All underwritten groups provide coverage of contraceptives and prior authorization is not required.

Some self-funded groups either exclude coverage of contraceptive products or require prior authorization. For such groups, this program accommodates for the use of contraceptives when they are prescribed for non-contraceptive purposes (i.e., to treat certain medical conditions).

This Prior Authorization applies for Commercial and Blue Partner

CLINICAL RATIONALE

Contraception or "birth control" is the use of an agent, device, method or procedure to diminish the likelihood of conception. In addition to contraception, the medical literature documents the benefit of contraceptives in the treatment of a variety of medical conditions. Examples of medically necessary conditions include, but are not limited to: acne vulgaris (hormonal treatment or in conjunction with isotretinoin therapy), amenorrhea, dysfunctional uterine bleeding, dysmenorrhea, endometriosis, fibroid uterus, hyperandrogenism (hirsutism), irregular menses (menorrhagia, oligomenorrhea and hypermenorrhea), menstrual migraine, ovarian cysts, ovarian/endometrial cancer prevention (patients with a family history of ovarian or endometrial cancer), perimenopause, polycystic ovarian syndrome, and premenstrual dysphoric disorder (PMDD).^1,2

References

1. Schindler AE. Non-contraceptive benefits of oral hormonal contraceptives. Int J Endocrinol Metab. 2013;11(1):41-47. doi:10.5812/ijem.4158.
2. Armstrong C. ACOG Guidelines on Noncontraceptive Uses of Hormonal Contraceptives. Am Fam Physician. 2010 Aug 1;82(3):288-295.

Contraceptive Prior Authorization

Target Agents

    All self-administered contraceptives

PRIOR AUTHORIZATION CRITERIA FOR APPROVAL

Contraceptives (self-administered)

Initial and Renewal Evaluation

Target Agents will be approved when the following is met:

1. The contraceptive is being prescribed to treat one of the accepted medically necessary conditions. Examples of medically necessary conditions include, but are not limited to, the following: acne vulgaris (hormonal treatment or in conjunction with isotretinoin therapy), amenorrhea, dysfunctional uterine bleeding, dysmenorrhea, endometriosis, fibroid uterus, hyperandrogenism (hirsutism), irregular menses (menorrhagia, oligomenorrhea and hypermenorrhea), menstrual migraine, ovarian cysts, ovarian/endometrial cancer prevention (patients with a family history of ovarian or endometrial cancer), perimenopause, polycystic ovarian syndrome, or premenstrual dysphoric disorder (PMDD)

Note: Medical conditions other than those listed above will be reviewed on a case by case basis.

Length of Approval: 12 months

This pharmacy policy is not an authorization, certification, explanation of benefits or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All pharmacy policies are based on (i) information in FDA approved package inserts (and black box warning, alerts, or other information disseminated by the FDA as applicable); (ii) research of current medical and pharmacy literature; and/or (iii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.
 
The purpose of Blue Cross and Blue Shield of Alabama’s pharmacy policies are to provide a guide to coverage. Pharmacy policies are not intended to dictate to physicians how to practice medicine. Physicians should exercise their medical judgment in providing the care they feel is most appropriate for their patients.
 
Neither this policy, nor the successful adjudication of a pharmacy claim, is guarantee of payment.

ALBP_CS_Contraceptive_PA_ProgSum_AR1122