CurrentCignaPolicy N/A

Contraceptives -Phexx Prior Authorization Policy

This policy defines prior authorization recommendations and medical necessity criteria for coverage of Phexx vaginal gel for prevention of pregnancy under Cigna-administered health benefit plans, including covered indication, duration of approval, and not-covered uses.

Policy Summary

PayerCigna

PolicyContraceptives -Phexx Prior Authorization Policy

Policy CodePolicy N/A

Change TypeName change; annual revisions (no criteria changes)

Effective Date

Next Review Date

Key ActionPrior authorization is recommended for Phexx; document that the patient has tried three other barrier methods and approve for 6 months when criteria are met.

SourceLink

POLICY UPDATE CHANGES

Phexxi name changed to Phexx; policy name updated accordingly.

Annual revisions occurred on 05/17/2023 and 05/08/2024 with no criteria changes.

1Covered Indications

3Prior barrier methods required

3Common not-covered uses

Coverage Summary

Scope: This policy defines prior authorization recommendations and medical necessity criteria for coverage of Phexx vaginal gel for prevention of pregnancy under Cigna-administered health benefit plans.

Key Thresholds & Quick Facts

Covered IndicationsPrevention of pregnancy (FDA‑approved on‑demand contraception)

Prior barrier methods triedPatient must have tried 3 other barrier methods (diaphragms, condoms, spermicides, or sponges)

Approval durationApprove for 6 months (when criteria met). 1 month = 30 days.

Common not-covered uses count3 common not medically necessary uses listed (personal lubricant; bacterial vaginosis treatment; protection against HIV/STIs)

Medically Necessary Criteria

Medically Necessary Coverage - FDA-Approved Indication

Phexx is covered as medically necessary for FDA-approved indication when ALL of the following are met:

ALL of the following

Indication: Prevention of pregnancy (use as an on-demand method of contraception).
Prior Authorization is requested/provided for prescription benefit coverage of Phexx.
Prior barrier methods tried: Patient has tried THREE other barrier methods of contraception (i.e., diaphragms, condoms, spermicides, or sponges).3 other barrier methods
Approval duration: Approve for 6 months.6 months
ACA/HRSA/PHS Act §2713 exception: Note: If compliance with ACA/HRSA/PHS Act §2713 is required and Recommended Authorization Criteria are not met, approval is granted if the prescriber states other barrier methods would not be as medically appropriate as the requested drug.
Operational exception for preventive service coverage mandate.

Not Medically Necessary / Exclusions

Phexx is considered not medically necessary for ANY other use(s) including, but not limited to, the following:

ANY of the following

Personal lubricant: Use as a personal lubricant.
Bacterial vaginosis treatment: Treatment of acute episodes of bacterial vaginosis.
STI/HIV protection: Protection against HIV or any other sexually transmitted infections.

Denial Risk

Denial for non-covered uses

Claims for uses other than prevention of pregnancy (e.g., personal lubricant, bacterial vaginosis treatment, STI/HIV protection) are considered not medically necessary and may be denied.

Provider Actions / Authorization

Prior Authorization

Prior Authorization Required

Prior Authorization is recommended for prescription benefit coverage of Phexx; approvals are provided for the duration noted (6 months when criteria met).

Documentation Required

Document prior barrier methods tried

Provider must document that the patient has tried three other barrier methods of contraception (diaphragms, condoms, spermicides, or sponges) to meet approval criteria.

Documentation Required

ACA/HRSA/PHS Act exception documentation

If ACA/HRSA/PHS Act §2713 compliance is required and criteria are not met, prescriber must state that other barrier methods would not be as medically appropriate to grant approval.

Background & Evidence

Phexx is indicated for prevention of pregnancy as an on-demand contraceptive when administered vaginally immediately before or up to one hour before intercourse; it is ineffective if used after intercourse. The recommended dose is one pre-filled 5 g applicator per act of vaginal intercourse; if more than one act occurs within one hour, an additional dose is required.

Evidence: Prescribing information, Phexx vaginal gel prescribing information, Evofem; May 2025.

Definitions: Month — when approvals are authorized in months, 1 month = 30 days.

Revision History

05/17/2023clarified

Phexx name changed to Phexx; policy name updated accordingly. No criteria changes associated with the name change.

05/08/2024revised