CurrentCentenePolicy HIM.PA.100

Non-Formulary and Formulary Contraceptives

Defines prior authorization criteria and coverage stance for non-formulary and formulary contraceptive medications for Centene-affiliated health plans; applies to providers submitting requests for contraceptive medications under the referenced lines of business.

Policy Summary

PayerCentene

PolicyNon-Formulary and Formulary Contraceptives

Policy CodePolicy HIM.PA.100

Change TypeRevised approval criteriaadded Washington exception

Effective DateMay 1, 2015

Next Review Date

Key ActionSubmit prior authorization with documentation; initial approval granted when requested quantity does not exceed 1 active pill per day or compendium-supported/plan limit.

SourceLink

POLICY UPDATE CHANGES

Revised initial approval criteria to 'Requested quantity does not exceed 1 active pill per day, compendium-supported maximum dose, or health plan-approved quantity limit' (removed provider attestation).

For HIM Washington requests, prior authorization requests that exceed the health plan-approved quantity limit should be approved without further medical justification in compliance with the Washington Reproductive Parity Act.

Removed reminders for entering copay code and deductible code exceptions once approval is entered in the system.

1 active pill/daymaximum requested quantity for approval

12 monthsapproval duration for continued therapy

Approved w/o justificationWashington exception

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Coverage Criteria

inv-01: Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Initial Approval - Contraceptive Therapy: Requested quantity does not exceed 1 active pill per compendium-supported maximum dose or health plan-approved quantity limit.1 active pill/day or compendium-supported max

Approval duration: duration of request or 12 months, whichever is less.

inv-02: Other Indications / Off-label referral — When initial contraceptive therapy criterion does not apply

When initial contraceptive therapy criterion does not apply

Other Diagnoses/Indications: For drugs on the formulary (commercial, health insurance marketplace) or PDL (Medicaid), follow the no coverage criteria policy for the relevant line of business (e.g., HIM.PA.33); for drugs NOT on the formulary/PDL, follow the non‑formulary policy for the relevant line of business (e.g., HIM.PA.103). If the requested use is not specifically listed under Diagnoses/Indications for which coverage is NOT authorized, refer to the off‑label use policy for the relevant line of business (HIM.PA.154).N/A

If the drug has undergone a label change within the last 6 months that is not yet reflected in this policy, follow the referenced policies as applicable.

inv-03: Continuation Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Continued Therapy - Contraceptive Therapy: Member is currently receiving medication via Centene benefit or has previously met initial approval criteria; or member is currently receiving medication and is enrolled in a state/product with continuity of care regulations.N/A

Approval duration: 12 months.

Non‑FDA approved indications that are not specifically addressed in this policy are excluded from coverage unless the request is supported by sufficient documentation demonstrating efficacy and safety in accordance with the off‑label use policy HIM.PA.154 or applicable evidence of coverage documents.

Uses that are not FDA‑approved and that do not have adequate supporting documentation per the off‑label use policy HIM.PA.154 (or applicable evidence of coverage) are considered not authorized and may be denied.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial approval may be granted when the requested quantity does not exceed 1 active pill per compendium-supported maximum dose or the health plan–approved quantity limit. Approval duration: duration of request or 12 months, whichever is less.

Approval duration: Duration of request or 12 months, whichever is less

Documentation Required

Required Documentation

Provider must submit documentation (such as chart notes, lab results, or other clinical information) supporting that the member has met all approval criteria. Requests that lack supporting documentation may be denied.

Examples of acceptable documentation: chart notes, lab results, imaging, prior medication history

Background

Contraceptives are medications indicated for the prevention of pregnancy. Coverage determinations prioritize FDA‑approved indications; when a requested use is outside an FDA‑approved indication, authorization requires documentation in line with the off‑label use policy HIM.PA.154 to establish efficacy and safety.

Definitions

Contraceptives — definition

DefinitionContraceptives are medications indicated for the prevention of pregnancy.

Off-label use requirementNon‑FDA approved indications require sufficient documentation of efficacy and safety per the off‑label use policy HIM.PA.154 (health insurance marketplace) or applicable evidence of coverage documents.

Scope of termApplies to both formulary and non‑formulary contraceptive medications addressed by this policy (coverage contingent on FDA indication or off‑label documentation).