Currentmedical mutual - ohioPolicy N/A

Contraceptives (coverage for non-contraceptive use)

This policy governs prior authorization and coverage criteria for contraceptive medications when prescribed for non-contraceptive indications, and applies to members whose benefits or beliefs exclude contraceptives for pregnancy prevention.

Policy Summary

Payermedical mutual - ohio

PolicyContraceptives (coverage for non-contraceptive use)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateSep 19, 2024

Key ActionObtain prior authorization for pharmacy benefit coverage of contraceptive medications for non-contraceptive indications when criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1 yrInitial approval duration

1 yrExtended approval duration

AnnualReview frequency

Coverage criteria for non-contraceptive use

Recommended Authorization Criteria

Covered when ALL of the following are met:

Policy Summary

Payermedical mutual - ohio

PolicyContraceptives (coverage for non-contraceptive use)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateSep 19, 2024

Key ActionObtain prior authorization for pharmacy benefit coverage of contraceptive medications for non-contraceptive indications when criteria are met.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Primary coverage condition: Contraceptives are allowed for non-contraceptive use for members/groups who exclude contraceptive coverage for pregnancy prevention

From policy overview and statement

Authorization duration: Initial approval: 1 year; Extended approval: 1 year

Durations specified under Initial/Extended Approval

This policy provides coverage for contraceptive medications when they are prescribed for non-contraceptive uses in members or groups that exclude contraceptive coverage for pregnancy prevention. Coverage is intended specifically for those select groups whose benefits or beliefs exclude contraceptives for pregnancy prevention, and where the medication is being used for an alternative, medically indicated purpose.

The Company may determine that drugs or services are not medically necessary and deny reimbursement when the documentation does not support medical necessity. As part of its coverage determination, the Company reserves the right to request additional documentation and may deny payment if the service is investigational, experimental, not within the member’s scope of benefits, or part of a pattern of inappropriate or excessive billing.

Provider requirements and authorization

Prior Authorization

Prior Authorization Recommended

Prior authorization is recommended for pharmacy benefit coverage of contraceptive medications.

Note

Documentation Required

Documentation to Support Medical Necessity

Additional documentation supporting medical necessity must be made available upon request. The Company may request patient records, test results, and provider credentials, and may require other documentation as part of its coverage determination process.

Denial Risk

Denial Triggers

The Company may deny reimbursement when it determines the drug or services were not medically necessary, investigational or experimental, not within the scope of benefits, or when a pattern of inappropriate or excessive billing/practice is identified.

Policy background and intent

This policy is intended for members or groups who, because of beliefs or benefit design, exclude contraceptives when used for pregnancy prevention. In those populations, contraceptive products may be covered when prescribed for non-contraceptive indications.

Key definitions

inv-09: Non-contraceptive use — Use of contraceptive medications for indications other than pregnancy prevention in populations or benefit plans that exclude contraceptives.

DefinitionUse of contraceptive medications for indications other than pregnancy prevention in populations or benefit plans that exclude contraceptive coverage for that purpose.

Policy scopeApplies to select member groups who, due to beliefs or coverage requirements, exclude contraceptives for pregnancy prevention but may allow them for non-contraceptive indications.

Intended applicationUsed to evaluate pharmacy benefit prior authorization requests when contraceptives are prescribed for non-contraceptive indications for covered populations.

Related actionPrior authorization is recommended for pharmacy benefit coverage of contraceptive medications for eligible non-contraceptive uses.

Documentation noteThe Company may request additional documentation to support medical necessity for non-contraceptive use.