ModifiedCignaPolicy IP0036

Contraceptives

Defines prior authorization requirements, coverage criteria, and plan-specific approval conditions for a wide range of prescription contraceptive products for Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyContraceptives

Policy CodePolicy IP0036

Change TypePreferred product updates and removalsIFP support added

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization and document medical justification when requesting non-formulary or preferred-restricted contraceptives.

SourceLink

POLICY UPDATE CHANGES

Removed Estrostep FE, LoSeasonique, and Ortho Micronor from coverage policy; no longer marketed.

Added IFP box table; coverage policy supports Employer Group and IFP benefit plans.

Added preferred product requirement criteria for Lo Loestrin FE for employer plans.

Added preferred product requirement criteria for Femlyv for Employer plans and Individual and Family plans.

Added preferred product requirement criteria for Annovera, Loestrin 1.5/30, Loestrin 1.5/30 FE, and Tyblume for Employer plans; removed Phexxi preferred requirement for Employer plans; updated multiple preferred product criteria.

~40products listed

12 monthsdefault approval duration

PA requiredcoverage mechanism

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plan types supported

Annualrevision cadence

Coverage Criteria

Product-specific Prior Authorization Criteria

Covered when plan-specific prior authorization criteria are met.

Primary branch by plan type: Coverage criteria vary by plan type (Employer Plans vs Individual and Family Plans) and by specific product; follow the product-specific node below.

See product-specific children.

Employer Plans - product-specific

Option 1 (uses other than prevention of pregnancy): Patient has tried the specified number of other contraceptive agents or the bioequivalent generic product and cannot take it due to formulation difference in inactive ingredient(s) that per the prescriber would result in a significant allergy or serious adverse reaction.varies by product (examples: 1,2,3,4,5 prior agents)
Examples in policy: three other agents for Annovera; trial of bioequivalent generic for many brands; four other oral agents for several products; five for Twirla; two for Lo Loestrin FE; one progesterone-only for certain products.
Option 2 (prevention of pregnancy): Requested non-formulary drug is being prescribed primarily for the prevention of pregnancy AND other oral or bioequivalent generic contraceptive agents would not be as medically appropriate for the patient as the requested non-formulary drug (prescriber attestation required).
Applies across many Employer plan product rows.

Individual and Family Plans: Approve if, according to the prescribing physician, other formulary contraceptives would not be as medically appropriate for the patient as the requested non-formulary drug (criterion developed in accordance with the Affordable Care Act, HRSA Guidelines, and PHS Act section 2713).

Applies to multiple branded products listed for IFP; less prescriptive step requirements than Employer Plans.

Non-formulary medical appropriateness requirement

Covered when ALL of the following are met for specified non-formulary products (Individual and Family Plans):

Non-formulary approval for listed products: Prescribing physician documents that other formulary contraceptives would not be as medically appropriate for the patient as the requested non-formulary drug.

Applied to multiple branded products listed (e.g., Loestrin, Loestrin FE, Minastrin 24 FE, Mircette 28 Day, Balcoltra, Beyaz, Depo-Provera, Femlyv, Generess FE, Layolis FE, Nextstellis, Nuvaring, Quartette, Safyral, Twirla, Yasmin, Yaz, and others).

Preferred Product Table rules

Preferred product rules for Employer and/or Individual & Family Plans:

Preferred product requirement: Certain products require adherence to preferred product requirements for Employer plans and/or Individual & Family Plans as specified in the Preferred Product Table; lack of meeting these requirements may affect coverage or prior authorization status.

Revision history: added preferred product requirement criteria for Lo Loestrin FE (Employer), Femlyv (Employer and IFP), Annovera, Loestrin 1.5/30, Loestrin 1.5/30 FE, Tyblume (Employer); removed Phexxi preferred requirement for Employer plans; multiple preferred product criteria were updated.

Services billed for conditions or diagnoses that are not covered under this Coverage Policy will not be reimbursed. Providers must submit requests and claims using the most appropriate diagnosis and procedure codes in effect on the date of service; claims lacking covered code(s) under this Coverage Policy will be denied as not covered.

This policy was updated to remove Estrostep FE, LoSeasonique, and Ortho Micronor from the coverage policy because they are no longer marketed. The Revision Details document these removals and related preferred product table updates.

Coding and Product Listing

Listed Contraceptive Products (no codes provided)mixed

NDC or CPT not listed	Document lists product names and formulations but no explicit billing codes in this section.
Annovera	(ethinyl estradiol 13 µg/day - 21 days, segesterone acetate 0.15 mg /day 21 days - Mayne)
Balcoltra	(ethinyl estradiol 20 µg - 21 days, levonorgestrel 0.1 mg - 21 days - Avion)
Beyaz	(ethinyl estradiol 20 µg - 24 days, drospirenone 3 mg - 24 days - Bayer)
Depo-Provera	(medroxyprogesterone acetate intramuscular injection - Pfizer, generics)
Femlyv	(ethinyl estradiol 20 µg - 24 days, norethindrone acetate 1 mg - 24 days - Millicent)
Generess FE	(ethinyl estradiol 25 µg - 24 days, norethindrone acetate 0.8 mg - 24 days - Allergan)
Layolis FE	(ethinyl estradiol 25 µg - 24 days, norethindrone acetate 0.8 mg - 24 days - Actavis)
Loestrin 1/20	(ethinyl estradiol 20 µg - 21 days, norethindrone acetate 1 mg - 21 days - Teva Women's Health)
Loestrin 1.5/30	(ethinyl estradiol 30 µg - 21 days, norethindrone acetate 1.5 mg - 21 days - Teva Women's Health)

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Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization is required for prescription benefit coverage of contraceptives. All approvals are provided for a 12-month duration unless otherwise noted. Providers must submit a PA request when prescribing non-formulary or product-specific agents; incomplete requests or missing required documentation may delay or result in denial.

All contraceptive products require PA per plan-specific criteria.
Default approval duration: 12 months unless otherwise specified.

Note

Product-specific PA Criteria

Many products have plan-specific prior authorization criteria that may include trials of formulary or bioequivalent generics, intolerance to inactive ingredients, or inability to use alternative dosage forms. Review the Employer and Individual/Family plan criteria for the specific product being requested.

Criteria vary by plan (Standard/Performance/Value/Advantage/Total Savings/Legacy/IFP).
Some brand products require trial and failure of the bioequivalent generic unless a formulation-related adverse reaction is documented.

Definitions and Policy Context

Preventive services (ACA/HRSA/USPSTF/ACIP)

Statutory sourcesAffordable Care Act (ACA) — preventive services coverage requirements

USPSTFUnited States Preventive Services Task Force (USPSTF) grade A or B recommendations

ACIPAdvisory Committee on Immunization Practices (ACIP) recommendations adopted by the CDC Director

HRSAHealth Resources and Services Administration (HRSA) recommendations

Reasonable medical managementPlans may apply reasonable medical management (eg, precertification, concurrent review, claim review) when guidelines do not specify frequency/method

Non‑formulary contraceptive approval — Individual & Family Plans

Background

Oral and other hormonal contraceptives are used primarily for pregnancy prevention but also have established roles in managing a range of gynecologic conditions, including acne, dysmenorrhea, endometriosis, and menstrual irregularities. Coverage for contraceptive products may therefore be requested for either contraceptive purposes or for treatment of these other conditions. Preventive service coverage is governed by the Affordable Care Act and related guidance (USPSTF, ACIP, HRSA); where those resources do not specify frequency or method, reasonable medical management may be applied. Clinical references used to develop criteria include the Clinical Pharmacology database and ACOG practice guidance.

Policy Summary

PayerCigna

PolicyContraceptives

Policy CodePolicy IP0036

Change TypePreferred product updates and removalsIFP support added

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization and document medical justification when requesting non-formulary or preferred-restricted contraceptives.

SourceLink

On This Page

For prevention of pregnancy indications, prescriber must justify medical appropriateness when formulary alternatives exist.

Documentation Required

Non‑Formulary Product Approval

Approval of non-formulary contraceptive products requires documentation that formulary options are not medically appropriate for the patient. For prevention-of-pregnancy use, the prescriber must state why formulary or bioequivalent products would not be as medically appropriate.

Non-formulary approval often requires ONE of the following: inability to use bioequivalent generic due to inactive ingredient reaction, failure of a specified number of alternative agents (range 1–5 as defined per product), or prescriber attestation that formulary products are not medically appropriate.
Examples: trials of 2–5 other oral contraceptives for certain products; trial of bioequivalent generic required unless contraindicated.

Step Therapy

Step/Treatment Trials Required

Many products require prior trials of other agents before approval (step/treatment therapy). Required trials range from 1 to 5 agents depending on the product and plan. Document prior agents tried, duration, and reason for discontinuation or intolerance.

Examples of trial requirements by product: 1–4 trials of oral contraceptives for brands where bioequivalent generics exist; up to 5 trials for Twirla.
A trial of multiple different oral contraceptive tablets can satisfy multi‑agent requirements when specified.
Prescriber documentation must indicate dates, agents, and reason for failure/intolerance.

Documentation Required

Non‑Formulary Approval Justification

When requesting non-formulary approval, include prescriber justification that formulary options are not medically appropriate and, when applicable, evidence of allergy or serious adverse reaction to inactive ingredients of bioequivalent generics.

Documentation should specify why the bioequivalent generic or other formulary options are unsuitable.
Receipt of sample product does not satisfy criteria requirements.
Medical necessity decisions are reviewed in context of the patient’s plan and applicable law/regulation.

Billing Rule

Billing, Coding, and Clinical Documentation Requirements

When coverage is available and medically necessary, dosage, frequency, duration of therapy, and site of care must be reasonable, clinically appropriate, and supported by evidence-based literature. Use the most appropriate billing codes; claims without covered code(s) will be denied as not covered.

Dosage, frequency, and duration should align with clinical evidence and patient needs.
Providers must use current appropriate codes at time of submission; unsupported codes will lead to claim denial.
Receipt of sample product does not satisfy coverage criteria.

Approval condition (IFP)Approve if the prescribing physician documents that other formulary contraceptives would not be as medically appropriate for the patient as the requested non-formulary drug (criterion developed in accordance with ACA, HRSA, and PHS Act §2713).

Standard durationAll products approved for a duration of 12 months unless otherwise noted

Plan applicabilityApplies to Individual and Family Plans; Employer Plans may have different step/trial requirements

Prescriber documentationPrescriber must attest/justify medical appropriateness of the non-formulary product compared to formulary alternatives

Clinical references

Clinical PharmacologyClinical Pharmacology [database online]. Elsevier 2023 (search term: oral contraceptive, combinations).

ACOG — Dysmenorrhea/EndometriosisACOG Committee Opinion No. 760 (Dec 2018): Dysmenorrhea and Endometriosis in the Adolescent.

ACOG — PCOSACOG Practice Bulletin No. 194 (June 2018): Polycystic Ovary Syndrome.

ACOG — Endometriosis managementACOG Practice Bulletin No. 114 (July 2010; reaffirmed 2018): Management of endometriosis.