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excluded contraceptives — Highmark

contraceptives

Initial criteria

  • When a benefit, coverage of an excluded contraceptive may be approved if a member meets one (1) of the following criteria (A. or B.):
  • A. The prescribing physician indicates that the requested drug is medically necessary.
  • OR
  • B. The member has tried and failed one (1) therapeutic alternative:
  • 1. For an Rx with OTC Equivalent medication, the alternative must be the similar chemical entity product which is available over the counter.
  • 2. For a High Cost Low Value medication, the alternative must be from the middle column of the table below for the corresponding targeted medication.
  • 3. For a New to Market medication, the alternative must be in the same therapeutic class/category as the requested medication; if none exists in the class/category, the alternative may be in a different therapeutic class/category, however it must have the same indication.