CommercialCoverageMedium impact
Member Cost-Share Waiver: Contraceptives (Revised)
Humana·OB-GYN, Pharmacy·Commercial
Effective date
Nov 29, 2023
We identified it
Jun 25, 2026
Summary
Humana revised its Member Cost-Share Waiver policy for contraceptives, effective November 29, 2023. The policy clarifies that preferred contraceptives are covered with zero cost-share at network pharmacies, while non-preferred contraceptives require a cost-share waiver only when the member has tried at least two preferred alternatives or has documented medical necessity. This is a pharmacy coverage guidance policy under the Affordable Care Act requiring no cost-sharing for FDA-approved contraceptive methods.
Action Required
By December 29, 2023: Billing and pharmacy teams must update claims processing workflows to implement the revised waiver criteria. (1) Ensure claims systems differentiate between preferred and non-preferred contraceptives and automatically apply zero cost-share for preferred products at in-network pharmacies only. (2) Update prior authorization protocols to require documentation of either: (a) trial/intolerance to two preferred contraceptives, OR (b) documented medical necessity for non-preferred methods before waiving cost-share. (3) Train billing staff to deny cost-share waivers for members in excluded groups (grandfathered plans, religious employers, eligible organizations with religious objections) and for out-of-network pharmacy claims. (4) Verify members meet all criteria before processing waiver approvals, which are limited to the current plan year. Failure to enforce these restrictions may result in incorrect claim processing and coverage denials.