Aetna covers contraceptives where mandated by law, in certain non-HMO plans, and under our contraceptives option to the pharmacy rider. Unless otherwise required by law and if covered as indicated above, Aetna will cover contraceptives in accordance with the criteria below.

Pharmacy Benefit Plans with Contraceptive coverage:

1. Precertification Criteria
   
   Under some plans, including plans that use an open or closed formulary, oral contraceptives (except for Seasonale) indicated in the table below are subject to precertification quantity limits.
   
   

   Quantity Limits:

   Manufacturer oral contraceptive package inserts recommend 1 tablet be taken per day for 21 days; no tablets are taken for 7 days or 7 inert or iron-containing tablets are taken to permit continuous daily dosage during the entire 28-day cycle for maximum contraceptive efficacy. A quantity limit of 1.4 tablets per day for 28-day supply will be considered medically necessary for oral contraceptives (except for Seasonale).

   
   
   For coverage of additional quantities, a member's treating physician must request prior authorization through the Pharmacy Management Precertification Unit. Additional quantities of contraceptives will be considered medically necessary for those members who meet the following criterion:
   
   
   • Member's physician provides documentation (controlled clinical trial) from the peer-reviewed medical literature for use of a higher dose.
     
     
2. Medical Exception Criteria
   
   Certain contraceptives are currently included on the Aetna Formulary Exclusions List (see list below).* These Formulary Excluded contraceptives therefore are excluded from coverage for members enrolled in prescription drug benefit plans that use a closed formulary, unless a medical exception is obtained. Aetna considers the Formulary Excluded oral contraceptives to be medically necessary for members who meet ANY of the following criteria:
   
   
   1. A documented:
      
      
      • Contraindication to one preferred alternative from the same subcategory (see table below) OR,
      • Intolerance to one preferred alternative from the same subcategory (see table below)
   
   
   

Pharmacy Benefit Plans without Contraceptive coverage:

Medical Necessity Review

Based on available clinical literature, contraceptives may be considered medically necessary for any of the following documented conditions:

• Acne, recalcitrant (resistant to treatment)
• Amenorrhea (absence of menstruation)
• Dysfunctional uterine bleeding (DUB) is characterized by abnormal uterine bleeding in pattern, frequency, regularity or quantity and can include:
  
  
  Hypermenorrhea: cycles regular and menses of normal duration, but blood loss excessive (>80mL per cycle)
  Menorrhagia: interval normal but duration and flow excessive
  Metrorrhagia: interval irregular, duration and flow excessive
  Menometrorrhagia: interval irregular, duration and flow excessive and intermenstrual bleeding
  Oligomenorrhea: interval >35 days, normal flow
  Polymenorrhea: interval <21 days, normal flow
  Hypomenorrhea: cycles regular, but blood loss abnormally decreased
  
  
• Dysmenorrhea (painful or difficult menstruation)
• Endometriosis
• Hirsutism secondary to ovarian dysfunction (excessive hairiness)
• Polycystic ovary syndrome (many cysts on the ovary/cystic ovaries)
• Perimenopausal symptoms - hormone replacement for menopause

Note: Aetna does not cover contraceptives for treatment of headaches or premenstrual syndrome (PMS), except as noted above.

Table: Oral Contraceptives, listed by subcategory

*P = Preferred; FE = Formulary Excluded; NP = Nonpreferred PR = Precertification; QL = Quantity Limits; AL = Age Limits; ST = Step-Therapy ‡M EX = Medical Exception - This means the physician or health care professional must obtain a medical exception from Aetna, in order for the medication to be eligible for coverage. Medical Exception criteria apply to Formulary Excluded drugs for members enrolled in or covered by closed benefits plans, and also apply to Step-Therapy drugs in cases where a member's physician believes it is medically necessary for the member to use a step-therapy drug in the first instance without a trial of the prerequisite alternative drug(s).