Modifiedblue cross blue shield - michiganPolicy N/A

Contraceptive devices and services — Medicare Plus Blue enhanced benefit PPO

Defines coverage, coding, provider and payment rules for contraceptive methods and related services under the Medicare Plus Blue enhanced benefit PPO for affected members and providers.

Policy Summary

Payerblue cross blue shield - michigan

PolicyContraceptive devices and services — Medicare Plus Blue enhanced benefit PPO

Policy CodePolicy N/A

Change TypeTemplate consolidation and policy combination

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain a coverage determination from Medicare Plus Blue when coverage is uncertain before providing an item or service.

SourceLink

POLICY UPDATE CHANGES

Policy transferred to a new template and two policies (MAPPO Contraceptive Devices and U of M Contraceptive Devices) were combined.

No age restrictionsage limits for coverage

No frequency limitsfrequency limits for contraceptive devices

Multipleprocedure and supply codes enumerated

Cost share appliesmember payment responsibilities

Medicare Plus Blue

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plan for reimbursement guidance

CMS1500/UB04/837claim forms required

Coverage Criteria

General coverage conditions

Covered under the Medicare Plus Blue enhanced benefit when following conditions are met:

Enhanced benefit basis: Items/services are governed by Medicare Plus Blue enhanced benefit which may provide coverage where Original Medicare excludes contraceptive devices and injectables

Blue Cross groups selecting this benefit determine scope, reimbursement, and member cost sharing

Eligible provider and location: Services payable when provided by eligible providers (M.D., D.O., physician assistant, nurse practitioner, registered nurse, clinical specialist) and at inpatient hospital, outpatient hospital, or office locations

Frequency and diagnosis restrictions: No frequency or diagnosis restrictions specified

Coverage and payment rules

Coverage and payment rules under Medicare Plus Blue enhanced benefit

Reimbursement mechanics: Provider will be paid the lesser of the allowed amount on the Availity Essentials fee schedule or the provider's charge, minus the member's cost share; this represents payment in full and providers are not allowed to bill the member for the difference.

Find Medicare Plus Blue plan maximum payment amounts on Availity Essentials under Medicare Plus Blue PPO Enhanced Benefit Fee Schedule.

Member cost sharing: Collect applicable Medicare Plus Blue cost sharing (copayment, coinsurance, or deductible) at time of service when possible; providers may only collect the appropriate Medicare Plus Blue cost sharing amounts.

Providers may verify benefits and cost-share via Availity Essentials or by calling 1-866-309-1719.

Noncovered services: If the member elects a noncovered service, the member is responsible for the entire charge; providers may not have members sign an Advance Beneficiary Notice of Noncoverage. If there is uncertainty about coverage, obtain a coverage determination from Medicare Plus Blue before providing the item. If a provider issues a noncovered item without a prior coverage determination, the member must be held harmless for all charges except any applicable cost share.

Providers contracted with BCBSM/BCN should review provider manual for additional claim submission requirements and documentation.

Original Medicare excludes coverage for contraceptive devices, surgical procedures related to contraceptive devices, and contraceptive injectables. Medicare Plus Blue is a Medicare Advantage PPO that uses Original Medicare as its base but may provide enhanced benefits beyond Original Medicare. Where Original Medicare excludes these items or imposes restrictions, the availability of coverage, reimbursement methodology, maximum allowable payment amounts, and member cost sharing for contraceptive devices and related services are determined by the Blue Cross groups that select this enhanced benefit.

Providers may not ask members to sign an Advance Beneficiary Notice of Noncoverage (ABN) to accept financial responsibility for items that are noncovered under the member’s plan. If there is any uncertainty about coverage, providers must obtain a coverage determination from Medicare Plus Blue before providing the item or service.

If an item or service is noncovered under the member’s plan and the provider does not obtain a prior coverage determination, the member is responsible for the entire charge for the noncovered service. However, if a provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share. Providers should collect applicable Medicare Plus Blue cost sharing (copayment, coinsurance, or deductible) at the time of service when possible.

Coding and Billing Identifiers

CPT/HCPCS Codesmixed

58300	Insertion of intrauterine device (IUD)
A4261	Cervical cap for contraceptive use
A4266	Diaphragm for contraceptive use
J1050	Injection, medroxyprogesterone acetate, 1 mg
J2760	Injection, phentolamine mesylate, up to 5 mg
J7294	Segesterone acetate and ethinyl estradiol 0.15 mg, 0.013 mg per 24 hours; yearly vaginal system, ea.
J7295	Ethinyl estradiol and etonogestrel 0.015 mg, 0.12 mg per 24 hours; monthly vaginal ring, ea.
J7297	Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg
J7298	Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg
J7300	Intrauterine copper contraceptive (Paragard)

1–10 of 16

1/2

ICD-10 CodesICD-10

No codes listed

Required claim forms / transactionsmixed

CMS 1500 (02/12)	Claim form
UB-04	Claim form
837	Electronic claim transaction

Billing identifiersmixed

NPI	Report National Provider Identifier number on all claims

Provider Actions and Requirements

Prior Authorization

Coverage determination required when uncertain

If there is any question about whether an item or service is covered, obtain a coverage determination from Medicare Plus Blue before providing the item. Coverage follows Medicare Plus Blue enhanced benefit determinations; obtain determinations when uncertain to avoid member liability.

Seek prior coverage determination when coverage is uncertain
Coverage follows Medicare Plus Blue enhanced benefit decisions

Denial Risk

Obtain coverage determination when coverage is uncertain

Providers must obtain a prior coverage determination before providing items or services that may be noncovered. If the provider issues a noncovered item without first obtaining a coverage determination, the member must be held harmless for all charges except any applicable cost share.

Do not have members sign an Advance Beneficiary Notice of Noncoverage to accept financial responsibility

Definitions

Intrauterine device (IUD) — definition, types, duration

DefinitionA small T-shaped device placed inside the uterus to prevent pregnancy; available as copper (non-hormonal) or levonorgestrel-releasing hormonal IUDs.

TypesCopper IUD (non-hormonal) and multiple levonorgestrel-releasing hormonal IUDs (four devices marketed in the U.S.).

Duration / FDA-approved useCopper IUD: up to 10 years; hormonal levonorgestrel IUDs: FDA-approved for 3–7 years depending on the specific device.

Hormonal contraception — definition and delivery methods

DefinitionContraceptives that release estrogen and/or progestin to prevent pregnancy.

Delivery methodsOral pills (combined estrogen–progestin or progestin-only), injections (e.g., DMPA lasting ~3 months), vaginal rings, skin patches, and subdermal implants.

Background

Contraception includes a range of methods such as barrier methods, hormonal methods, non-hormonal devices, and permanent surgical sterilization, each with different effectiveness and potential complications. Hormonal methods encompass pills, injections, rings, patches, implants and intrauterine devices (IUDs). The policy recognizes that Original Medicare may not cover certain contraceptive devices and services and that Medicare Plus Blue plans can provide enhanced coverage and define reimbursement and member cost-sharing for these methods.

Revision History

2026-01-01Policy revision and consolidationLatest

Policy transferred to a new template and two prior policies (MAPPO Contraceptive Devices and U of M Contraceptive Devices) were combined into this policy.

Policy Summary

Payerblue cross blue shield - michigan

PolicyContraceptive devices and services — Medicare Plus Blue enhanced benefit PPO

Policy CodePolicy N/A

Change TypeTemplate consolidation and policy combination

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionObtain a coverage determination from Medicare Plus Blue when coverage is uncertain before providing an item or service.

SourceLink

On This Page

If noncovered item provided without prior determination, provider bears financial responsibility (member held harmless)

Note

No step therapy specified

No step therapy, frequency, diagnosis, or age restrictions are specified for payment. Eligible providers and payable locations are defined in the Conditions for Payment table; verify eligibility and location-specific reimbursement rules prior to billing.

Eligible providers: M.D., D.O., physician assistant, nurse practitioner, registered nurse, clinical specialist
Payable locations: Inpatient hospital, outpatient hospital, office
Frequency limits: No restrictions; Diagnosis and age restrictions: No restrictions

Billing Rule

Benefit verification and cost-share collection

Verify member benefits and collect the appropriate Medicare Plus Blue cost share from the member at the time of service when possible. Use the provider portal (Availity Essentials™) or call 1-866-309-1719 to confirm benefits and the exact patient responsibility. Providers may only collect the applicable Medicare Plus Blue cost share amounts.

Verify benefits and cost-share via Availity Essentials™ or 1-866-309-1719
Collect only the Medicare Plus Blue applicable cost share at time of service

Documentation Required

Support claims with documentation

Providers contracted with BCBSM/BCN Medicare Advantage networks should follow applicable reimbursement policies and the provider manual. Non-contracted providers may be required to submit supporting documentation, including medical records, to substantiate billed claims.

Be prepared to submit documentation supporting billed claims (e.g., medical records) if requested
Review BCBSM reimbursement policies prior to claim submission

Denial Risk

Noncovered service risk

If a provider issues a noncovered item to a member without first obtaining a coverage determination, the member must be held harmless for all charges except for any applicable cost share. Providers may not collect from the member beyond the allowed cost share.

Member held harmless if noncovered item provided without prior determination
Providers may not collect payment beyond applicable cost share

Denial Risk

Member hold-harmless for noncovered items issued without coverage determination

Duplicate of member hold-harmless requirement: ensure members are not billed for noncovered services provided without a prior coverage determination; providers must absorb charges beyond allowed cost share.

Ensure member protection for noncovered items issued without prior determination
Do not obtain Advance Beneficiary Notice signatures to shift financial responsibility

Oral pills detailsCombined pills contain ethinyl estradiol plus a progestin; progestin-only pills contain only progesterone.

Implant durationContraceptive implant approved for up to 3 years (releases steady dose of progesterone).

Emergency contraception — definition and included agents

DefinitionPostcoital therapy used to prevent pregnancy after unprotected or inadequately protected intercourse.

Included agents / methodsOral combined estrogen–progestin regimens, progestin-only regimens, and selective progesterone receptor modulators are used for emergency contraception.

Common indicationsContraceptive failure (e.g., condom breakage), missed doses of oral contraceptives, or no contraception used.