CurrentUnitedHealthcarePolicy N/A

Contraceptive Medications Prior Authorization/Notification (Religious Exempt/Grandfathered clients)

Defines prior authorization/notification criteria for contraceptive medications (e.g., Depo-Provera, NuvaRing, oral contraceptives, OrthoEvra, Annovera, Twirla) for clients grandfathered or designated Religious Exempt who elect to exclude contraceptive coverage; approval is limited to non-contraceptive indications and issued for 12 months.

Policy Summary

PayerUnitedHealthcare

PolicyContraceptive Medications Prior Authorization/Notification (Religious Exempt/Grandfathered clients)

Policy CodePolicy N/A

Change TypeAnnual review; historical authorization revision

Effective DateJun 1, 2026

Next Review Date

Key ActionObtain prior authorization/notification and document the non-contraceptive indication when requesting contraceptive medications for qualifying grandfathered or Religious Exempt members; authorizations are issued for 12 months.

POLICY UPDATE CHANGES

3/2026 annual review: No changes.

10/2016 Updated the authorization to 12 months.

16Listed Non-contraceptive Indications

12Authorization Duration

2026-06-01Effective Date

Coverage Summary

Initial Therapy Criteria

Approval Criteria for Contraceptive Medications

Covered when ALL of the following are met:

ALL of the following

Patient is part of a grandfathered and/or Religious Exempt organization per the Patient Protection and Affordable Care Act.
Medication is being used for non-contraception purposes. Examples include: abnormal or excessive bleeding disorders (e.g., amenorrhea, oligomenorrhea, menorrhagia, dysfunctional uterine bleeding); acne; decrease in bone mineral density; dysmenorrhea; endometriosis; hirsutism; irregular menses/cycles; ovarian cysts; perimenopausal symptoms; history of Pelvic Inflammatory Disease (PID); polycystic ovarian syndrome (PCO or PCOS); premenstrual syndrome (PMS); premenstrual dysphoric disorder (PMDD); prevention of endometrial and/or ovarian cancer; prevention of menstrual migraines; Turner's syndrome; uterine fibroids or adenomyosis.
Authorization will be issued for 12 months.
State mandates may apply. Any federal regulatory requirements and the member-specific benefit plan coverage may also impact coverage criteria. Other policies and utilization management programs may apply.

Limitations / Exclusions

Coverage is limited to non-contraceptive indications for clients who elect to exclude contraceptive coverage; Authorization will be issued for 12 months. State mandates, federal regulatory requirements, and the member-specific benefit plan may impact coverage.

Applicable Codes

Referenced contraceptive medications (examples in policy body)mixed

	medroxyprogesterone acetate (Depo-Provera®)
	etonogestrel/ethinyl estradiol (NuvaRing®)
	Oral Contraceptives
	norelgestromin/ethinyl estradiol (OrthoEvra®)
	Annovera® (segesterone/ethinyl estradiol)
	Twirla® (levonorgestrel/ethinyl estradiol)

Provider Actions

Prior Authorization

Prior authorization required for contraceptive medications under this program

Prior authorization/notification must be obtained when members who are grandfathered or designated Religious Exempt elect to exclude contraceptive coverage and request contraceptive medications for non-contraceptive indications; authorization issued for 12 months.

Documentation Required

Clinical indication documentation

Provider must document the non-contraceptive indication (one of the listed examples) on the claim or prior authorization request; approvals may be based solely on previous claim/medication history, diagnosis codes (ICD-10) and/or claim logic.

Billing Rule

State and plan limitations apply

State mandates, federal regulatory requirements, and member-specific benefit plan coverage may impact coverage criteria and authorization.

Background & Definitions

This program is intended for clients who are grandfathered and/or designated Religious Exempt and elect to exclude contraceptive products for contraception. The policy permits approval of contraceptive medications only when used for non-contraceptive medical indications and provides examples of acceptable indications. Authorizations are typically issued for 12 months.

Religious Exempt: Organizations designated as religiously exempt under the Patient Protection and Affordable Care Act that may elect to exclude contraceptive coverage.