CurrentUnitedHealthcarePolicy N/A

Contraceptive Medications Prior Authorization

Defines prior authorization/notification requirements for contraceptive medications for UnitedHealthcare clients who are grandfathered or designated as Religious Exempt organizations and seek to exclude contraceptive products for contraception purposes.

Policy Summary

PayerUnitedHealthcare

PolicyContraceptive Medications Prior Authorization

Policy CodePolicy N/A

Change TypeClarified authorization durationadded examples of covered indications

Effective Date6/1/2025

Next Review DateN/A

Key ActionObtain prior authorization for contraceptive medications; approvals are issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Authorization will be issued for 12 months.

Program includes examples of non-contraceptive indications for contraceptive medications (e.g., acne, endometriosis, PCOS).

12 monthsstandard authorization duration

6/1/2025effective date

3/2025last P&T approval dates

Coverage Criteria

This program is designed for clients who are grandfathered and/or designated as a Religious Exempt organization under the Patient Protection and Affordable Care Act who wish to exclude contraceptive products for contraception purposes. Clients who do not have grandfathered status and are not designated as Religious Exempt are not eligible to use this exclusion program.

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Initial Therapy

Initial approval

Initial approval criteria: Contraceptive medications may be approved when used for a covered non-contraceptive medical indication OR when approval can be supported by previous claim/medication history and relevant diagnosis codes; state and member plan mandates may affect approval.

Approvals may rely on clinical documentation, prior medication history, and diagnosis coding; include ICD-10 codes as applicable.

Reauthorization / Continuation Criteria

Reauthorization

Reauthorization period: Authorizations will be issued for 12 months.

State mandates, federal requirements, and member-specific benefit plans may impact coverage; reauthorization may be granted based on prior claim/medication history, diagnosis codes (ICD-10), and/or automated approval processes as applicable.

Provider Actions and Requirements

Prior Authorization

Prior Authorization and Authorization Period

Prior authorization is required for requests to exclude contraceptive products for clients who are grandfathered or designated as Religious Exempt organizations. Approvals are issued for 12 months. State mandates, federal requirements, and the member's specific benefit plan may affect coverage and authorization decisions.

Authorization period: 12 months
Coverage may be affected by state mandates, federal requirements, and the member benefit plan

Step Therapy

No step therapy requirements are specified in this document.

Documentation Required

Supporting Documentation and Automated Approvals

UnitedHealthcare may approve initial requests and reauthorizations based on previous claim/medication history, relevant diagnosis codes (ICD-10), and/or automated claim logic. Automated approval and re‑approval processes may vary by program and therapeutic class; providers should include supporting documentation when submitting requests to facilitate timely review.

Approval may be based on prior claims/medication history
Approval may use diagnosis codes (ICD-10) and claim logic
Automated approval processes vary by program/therapeutic class

Note

Eligibility for Exclusion

Requests for exclusion of contraceptive products are processed for clients who are grandfathered and/or designated as Religious Exempt organizations per applicable law.

Step	Requirement
1
No specific step therapy requirements are specified in this policy.

Definitions

Religious Exempt / Grandfathered client

DefinitionA client designated under the Patient Protection and Affordable Care Act as grandfathered and/or a Religious Exempt organization that may request exclusion of contraceptive products for contraception purposes.

Program purposeAllows eligible clients (grandfathered or Religious Exempt) to request exclusion of contraceptive products for contraception while still permitting coverage when those medications are used for non-contraceptive medical indications.

Eligibility for exclusionRequests for exclusion are processed only for clients who are grandfathered and/or designated as Religious Exempt organizations; clients without that designation are not eligible to use this exclusion.

Implication for prescribing/coverageEven if an organization has excluded contraceptive coverage for contraception, contraceptive medications may still be approved when used to treat listed non-contraceptive conditions (e.g., acne, endometriosis, PCOS, abnormal bleeding).

Governing authorityDesignation and exclusion are referenced to the Patient Protection and Affordable Care Act.

Background

This program permits certain UnitedHealthcare clients—specifically those that are grandfathered or designated as Religious Exempt organizations—to request exclusion of contraceptive products for contraception purposes. When exclusion is in place, contraceptive medications may still be approved if used for recognized non-contraceptive medical indications such as acne, endometriosis, polycystic ovarian syndrome (PCOS), abnormal or excessive bleeding disorders, PMS/PMDD, prevention of endometrial or ovarian cancer, prevention of menstrual migraines, uterine fibroids/adenomyosis, Turner’s syndrome, and other listed conditions.