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***

P & T Revisions

2025-06-20, 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

Revision History

• 2025-06-20: Removed end note.
• 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.