CurrentUnitedHealthcarePolicy N/A

Request for an Alternative Contraceptive Drug, Device, or Product

Form and process for providers to request coverage of a non-formulary contraceptive drug, device, or product for UnitedHealthcare members covered under New York health insurance policies (excluding self-funded ERISA, Medicaid, Medicare, and TRICARE).

Policy Summary

PayerUnitedHealthcare

PolicyRequest for an Alternative Contraceptive Drug, Device, or Product

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed request form (or phone/ePA submission) with product details and attestation to the insurer to obtain coverage for a non-formulary contraceptive.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

24 hoursexpedited decision turnaround

72 hoursstandard decision timeframe

2pharmacy fax lines

1medical-benefit portal

Coverage Criteria for Alternative Contraceptives

Policy Summary

PayerUnitedHealthcare

PolicyRequest for an Alternative Contraceptive Drug, Device, or Product

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed request form (or phone/ePA submission) with product details and attestation to the insurer to obtain coverage for a non-formulary contraceptive.

SourceLink

On This Page

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Primary conditions: 1) Member is covered under a New York health insurance policy (this policy does not apply to self-funded ERISA, Medicaid, Medicare, or TRICARE).

Clinical determination: 2) The attending health care provider has determined that the therapeutic and pharmaceutical equivalent versions of the contraceptive drug, device, or product on the formulary are either not available OR are medically inadvisable.

Provider must indicate which condition applies on the request form (Not available OR Deemed medically inadvisable).

Submission and documentation: 3) A completed request form or equivalent submission is provided that specifies the requested alternative contraceptive product (name, strength, quantity or units, J-code if applicable, proposed date of service), includes the provider's attestation and signature, and is submitted via the required channel for the benefit (retail pharmacy fax or ePA for pharmacy benefit; UHC Provider portal/phone for medical benefit).

Providers may request an expedited (24-hour) decision when waiting 72 hours could seriously harm the patient or the patient is mid-course of treatment; otherwise standard decision timeframe applies.

Provider Submission Requirements and Actions

Prior Authorization

Submission channels and requirement

Complete and send a Request for an Alternative Contraceptive Drug, Device, or Product form (or submit by phone/ePA) to obtain coverage when therapeutic and pharmaceutical formulary equivalents are not available or are medically inadvisable. Insurers must cover a non‑formulary contraceptive without cost‑sharing upon the provider's recommendation.

Submit retail pharmacy drug requests via fax to 1‑800‑527‑0531 (non‑specialty) or 1‑800‑853‑3844 (specialty).
Retail pharmacy requests may also be submitted via electronic prior authorization (ePA) through www.CoverMyMeds.com, any ePA‑enabled EMR, or by phone at 1‑800‑711‑4555.
Medical benefit drug requests may be submitted by calling the toll‑free number on the member ID card or by attaching the completed form to a secure portal request at www.UHCProvider.com/paan.
We will notify the provider using the preferred contact method on the form when the request has been processed.

Denial Risk

Denial risk when formulary equivalents are available

If a covered therapeutic or pharmaceutical equivalent is available and not medically contraindicated, the insurer may deny the request for the non‑formulary contraceptive. The provider must attest when equivalents are unavailable or would be medically inadvisable; failure to provide this attestation or documentation supporting medical inadvisability increases risk of denial.

Documentation Required

Required form fields and signature

The form must include patient and provider identifiers and product/clinical details necessary for review. Required fields include: patient name, date of birth, address, insurer name, member ID; attending provider name, address, phone, fax, Tax ID/NPI, facility (if applicable), and preferred contact method.

Product details: requested contraceptive name, strength, quantity per month, J‑code (if applicable), units requested, and proposed date of service.
Clinical rationale: statement that formulary equivalents are not available or are medically inadvisable; clinical justification for the requested alternative.
Signature: provider certification and dated health care provider signature required to validate the request.

Prior Authorization

Formulary equivalent attestation and expedited request

For expedited (fast) decisions, the provider must check that the covered therapeutic and pharmaceutical equivalent is either not available or is medically inadvisable and state why a 24‑hour decision is needed (waiting 72 hours could seriously harm life/health/ability to regain maximum function, or the patient is currently undergoing treatment with the non‑covered product). Providers may indicate whether a generic substitution is acceptable.

Expedited determinations are available when the provider attests that standard timing could seriously harm the patient or treatment is ongoing.
Include the same product and clinical fields described above when requesting an expedited review.

Background

This form is used when the attending clinician determines that a non‑formulary contraceptive drug, device, or product is warranted because the therapeutic and pharmaceutical equivalent versions on the insurer's formulary are not available or are medically inadvisable. Completing and submitting the request form (or using phone/ePA/portal channels where permitted) initiates review; insurers must cover a non‑formulary contraceptive without cost‑sharing when the clinician recommends it under these conditions.

If the situation meets criteria for an expedited review (for example, delay could seriously harm the patient or the patient is mid‑course of treatment with the non‑covered product), the provider may indicate an Expedited (Fast) Decision on the form to request faster handling.

Definitions

Expedited decision — key facts

DefinitionExpedited (Fast) Decision: a request by the attending provider when waiting the standard 72-hour decision could seriously harm the patient’s life, health, or ability to regain maximum function, or the patient is currently undergoing treatment with the non-covered product.

Standard decision timeframe72 hours

Expedited decision turnaroundDecision requested within 24 hours when criteria for expedited review are met.

Provider attestation requiredProvider must indicate that formulary therapeutic or pharmaceutical equivalents are not available or are medically inadvisable and state the reason for expedited review (serious harm or ongoing treatment).

When to completeAttending health care provider completes the expedited section on the form when applicable, including product details and justification.

OpenPayer

Request for an Alternative Contraceptive Drug, Device, or Product

Coverage Criteria for Alternative Contraceptives

Billing and Coding

Provider Submission Requirements and Actions

Background

Definitions