvic inflammatory disease. Available at: http://www.uptodate.com/contents/pathogenesis-of-and-risk-factors-for-pelvic-inflammatory-disease. Accessed August 2, 2023.
12. Schindler, Adolf E. “Non-contraceptive benefits of oral hormonal contraceptives.” International journal of endocrinology and metabolism vol. 11,1 (2013): 41-7.

Revision History

• 2024-08-19: 2024 annual review: no changes.
• 2023-08-02: 2023 Annual Review. No criteria changes.
• 2022-08-02: 2022 Annual Review- no criteria changes
• 2021-07-23: Annual Review: No changes.
• 2021-05-20: Addition of EHB formulary to guideline, no changes to criteria
• 2021-04-19: Updated PA note.
• 2021-02-02: Updated Guideline name
• 2021-01-07: added guideline note
• 2020-12-21: Removed guideline note.
• 2020-07-18: Annual Review.