Preventive Contraceptive Coverage (no cost-sharing when in‑network)
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Describes contraceptive drugs, devices, and services that may be covered with no member cost-sharing when provided by an in‑network pharmacy or doctor; applies to members of the payer's health plans (plan-specific variations and exemptions may apply).
No material clinical or coverage changes in this revision.
Preventive Contraceptive Coverage Criteria
Preventive contraceptive coverage criteria
Covered when ALL of the following are met
No copay, deductible, or coinsurance when in-network
Includes devices, injections, IUDs, implants, oral contraceptives, rings, patches, sponges, condoms, spermicides, and emergency contraceptives
If product is not listed, provider may submit copay waiver or coverage exception; payer will review and notify provider and member of decision
Coverage can vary by plan type and drug list; some products may be covered under medical vs pharmacy benefit depending on how provided
Products that have at least one therapeutic equivalent listed may not be eligible under this preventive contraceptive list; if your specific product is not listed on the plan's prescription drug list, normal cost-sharing (copay, deductible, or coinsurance) may apply unless an exception is approved. The policy notes that coverage is plan- and drug-list dependent and that members should check their prescription drug list or call the number on their member ID card to confirm which products are provided at no cost-sharing when obtained through an in-network pharmacy or doctor.
For over-the-counter FDA‑approved contraceptives, a prescription may be required for coverage without cost-sharing under the pharmacy benefit for non-grandfathered plans; providers may submit a copay waiver or coverage exception request for products not on the prescription drug list, and decisions will be communicated to the provider and member.
Certain group health plans established or maintained by organizations that qualify as religious employers may be exempt from the federal requirement to cover contraceptive services. The document states these exemptions can result in noncoverage for affected members and references federal rules and accommodations that may apply to religious‑affiliated organizations.
Members or providers with questions about whether a specific employer plan is exempt are advised to contact the phone number on the member ID card for plan‑specific information and guidance on available accommodations or alternate payment arrangements.
This policy does not use traditional “not medically necessary” language for contraceptives. Instead, coverage is framed around plan terms and the prescription drug list: contraceptive items and services are provided at no cost-sharing only when they meet the policy conditions (in‑network provider or pharmacy, FDA‑approved method as applicable, and listed on the plan's drug list or approved via a coverage exception).
If a requested contraceptive is not listed or an exception request is denied, the payer will notify the provider and member of the reason and, when applicable, offer a covered alternative drug.
Contraceptive Product Codes
| NEXPLANON | etonogestrel subdermal implant 68 mg (listed as covered; † indicates medical benefit) |
| MIRENA | levonorgestrel releasing IUD (listed; † indicates medical benefit) |
| KYLEENA | levonorgestrel releasing IUD (listed) |
| LILETTA | levonorgestrel releasing IUD (listed) |
| PARAGARD | copper IUD (listed) |
| ELLA | ulipristal acetate 30 mg (emergency contraceptive listed) |
| Plan B One-Step | levonorgestrel emergency contraceptive (listed) |
| DEPO-PROVERA | medroxyprogesterone acetate IM suspension 150 mg/mL (listed; injection) |
| DEPO-SUBQ PROVERA 104 | medroxyprogesterone acetate subcutaneous 104 mg/0.65 mL (listed) |
| ANNOVERA | segesterone acetate-ethinyl estradiol vaginal ring (listed) |
Provider Actions, Exceptions, and Appeals
Submit copay waiver / coverage exception for non‑listed products
Providers may request a copay waiver or coverage exception from BCBSMT for contraceptive products not covered on the member's prescription drug list; the payer will review the request and notify the provider and member of the decision.
- Request option applies when the contraception product is not listed on the prescription drug list.
- Decision and any rationale will be communicated to both the member and the requesting provider.
If exception request is denied — notification and alternatives
When submitting coverage requests, providers should supply the requested documentation and be prepared that the payer may deny the request; if denied, BCBSMT will notify the provider and member and, when applicable, offer a covered alternative drug.
- BCBSMT will explain why a request was denied.
- A covered alternative drug will be offered if applicable.
How to submit a copay waiver / coverage exception
Copay waiver and coverage exception forms are available at bcbsmt.com/provider or myprime.com; providers may also call the number on the member’s ID card to request a review. BCBSMT will communicate the coverage decision to the provider and member after receiving the request.
- Use the copay waiver / coverage exception forms on bcbsmt.com/provider or myprime.com.
- Alternatively, call the phone number on the member’s ID card to request a review.
Prescription may be required for OTC contraceptives to get $0 cost‑sharing
A prescription may be required for coverage without cost‑sharing for FDA‑approved over‑the‑counter contraceptives when prescribed and dispensed via a network pharmacy for non-grandfathered plans.
- OTC FDA‑approved contraceptives (foam, sponge, birth control pills, condoms) are covered when prescribed and dispensed via a network pharmacy.
- A prescription may be required under the pharmacy benefit for non‑grandfathered plans.
Denial process — provider and member notified with reasons and alternatives
If a copay waiver or coverage exception is denied, BCBSMT will notify both the provider and the member, state the reason for denial, and—if applicable—offer a covered alternative drug.
- Denial notifications include the reason for denial.
- Provider and member will be informed of any covered alternative options.
Check for religious employer exemptions that may limit coverage
Certain group health plans maintained by qualifying religious employers may be exempt from the contraceptive coverage requirement; providers should confirm plan-specific coverage and direct questions about the exemption or accommodations to the member’s ID card phone number.
- Religious employer exemption can result in noncoverage for affected members.
- For more information about the exemption or the eligible organization accommodation, contact the phone number on the member ID card.
Background and Scope
The policy covers a broad range of FDA‑approved contraceptive products and methods, including oral contraceptive pills (combined and progestin‑only), intrauterine devices (IUDs) including levonorgestrel and copper IUDs, implantable devices (e.g., etonogestrel implants), injectable contraceptives, vaginal rings and patches, emergency contraceptives, and barrier methods and spermicides (male and female condoms, diaphragms, sponges, spermicidal products and gels).
Coverage for particular products may be under the medical benefit when provided by a doctor (items marked †) or under the pharmacy benefit when dispensed by a network pharmacy; the list is illustrative and reviewed periodically, and additional products may be covered at no additional cost subject to plan terms.
Key Definitions
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