CurrentColorado Rocky Mountain Health PlansPolicy 2025 P 2220-7

Phexxi (lactic acid, citric acid, potassium bitartrate) vaginal gel prior authorization

Defines UnitedHealthcare prior authorization / medical necessity criteria for Phexxi for prevention of pregnancy in females of reproductive potential; affects providers requesting coverage for this medication.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyPhexxi (lactic acid, citric acid, potassium bitartrate) vaginal gel prior authorization

Policy CodePolicy 2025 P 2220-7

Change TypeAnnual review; no material changes

Effective Date8/1/2025

Next Review Date

Key ActionObtain prior authorization and document provider attestation that the patient was counseled about higher pregnancy prevention rates with other contraceptive methods and is unable to use those methods.

SourceLink

POLICY UPDATE CHANGES

5/2025 annual review noted; no changes.

5/2024 updated methods of contraception examples a member is unable to use.

Provider attestation requirement added/modified in 5/2021 and 5/2022.

12 monthsauthorization duration

2025-05most recent P&T review

1program number

on-demandmethod

Coverage Criteria

Initial Therapy — Approve when ALL of the following are met

Approve when ALL of the following are met:

Phexxi approved when all conditions below are satisfied

Condition 1: Used for the prevention of pregnancy

(see chunk 2)

Condition 2: Patient is unable to use other methods of contraception due to failure, contraindication, intolerance, or refusal

Examples include: injection (e.g., Depo-Provera); oral contraceptive (e.g., norethindrone, Yaz); transdermal patch (e.g., Twirla, Xulane); vaginal ring (e.g., Annovera, NuvaRing); diaphragm; sponge (e.g., Today); cervical cap (e.g., FemCap); female condom (see chunk 3)

Condition 3: History of failure, contraindication, or intolerance to nonoxynol-9 based spermicide

(see chunk 3)

Condition 4: Provider attests they have counseled the patient regarding a higher rate of pregnancy prevention with other methods of contraception compared to Phexxi

Examples of other methods: injection, oral contraception, transdermal patch, vaginal ring (see chunk 3)

Phexxi is not approved for use after intercourse and is only indicated for prevention of pregnancy when used as an on‑demand method prior to intercourse. Coverage is not indicated if the specific coverage criteria are not met (see initial authorization requirements that must all be satisfied before approval).

Prior authorization is required and will be denied if the medication is being requested for use after intercourse or if the patient does not meet the other specified criteria (for example, documentation that the patient is unable to use other contraceptive methods or history of failure/intolerance to nonoxynol-9 spermicide).

Initial Authorization Criteria

Initial authorization

Initial authorization nodes: Authorization will be issued for 12 months when all criteria are met12 months

See individual criteria for required elements (chunks 2-3).

Provider Actions and Requirements

Prior Authorization

Prior Authorization Required

Prior Authorization Required: Prior authorization is required for Phexxi. Authorization will be issued for 12 months when criteria are met.

Approval duration: 12 months
Prior authorization required

Step Therapy

Step Therapy / Step Requirement

Step therapy / Step requirement: Member must have inability to use other methods of contraception due to failure, contraindication, intolerance, or refusal before Phexxi will be approved. Examples of other methods include injection (e.g., Depo‑Provera), oral contraceptives (e.g., norethindrone, Yaz), transdermal patch (e.g., Twirla, Xulane), vaginal ring (e.g., Annovera, NuvaRing), diaphragm, sponge (e.g., Today), cervical cap (e.g., FemCap), and female condom.

Required prior failure/contraindication/intolerance/refusal of other contraceptive methods

Step Therapy Requirements

Step	Requirement
1	Document that the patient is unable to use other methods of contraception due to failure, contraindication, intolerance, or refusal. Examples include injection (e.g., Depo‑Provera); oral contraceptive (e.g., norethindrone, Yaz); transdermal patch (e.g., Twirla, Xulane); vaginal ring (e.g., Annovera, NuvaRing); diaphragm; sponge (e.g., Today); cervical cap (e.g., FemCap); female condom.
	Document history of failure, contraindication, or intolerance to nonoxynol‑9 based spermicide and provider attestation that the patient was counseled that other methods (e.g., injection, oral contraception, transdermal patch, vaginal ring) have higher pregnancy prevention rates compared to Phexxi.

Definitions

On-demand contraception — key facts

DefinitionOn-demand contraception: method used at the time of intercourse to prevent pregnancy; Phexxi must be used before intercourse and is ineffective if used after.

AgentPhexxi (lactic acid, citric acid, and potassium bitartrate) vaginal gel

Indication contextPrevention of pregnancy in females of reproductive potential when used as an on‑demand method of contraception

Timing requirementMust be administered prior to intercourse to be effective; not effective if given after intercourse

Clinical counseling noteProviders should counsel patients that Phexxi is an on‑demand option and discuss comparative efficacy versus other contraceptive methods

Background

Phexxi (lactic acid, citric acid, and potassium bitartrate) is an on‑demand vaginal gel indicated to prevent pregnancy in females of reproductive potential when used at the time of intercourse. It is not effective if administered after intercourse, and counseling should address its on‑demand use and comparative effectiveness versus other contraceptive methods.