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 reviewhistorical 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.

SourceLink

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

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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.

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.

Policy Summary

PayerUnitedHealthcare

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

Policy CodePolicy N/A

Change TypeAnnual reviewhistorical authorization revision

Effective DateJun 1, 2026

Next Review Date

SourceLink

On This Page

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

OpenPayer

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

Coverage Summary

Initial Therapy Criteria

Limitations / Exclusions

Applicable Codes

Provider Actions

Background & Definitions

Clinical Evidence

Revision History