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PW_E187038
Women’s Prescription Contraception Coverage with Top 25 Prescription Contraception Drug List  
The federal Department of Health and Human Services has issued guidance on required women’s preventive health services. These benefits aim to reduce financial barriers that may prevent members from seeking these services by lowering their share of costs. In compliance with the Affordable Care Act (health care reform), we are adding coverage for prescription contraceptives for women to most health plans. The following frequently asked questions provide information about the new contraceptive coverage benefits.  
 
Which medical plans are impacted by the new contraception coverage provisions – and when?  
The new coverage applies to all group and individual nongrandfathered health plans [with prescription drug benefits]. 
For group health plans, coverage will be effective at the first plan year on or after August 1, 2012.
For new individual policies, coverage will begin on or after August 1, 2012.
For existing individual policies, coverage generally will be effective January 1, 2013.
 
Providers should continue to verify eligibility and benefits when determining copayments or coinsurance due by members for services rendered. 
 
What drugs are covered under the health care reform women’s preventive care pharmacy benefit? 
We are adding coverage for women’s prescription contraceptives to the preventive benefit. We will not cover over-the-counter contraceptives or contraceptives for men. Coverage will be available through network retail or home delivery pharmacies. 
We will cover: 
Oral contraceptives (birth control pills)
Contraceptive patch
Contraceptive ring
Prescription diaphragm or cervical cap
Prescription oral “morning after” pill, with conditions
For the most commonly used covered contraceptives, please see the top 25 list at the end of this FAQ. 
 
What drugs are not covered under the health care reform women’s preventive care pharmacy benefit? 
Contraceptives not requiring a prescription, such as condoms, contraceptive sponges, spermicides and non-prescription oral “morning after” pills
contraceptives obtained from non-network pharmacies
Contraception methods for males
IUDs (covered under medical benefit at 100%)
Contraceptive implants (covered under medical benefit at 100%)
Injectables that are not self-administered (may be covered under the medical benefit)
 
What will be the patient’s cost-sharing? 
Cost-sharing for prescription contraceptives will vary based on the type of drug and the plan’s benefit structure.
Generic drugs and single-source brands that don’t have a generic equivalent will have no cost–sharing (100% coverage) at an in network pharmacy.
Multi-source brand drugs that have a generic equivalent may be paid under the existing benefits with patient cost-sharing.
 
Is there an out-of-network benefit? 
No. 
 
What is the process for covering non-preferred contraceptives? 
In some cases, step therapy will promote the use of generic or preferred contraceptives before using brand contraceptives. Requests for brand contraceptives may be approved for members who meet the following criteria:  

A. The member has tried or had intolerance to at least two generic oral contraceptives in the previous 180 days

AND

B. If the member requests NuvaRing® or Ortho Evra® Transdermal patch, documentation must be provided as to why an oral contraceptive cannot be used.

(Documentation should include, but is not limited to, chart notes, prescription claims records, prescription receipts, laboratory data, reason for failure of medications tried.)

OR

C. Member requests Natazia® for treatment of heavy menstrual bleeding.

Sometimes we cover 100% of a brand-name drug, but only if the plan has brand-name drug benefits and there is no generic form available. We may require prior authorization for brand-name drugs with available generics. A deductible, copay or coinsurance also may apply. Providers should verify eligibility and benefits for specific members.  
 
Will we cover Depo-Provera?  
We will cover Depo-Provera (injectable contraceptive) at 100% if the particular benefit plan included coverage for this product under the prescription benefit. In the instances where the benefit plan did not include coverage, we will continue to cover it under the medical benefit.  
 
Will we cover Plan-B (emergency contraceptives – the “morning after” pill)? 
We will cover emergency contraceptives at 100% for members who have a prescription and are under age 17. Members age 17 and older will not receive the benefit because these products are available without a prescription and our benefit plans do not cover over-the-counter items. 
 
Are there any plans that the benefit does not apply to? 
Most grandfathered plans will not have this benefit, but some grandfathered plans will receive the new contraceptive coverage if the plan previously implemented the Affordable Care Act’s preventive benefits. Additionally, some large group grandfathered plans may be able to customize their plans to not cover contraception. In addition, Providers should continue to verify eligibility and member benefits, as this is the most effective method to determine which benefits apply to a specific member policy. 
 
Top 25 Women’s Prescription Contraceptive Drugs  
The prescription drugs on this list are those most commonly used by women for contraception. Covered drugs are available through network retail or home delivery pharmacies, according to the terms of the plan. Coverage is intended to comply with the Affordable Care Act (health care reform) and increase women members’ access to preventive care.  
This list includes only prescription products. Brand-name drugs are listed with a first capital letter. Non-brand drugs (generics) are in lowercase letters. 

Tier 1 (Formulary) 
Tier 2 (Formulary) 
Tier 3 (Non-formulary) 
aviane
Loestrin 24 FE  
Beyaz 
camila  
Ortho Evra  
Lo Loestrin FE  
errin Ortho Tri-Cyclen Lo Micronor
gianvi Plan B One-Step 1.5mg Nor-Q-D
jolivette   Nuvaring
junel FE   Plan B 0.75mg
kariva   Yasmin
loryna   Yaz
lutera    
microgestin FE    
Next Choice    
nora-be    
ocella    
Zarah    
     
 
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