excluded contraceptive (any) — Highmark
contraception
Initial criteria
- When a benefit, coverage may be approved if the prescribing physician indicates that the excluded drug is medically necessary OR the member has tried and failed one therapeutic alternative as follows:
- For an Rx with OTC Equivalent medication, the alternative must be the similar chemical entity product available over the counter.
- For a High Cost Low Value medication, the alternative must be from the middle column of the table for the corresponding targeted medication.
- For a New to Market medication, the alternative must be in the same therapeutic class/category as the requested medication; if none exists, the alternative may be in a different class/category but must have the same indication.
Approval duration
12 months