WHA covers a range of contraceptive and/or family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the Health Resources and Services Administration (HRSA) list. This includes:
Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process. For example, services for voluntary female sterilization surgery not performed in connection with another procedure, such as caesarean delivery or abortion, requires prior authorization from your Primary Care Physician's affiliated medical group or some cases directly from WHA. The prior authorization may be submitted directly to your medical group for review or you or your authorized representative may ask for a coverage request by calling WHA’s Member Services Department, at 888-563-2250.
Contraceptive coverage is available at no cost to FEHB members. WHA contracted physicians can prescribe the appropriate level of medically necessary medication to our FEHB members without unnecessary approvals. The contraceptive benefits include at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care).
Any contraceptive that is not already available without cost sharing on the formulary can be accessed through a prior authorization process which your provider can submit electronically through CoverMyMeds or filling out the “Prescription Drug Prior Authorization or Step Therapy Exception Request Form” here. All prior authorization requests will be reviewed and responded to within 24 hours of receipt of sufficient information necessary to make a coverage determination.
As a WHA member, you have infertility benefits and services covered under your plan. However, services are based on medical necessity for the treatment of infertility, and require prior authorization.
“Infertility” is defined as a condition of being infertile. A member is considered infertile if there is a presence of a demonstrated condition recognized by a licensed physician and surgeon as a cause of infertility, or the member is unable to conceive a pregnancy or to carry a pregnancy to a live birth after one (1) year of regular unprotected intercourse, or if the member is over age 35 years, after 6 months of regular unprotected intercourse. A member not having regular unprotected intercourse may be considered infertile if conception does not occur after at least 12 cycles of supervised artificial/donor insemination (6 cycles for members 35 years or older).
To learn more, you may click on the Infertility F Benefit. The summary also provides copayment information as well as exclusions and limitations.
vIn addition to Infertility Services, WHA also offers Family and Diversity (FamDiv) Support Benefit. This is a pregnancy support (with no exclusion of gender or relationship status), and without the diagnosis of infertility. It also covers pre-implantation genetic testing, supporting members with rare and life-threatening genetic conditions.
The FamDiv also requires prior authorization and covers up to 3 cycles of artificial insemination (AI). The Family and Diversity (FamDiv) Support Benefit summary also provides copayment information as well as exclusions and limitationas.
Note: Members an access AI benefits under WHA or FamDiv but cannot combine the WHA (Infertility) and FamDiv benefits.
WHA offers the Maven Maternity program to our FEHB members. This is an on-demand virtual support program that provides comprehensive support through pregnancy, postpartum, and potential miscarriage. Video chat or message with any of Maven’s maternity coaches anytime, anywhere. This includes the following:
You can learn more about Maven here.
We also provide additional resources and information for your pregnancy, Healthy Pregnancy.
Obesity counseling, screening and referral for those persons at or above the U.S. Preventive Services Task Force (USPSTF) obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
With prior authorization approval, members who meet specified medical criteria and who demonstrate a documented readiness to make nutrition and lifestyle changes, may take advantage of nutrition and dietary counseling with a WHA network nutritionist or registered dietician in these areas of focus:
Obesity
Eating Disorders
Malnourishment and Weight Loss
You can find more information regarding the Nutrition Counseling benefits here.
We cover diagnosis and treatment of morbid obesity and considers surgical procedures medically appropriate when all of the general criteria, along with the criteria specific to the procedures are met and prior authorization is approved:
Criteria for Adults 18 years of age or older:
Member is a candidate for bariatric surgery, as indicated by ALL of the following:
While Western Health Advantage is your health plan and we review prior authorization (pre-approval) for some services, certain covered services require prior authorization directly from your affiliated (assigned) medical group. This is required to make sure services are covered and paid for under your health plan benefits.
Your Primary Care Physician should know when pre-approval is needed. PCP staff will notify your medical group or WHA when you need to see a specialist or get another service that requires pre-approval. Decisions are made by qualified medical professionals (doctors, pharmacists and nurses), but only experienced physicians and pharmacists can deny or modify a requested service.
2349 Gateway Oaks Drive, Suite 100
Sacramento, California 95833
