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ph-91005

Contraceptive Prior Authorization Program Summary

Policy Number: PH-91005

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 program applies for Commercial and Blue Partner formularies.

POLICY REVIEW CYCLE

Effective Date	Date of Origin
01-01-2025

See package insert for FDA prescribing information: https://dailymed.nlm.nih.gov/dailymed/index.cfm

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

Number	Reference
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.

POLICY AGENT SUMMARY PRIOR AUTHORIZATION

Target Brand Agent(s)	Target Generic Agent(s)	Strength	Targeted MSC	Available MSC	Final Age Limit	Preferred Status

Afirmelle ; Altavera ; Alyacen 1/35 ; Alyacen 7/7/7 ; Amethia ; Amethyst ; Apri ; Aranelle ; Ashlyna ; Aubra ; Aubra eq ; Aurovela 1.5/30 ; Aurovela 1/20 ; Aurovela 24 fe ; Aurovela fe 1.5/30 ; Aurovela fe 1/20 ; Aviane ; Ayuna ; Azurette ; Balcoltra ; Balziva ; Beyaz ; Blisovi 24 fe ; Blisovi fe 1.5/30 ; Blisovi fe 1/20 ; Briellyn ; Camrese ; Camrese lo ; Chateal ; Chateal eq ; Cryselle-28 ; Cyred ; Cyred eq ; Dasetta 1/35 ; Dasetta 7/7/7 ; Daysee ; Delyla ; Elinest ; Enpresse-28 ; Enskyce ; Estarylla ; Falmina ; Fayosim ; Femynor ; Generess fe ; Hailey 1.5/30 ; Hailey 24 fe ; Introvale ; Isibloom ; Jaimiess ; Jasmiel ; Jolessa ; Juleber ; Junel 1.5/30 ; Junel 1/20 ; Junel fe 1.5/30 ; Junel fe 1/20 ; Junel fe 24 ; Kaitlib fe ; Kalliga ; Kariva ; Kelnor 1/35 ; Kelnor 1/50 ; Kurvelo ; Larin 1.5/30 ; Larin 1/20 ; Larin 24 fe ; Larin fe 1.5/30 ; Larin fe 1/20 ; Layolis fe ; Leena ; Lessina ; Levonest ; Levora 0.15/30-28 ; Lo loestrin fe ; Lo-zumandimine ; Loestrin 1.5/30-21 ; Loestrin 1/20-21 ; Loestrin fe 1.5/30 ; Loestrin fe 1/20 ; Lojaimiess ; Loryna ; Loseasonique ; Low-ogestrel ; Lutera ; Marlissa ; Mibelas 24 fe ; Microgestin 1.5/30 ; Microgestin 1/20 ; Microgestin 24 fe ; Microgestin fe 1.5/30 ; Mili ; Minastrin 24 fe ; Mircette ; Mono-linyah ; Natazia ; Necon 0.5/35-28 ; Necon 1/35 ; Nikki ; Nortrel 0.5/35 (28) ; Nortrel 1/35 ; Nortrel 7/7/7 ; Ocella ; Orsythia ; Ortho tri-cyclen lo ; Philith ; Pimtrea ; Pirmella 1/35 ; Pirmella 7/7/7 ; Portia-28 ; Quartette ; Reclipsen ; Rivelsa ; Safyral ; Seasonique ; Setlakin ; Simliya ; Simpesse ; Solia ; Sprintec 28 ; Sronyx ; Syeda ; Tarina 24 fe ; Tarina fe 1/20 ; Tarina fe 1/20 eq ; Taytulla ; Tilia fe ; Tri femynor ; Tri-estarylla ; Tri-legest fe ; Tri-linyah ; Tri-lo-estarylla ; Tri-lo-marzia ; Tri-lo-mili ; Tri-lo-sprintec ; Tri-mili ; Tri-sprintec ; Tri-vylibra ; Tri-vylibra lo ; Trinessa ; Trivora-28 ; Tydemy ; Velivet ; Vestura ; Vienva ; Viorele ; Volnea ; Vyfemla ; Vylibra ; Wera	desogest-eth estrad & eth estrad tab ; desogest-ethin est tab ; desogestrel & ethinyl estradiol tab ; drospirenone-estetrol tab ; drospirenone-ethinyl estrad-levomefolate tab ; drospirenone-ethinyl estradiol tab ; estradiol valerate-dienogest tab ; ethynodiol diacetate & ethinyl estradiol tab ; levonor-eth est tab ; levonorg-eth est tab ; levonorgestrel & ethinyl estradiol ( ; levonorgestrel & ethinyl estradiol chew tab ; levonorgestrel & ethinyl estradiol tab ; levonorgestrel-eth estra tab ; levonorgestrel-ethinyl estradiol (continuous) tab ; levonorgestrel-ethinyl estradiol-fe tab ; norethin-eth estradiol-fe tab ; norethindrone & ethinyl estradiol tab ; norethindrone & ethinyl estradiol-fe chew tab ; norethindrone ac-ethinyl estrad-fe tab ; norethindrone ace & ethinyl estradiol tab ; norethindrone ace & ethinyl estradiol tab disint ; norethindrone ace & ethinyl estradiol-fe tab ; norethindrone ace-eth estradiol-fe chew tab ; norethindrone ace-ethinyl estradiol-fe cap ; norethindrone ace-ethinyl estradiol-fe tab ; norethindrone-eth estradiol tab ; norgestimate & ethinyl estradiol tab ; norgestimate-eth estrad tab ; norgestrel & ethinyl estradiol tab	0.1-0.02 & 0.01 MG ; 0.1-20 MG-MCG ; 0.1-20 MG-MCG(21) ; 0.1/0.125/0.15 -0.025 MG ; 0.15-0.02/0.01 MG (21/5) ; 0.15-0.03 &0.01 MG ; 0.15-0.03 MG ; 0.15-30 MG-MCG ; 0.18/0.215/0.25 MG-25 MCG ; 0.18/0.215/0.25 MG-35 MCG ; 0.25-35 MG-MCG ; 0.3-30 MG-MCG ; 0.4-35 MG-MCG ; 0.5-35 MG-MCG ; 0.5/0.75/1-35 MG-MCG ; 0.5/1/0.5-35 MG-MCG ; 0.8-25 MG-MCG ; 1 MG-10 MCG / 10 MCG ; 1-0.02 MG ; 1-20 MG-MCG ; 1-20 MG-MCG(24) ; 1-20/1-30/1-35 MG-MCG ; 1-35 MG-MCG ; 1-50 MG-MCG ; 1.5-30 MG-MCG ; 3-0.02 MG ; 3-0.02-0.451 MG ; 3-0.03 MG ; 3-0.03-0.451 MG ; 3-14.2 MG ; 3/2-2/2-3/1 MG ; 42-21-21-7 DAYS ; 50-30/75-40/ 125-30 MCG ; 90-20 MCG	M ; N ; O ; Y	N ; O ; Y
Camila ; Deblitane ; Emzahh ; Errin ; Heather ; Incassia ; Jencycla ; Lyleq ; Lyza ; Nora-be ; Norlyda ; Norlyroc ; Opill ; Sharobel ; Slynd	drospirenone tab ; norethindrone tab ; norgestrel tab	0.075 MG ; 0.35 MG ; 4 MG	M ; N ; O ; Y	N ; Y
Annovera ; Eluryng ; Enilloring ; Haloette ; Nuvaring	etonogestrel-ethinyl estradiol va ring ; segesterone ace-ethinyl estradiol va ring	0.013-0.15 MG/24HR ; 0.12-0.015 MG/24HR	M ; N ; O ; Y	N ; O ; Y
Eluryng ; Enilloring ; Haloette ; Nuvaring	Etonogestrel-Ethinyl Estradiol VA Ring 0.120-0.015 MG/24HR	0.12-0.015 MG/24HR	M ; N ; O ; Y	O ; Y
Amethia ; Ashlyna ; Camrese ; Camrese lo ; Daysee ; Fayosim ; Iclevia ; Introvale ; Jaimiess ; Jolessa ; Lojaimiess ; Loseasonique ; Quartette ; Rivelsa ; Seasonique ; Setlakin ; Simpesse	levonor-eth est tab ; levonorg-eth est tab ; levonorgestrel & ethinyl estradiol (	0.1-0.02 & 0.01 MG ; 0.15-0.03 &0.01 MG ; 0.15-0.03 MG ; 42-21-21-7 DAYS	M ; N ; O ; Y	O ; Y
Amethia ; Ashlyna ; Camrese ; Daysee ; Jaimiess ; Seasonique ; Simpesse	Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab 0.01MG(7)	0.15-0.03 &0.01 MG	M ; N ; O ; Y	O ; Y
Aftera ; Afterpill ; Curae ; Econtra ez ; Econtra one-step ; Ella ; Her style ; My choice ; My way ; New day ; Opcicon one-step ; Option 2 ; Plan b one-step ; React ; Take action	levonorgestrel tab ; ulipristal acetate tab	1.5 MG ; 30 MG	M ; N ; O ; Y	M ; N ; O ; Y
Depo-provera contraceptiv ; Depo-subq provera 104	medroxyprogesterone acetate im susp ; medroxyprogesterone acetate im susp prefilled syr ; medroxyprogesterone acetate susp pref syr	104 MG/0.65ML ; 150 MG/ML	M ; N ; O ; Y	N ; O ; Y
Xulane ; Zafemy	norelgestromin-ethinyl estradiol td ptwk	150-35 MCG/24HR	M ; N ; O ; Y	Y
Alyacen 1/35 ; Balziva ; Briellyn ; Dasetta 1/35 ; Necon 0.5/35-28 ; Necon 1/35 ; Nortrel 0.5/35 (28) ; Nortrel 1/35 ; Nylia 1/35 ; Philith ; Pirmella 1/35 ; Vyfemla ; Wera	norethindrone & ethinyl estradiol tab	0.4-35 MG-MCG ; 0.5-35 MG-MCG ; 1-35 MG-MCG	M ; N ; O ; Y	Y
Aranelle ; Leena	Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG	0.5/1/0.5-35 MG-MCG	M ; N ; O ; Y	Y

CLIENT SUMMARY – PRIOR AUTHORIZATION

Target Brand Agent Name(s)	Target Generic Agent Name(s)	Strength	Client Formulary
Afirmelle ; Altavera ; Alyacen 1/35 ; Alyacen 7/7/7 ; Amethia ; Amethyst ; Apri ; Aranelle ; Ashlyna ; Aubra ; Aubra eq ; Aurovela 1.5/30 ; Aurovela 1/20 ; Aurovela 24 fe ; Aurovela fe 1.5/30 ; Aurovela fe 1/20 ; Aviane ; Ayuna ; Azurette ; Balcoltra ; Balziva ; Beyaz ; Blisovi 24 fe ; Blisovi fe 1.5/30 ; Blisovi fe 1/20 ; Briellyn ; Camrese ; Camrese lo ; Chateal ; Chateal eq ; Cryselle-28 ; Cyred ; Cyred eq ; Dasetta 1/35 ; Dasetta 7/7/7 ; Daysee ; Delyla ; Elinest ; Enpresse-28 ; Enskyce ; Estarylla ; Falmina ; Fayosim ; Femynor ; Generess fe ; Hailey 1.5/30 ; Hailey 24 fe ; Introvale ; Isibloom ; Jaimiess ; Jasmiel ; Jolessa ; Juleber ; Junel 1.5/30 ; Junel 1/20 ; Junel fe 1.5/30 ; Junel fe 1/20 ; Junel fe 24 ; Kaitlib fe ; Kalliga ; Kariva ; Kelnor 1/35 ; Kelnor 1/50 ; Kurvelo ; Larin 1.5/30 ; Larin 1/20 ; Larin 24 fe ; Larin fe 1.5/30 ; Larin fe 1/20 ; Layolis fe ; Leena ; Lessina ; Levonest ; Levora 0.15/30-28 ; Lo loestrin fe ; Lo-zumandimine ; Loestrin 1.5/30-21 ; Loestrin 1/20-21 ; Loestrin fe 1.5/30 ; Loestrin fe 1/20 ; Lojaimiess ; Loryna ; Loseasonique ; Low-ogestrel ; Lutera ; Marlissa ; Mibelas 24 fe ; Microgestin 1.5/30 ; Microgestin 1/20 ; Microgestin 24 fe ; Microgestin fe 1.5/30 ; Mili ; Minastrin 24 fe ; Mircette ; Mono-linyah ; Natazia ; Necon 0.5/35-28 ; Necon 1/35 ; Nikki ; Nortrel 0.5/35 (28) ; Nortrel 1/35 ; Nortrel 7/7/7 ; Ocella ; Orsythia ; Ortho tri-cyclen lo ; Philith ; Pimtrea ; Pirmella 1/35 ; Pirmella 7/7/7 ; Portia-28 ; Quartette ; Reclipsen ; Rivelsa ; Safyral ; Seasonique ; Setlakin ; Simliya ; Simpesse ; Solia ; Sprintec 28 ; Sronyx ; Syeda ; Tarina 24 fe ; Tarina fe 1/20 ; Tarina fe 1/20 eq ; Taytulla ; Tilia fe ; Tri femynor ; Tri-estarylla ; Tri-legest fe ; Tri-linyah ; Tri-lo-estarylla ; Tri-lo-marzia ; Tri-lo-mili ; Tri-lo-sprintec ; Tri-mili ; Tri-sprintec ; Tri-vylibra ; Tri-vylibra lo ; Trinessa ; Trivora-28 ; Tydemy ; Velivet ; Vestura ; Vienva ; Viorele ; Volnea ; Vyfemla ; Vylibra ; Wera	desogest-eth estrad & eth estrad tab ; desogest-ethin est tab ; desogestrel & ethinyl estradiol tab ; drospirenone-estetrol tab ; drospirenone-ethinyl estrad-levomefolate tab ; drospirenone-ethinyl estradiol tab ; estradiol valerate-dienogest tab ; ethynodiol diacetate & ethinyl estradiol tab ; levonor-eth est tab ; levonorg-eth est tab ; levonorgestrel & ethinyl estradiol ( ; levonorgestrel & ethinyl estradiol chew tab ; levonorgestrel & ethinyl estradiol tab ; levonorgestrel-eth estra tab ; levonorgestrel-ethinyl estradiol (continuous) tab ; levonorgestrel-ethinyl estradiol-fe tab ; norethin-eth estradiol-fe tab ; norethindrone & ethinyl estradiol tab ; norethindrone & ethinyl estradiol-fe chew tab ; norethindrone ac-ethinyl estrad-fe tab ; norethindrone ace & ethinyl estradiol tab ; norethindrone ace & ethinyl estradiol tab disint ; norethindrone ace & ethinyl estradiol-fe tab ; norethindrone ace-eth estradiol-fe chew tab ; norethindrone ace-ethinyl estradiol-fe cap ; norethindrone ace-ethinyl estradiol-fe tab ; norethindrone-eth estradiol tab ; norgestimate & ethinyl estradiol tab ; norgestimate-eth estrad tab ; norgestrel & ethinyl estradiol tab	0.1-0.02 & 0.01 MG ; 0.1-20 MG-MCG ; 0.1-20 MG-MCG(21) ; 0.1/0.125/0.15 -0.025 MG ; 0.15-0.02/0.01 MG (21/5) ; 0.15-0.03 &0.01 MG ; 0.15-0.03 MG ; 0.15-30 MG-MCG ; 0.18/0.215/0.25 MG-25 MCG ; 0.18/0.215/0.25 MG-35 MCG ; 0.25-35 MG-MCG ; 0.3-30 MG-MCG ; 0.4-35 MG-MCG ; 0.5-35 MG-MCG ; 0.5/0.75/1-35 MG-MCG ; 0.5/1/0.5-35 MG-MCG ; 0.8-25 MG-MCG ; 1 MG-10 MCG / 10 MCG ; 1-0.02 MG ; 1-20 MG-MCG ; 1-20 MG-MCG(24) ; 1-20/1-30/1-35 MG-MCG ; 1-35 MG-MCG ; 1-50 MG-MCG ; 1.5-30 MG-MCG ; 3-0.02 MG ; 3-0.02-0.451 MG ; 3-0.03 MG ; 3-0.03-0.451 MG ; 3-14.2 MG ; 3/2-2/2-3/1 MG ; 42-21-21-7 DAYS ; 50-30/75-40/ 125-30 MCG ; 90-20 MCG	Blue Partner ; Commercial
Aftera ; Afterpill ; Curae ; Econtra ez ; Econtra one-step ; Ella ; Her style ; My choice ; My way ; New day ; Opcicon one-step ; Option 2 ; Plan b one-step ; React ; Take action	levonorgestrel tab ; ulipristal acetate tab	1.5 MG ; 30 MG	Blue Partner ; Commercial
Alyacen 1/35 ; Balziva ; Briellyn ; Dasetta 1/35 ; Necon 0.5/35-28 ; Necon 1/35 ; Nortrel 0.5/35 (28) ; Nortrel 1/35 ; Nylia 1/35 ; Philith ; Pirmella 1/35 ; Vyfemla ; Wera	norethindrone & ethinyl estradiol tab	0.4-35 MG-MCG ; 0.5-35 MG-MCG ; 1-35 MG-MCG	Blue Partner ; Commercial
Amethia ; Ashlyna ; Camrese ; Camrese lo ; Daysee ; Fayosim ; Iclevia ; Introvale ; Jaimiess ; Jolessa ; Lojaimiess ; Loseasonique ; Quartette ; Rivelsa ; Seasonique ; Setlakin ; Simpesse	levonor-eth est tab ; levonorg-eth est tab ; levonorgestrel & ethinyl estradiol (	0.1-0.02 & 0.01 MG ; 0.15-0.03 &0.01 MG ; 0.15-0.03 MG ; 42-21-21-7 DAYS	Blue Partner ; Commercial
Amethia ; Ashlyna ; Camrese ; Daysee ; Jaimiess ; Seasonique ; Simpesse	Levonorg-Eth Est Tab 0.15-0.03MG(84) & Eth Est Tab 0.01MG(7)	0.15-0.03 &0.01 MG	Blue Partner ; Commercial
Annovera ; Eluryng ; Enilloring ; Haloette ; Nuvaring	etonogestrel-ethinyl estradiol va ring ; segesterone ace-ethinyl estradiol va ring	0.013-0.15 MG/24HR ; 0.12-0.015 MG/24HR	Blue Partner ; Commercial
Aranelle ; Leena	Norethindrone-Eth Estradiol Tab 0.5-35/1-35/0.5-35 MG-MCG	0.5/1/0.5-35 MG-MCG	Blue Partner ; Commercial
Camila ; Deblitane ; Emzahh ; Errin ; Heather ; Incassia ; Jencycla ; Lyleq ; Lyza ; Nora-be ; Norlyda ; Norlyroc ; Opill ; Sharobel ; Slynd	drospirenone tab ; norethindrone tab ; norgestrel tab	0.075 MG ; 0.35 MG ; 4 MG	Blue Partner ; Commercial
Depo-provera contraceptiv ; Depo-subq provera 104	medroxyprogesterone acetate im susp ; medroxyprogesterone acetate im susp prefilled syr ; medroxyprogesterone acetate susp pref syr	104 MG/0.65ML ; 150 MG/ML	Blue Partner ; Commercial
Eluryng ; Enilloring ; Haloette ; Nuvaring	Etonogestrel-Ethinyl Estradiol VA Ring 0.120-0.015 MG/24HR	0.12-0.015 MG/24HR	Blue Partner ; Commercial
Xulane ; Zafemy	norelgestromin-ethinyl estradiol td ptwk	150-35 MCG/24HR	Blue Partner ; Commercial

PRIOR AUTHORIZATION CLINICAL CRITERIA FOR APPROVAL

Module	Clinical Criteria for Approval
	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: 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

Module

Clinical Criteria for Approval

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:

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.