Request for an Alternative Contraceptive for Patients Covered Under a Colorado Health Benefit Plan
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Form and policy governing coverage of non‑formulary contraceptives for members of Colorado health benefit plans (excluding self‑funded ERISA, Medicaid, Medicare, and TRICARE) when a provider determines a non‑formulary contraceptive is medically necessary.
No material clinical or coverage changes in this revision.
Coverage Criteria for Non‑Formulary Contraceptives
Coverage for non‑formulary contraceptives
Covered when ALL of the following are met
Required fields listed on the form (Contraceptive Name, Strength, Quantity per Month, J-code/Units Requested, Proposed Date of Service).
Form provides two selectable options for the covered therapeutic/pharmaceutical equivalent: 'Not available' OR 'Deemed medically inappropriate'.
Scope and exclusions stated on the request form header.
This form and the associated policy apply only to carriers for Colorado health benefit plans. It does not apply to self‑funded ERISA coverage, Medicaid, Medicare, or TRICARE.
Under Colorado law, an exception request for a non‑formulary contraceptive must be treated as an expedited exception request; the carrier must respond within 24 hours of receipt. Carriers are prohibited from requiring the covered person, the person's authorized representative, or the individual's provider to use the carrier’s internal claims and appeals process (i.e., to file an internal appeal) for an adverse benefit determination related to a contraceptive.
Billing and Coding
| J-code | Field provided to list J‑code when applicable (exact code to be supplied by provider) |
Provider Submission and Documentation Requirements
Written provider request required
A written request (the completed Alternative Contraceptive Request form) from the attending health care provider is required to obtain coverage for a contraceptive not on the plan formulary when the provider determines it is medically necessary for the patient.
Therapeutic equivalence attestation
The provider must attest on the Alternative Contraceptive Request form whether the covered therapeutic or pharmaceutical equivalent is either “Not available” or “Deemed medically inappropriate.”
Required documentation on form
The form must include patient identifiers and provider/facility contact details (including Tax ID / NPI if available) and the attending provider must complete the Alternative Contraceptive Request section specifying drug/device name, strength, quantity, J‑code/units requested, proposed date of service, and whether a generic may be substituted.
- Patient: name, date of birth, address, insurer name, member ID (chunk 1).
- Provider/facility: name, address, phone, fax, Tax ID / NPI (if available), facility name, office contact (chunk 2).
- Clinical request: contraceptive name, strength, quantity, J‑code, units requested, proposed date of service, and generic substitution indicator (chunk 4).
Failure to submit required form
If the carrier or pharmacy benefit manager requires a written request and the provider does not submit the completed form, coverage for the non‑formulary contraceptive may be denied.
Definitions
Background and Purpose
This form supports requests for coverage of a non‑formulary contraceptive when the attending health care provider reasonably determines the requested product is medically necessary for the patient. If a carrier or its pharmacy benefit manager requires a written request, the provider must complete this Alternative Contraceptive Request form and submit it to the member’s health benefit plan to obtain coverage for the non‑formulary product.
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