Anthem contraceptive coverage notice

Anthem provides coverage of the FDA-approved methods for women’s contraceptive services, sterilization procedures, and counseling, including:

• Generic contraceptive drugs.
• Injectable contraceptive drugs and patches.
• Contraceptive devices such as diaphragms, intra uterine devices (IUDs), cervical caps and implants.
• Over-the-counter FDA-approved contraceptives for women as prescribed by a healthcare provider.
• Voluntary sterilization procedures for women.
• Education and counseling.

Important note about contraceptive drugs

Anthem provides coverage for contraceptive services and will be covered at a $0 cost sharing when obtained from an in-network pharmacy. Some categories and classes of contraception do not have generics available and, in each of these categories, at least one brand name product is available at a $0 cost sharing. If the provider determines that a brand name drug with an available generic therapeutic equivalent is necessary because a generic therapeutic equivalent drug is not appropriate , the member may obtain coverage of the drug with a $0 cost sharing if a provider submits an Exception Request to receive prior approval to prescribe the contraceptive. Members can find additional information regarding these contraceptive benefits, including the Exception Request process, in the Evidence of Coverage and Disclosure Form. Cost sharing may vary depending on state laws and regulations.

Evidence of Coverage and Disclosure Form: Exception request for a quantity, dose or frequency limitation, step therapy, or a drug not on the prescription drug list (including contraceptive drugs)

If an exception is needed to limit to a quantity, dose or frequency limitation, to step therapy, or need a prescription drug that is not on the prescription drug list, the provider must complete a uniform prior authorization form and return it to us. The form can be found online at anthem.com/ca/provider or by calling the number listed on the back of the member ID card. If medical necessity has been determined, an exception will be granted. We will make a coverage decision within 72 hours of receiving your request. If we approve the exception request, coverage will be provided for the duration of your prescription, including refills. If we deny the request, you have the right to request an external review by an independent review organization (IRO). The IRO will make a coverage decision within 72 hours of receiving your request. If the IRO approves the request, coverage will be provided for the duration of your prescription, including refills. If the approved drug is a contraceptive drug, coverage of the drug will be provided at no cost to the member.

The provider or member may also submit a request for a prescription drug that is not on the prescription drug list based on exigent circumstances. Exigent circumstances exist if suffering from a health condition that may seriously jeopardize life, health, or ability to regain maximum function, or if undergoing a current course of treatment using a drug not on the prescription drug list. We will make a coverage decision within 24 hours of receiving your request. If we approve the coverage of the drug, coverage of the drug will be provided for the duration of the prescription, (including refills) or duration of the exigency, as applicable. If the approved drug is a contraceptive drug, coverage of the drug will be provided at no cost to the member. If we deny coverage of the drug, the member has the right to request an external review by an IRO. The IRO will make a coverage decision within 24 hours of receiving your request. If the IRO approves the coverage of the drug, coverage of the drug will be provided for the duration of the exigency.

The external exception review process is in addition to a member’s right to file a grievance or request an Independent Medical Review by the Department of Managed Health Care. If we or the IRO approve a drug that is a contraceptive drug, coverage of the drug will be provided at no cost to the member. Coverage of a drug approved as a result of your request or your doctor’s request for an exception will only be provided if you are a member enrolled under the plan.