CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy | Contraceptive Drugs and Devices Mandate

Defines state-mandated coverage guidelines for FDA-approved prescription contraceptive drugs and devices for BCBSRI products (including BlueCHiP for Medicare and Commercial Products) and notes exceptions, pharmacy vs medical benefit coding, and dispensing quantity limits.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy | Contraceptive Drugs and Devices Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective DateApr 1, 2019

Next Review Date

Key ActionIf a religious employer invokes the exemption, the employer must provide written notice to prospective enrollees prior to enrollment listing contraceptive services the employer refuses to cover.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes to report.

9+Listed contraceptive product types

365Maximum days' supply reimbursed

17EC prescription age threshold

Coverage Summary

This policy implements Rhode Island General Law 27-20-43 and mandates coverage for FDA-approved prescription contraceptive drugs and devices when a health plan provides prescription coverage. It applies to BCBSRI products, including Commercial plans and BlueCHiP for Medicare (noting that RI mandates generally do not apply to BlueCHiP for Medicare but coverage for prescription contraceptives is included here). Beginning the first day of each plan year after April 1, 2019, issuers shall not restrict reimbursement for dispensing a covered prescription contraceptive for up to 365 days at a time.

Key thresholds and facts

Maximum dispensing quantity365 days (beginning first day of each plan year after April 1, 2019)

Emergency contraception (EC) prescription age limitCovered when prescribed for individuals 17 years of age and under; OTC for 18+

Listed contraceptive product types9+ types (e.g., IUD, hormonal IUD, vaginal ring, diaphragm/cervical cap, hormonal implant, injectable, oral contraceptives, patch)

Mandated Coverage Criteria

Coverage required by Rhode Island General Law 27-20-43 for FDA-approved prescription contraceptive drugs and devices that require a prescription, subject to exceptions and exemptions.

ALL of the following

Insurer shall provide coverage for FDA-approved contraceptive drugs and devices requiring a prescription when the contract provides prescription coverage.
Coverage requirement does not mandate coverage for the prescription drug RU-486 (mifepristone).
Refer to Termination of Pregnancy policy for RU-486 coverage across lines of business.
Religious employer exemption allowed: medical service corporation may issue plans to religious employers that exclude contraceptive methods contrary to bona fide religious tenets.
Religious employers invoking the exemption must provide written notice to prospective enrollees listing contraceptive services refused prior to enrollment.
Issuers shall not restrict reimbursement for dispensing a covered prescription contraceptive up to 365 days at a time beginning the first day of each plan year after April 1, 2019.365 days
Applies to group or individual health-insurance coverage that covers prescription contraception.

Product and Age-Specific Coverage Notes

Product / Age Specific Coverage Notes

Additional coverage notes for specific products and ages under BCBSRI policy.

Emergency Contraception (EC)

Emergency contraception (EC) is covered for individuals 17 years of age and under and requires a prescription; it will be covered under the member's pharmacy benefit.
Emergency contraception is not covered for individuals 17 years of age and older because it is an over-the-counter product.

Over-the-counter contraceptive supplies

Foam, condoms, spermicidal cream/jelly, and sponges are denied coverage as they are over-the-counter purchases.

BlueCHiP for Medicare

Although Rhode Island mandated benefits generally do not apply to BlueCHiP for Medicare, this policy includes coverage for FDA-approved contraceptive drugs and devices that require a prescription for BlueCHiP for Medicare members.
Oral contraceptives are covered under Medicare Part D benefits.

Coding

Covered medical/procedure and supply codes (BlueCHiP for Medicare and Commercial Products)mixedCovered

11976	Removal, implantable contraceptive capsules
11981	Insertion, non-biodegradable drug delivery implant
57170	Diaphragm or cervical cap fitting with instructions
58300	Insertion of intrauterine device (IUD)
58301	Removal of intrauterine device (IUD)
A4261	Cervical cap for contraceptive use
A4266	Diaphragm for contraceptive use
J1050	Injection, medroxyprogesterone acetate, 1 mg
J7296	Levonorgestrel-releasing intrauterine contraceptive system (Kyleena), 19.5 mg
J7297	Levonorgestrel-releasing intrauterine contraceptive system, 52 mg, 3 year duration (Liletta)

1–10 of 15

1/2

Codes not separately reimbursed for all BCBSRI productsHCPCSNot Covered

A4264

Permanent implantable contraceptive intratubal occlusion device and delivery system (not separately reimbursed for all BCBSRI products)

Covered under Pharmacy Benefit (BlueCHiP for Medicare and Commercial Products)mixedCovered

S4993	Contraceptive pills for birth control (use alternate code) - pharmacy benefit
J7303	Contraceptive supply, hormone containing vaginal ring, each (pharmacy benefit)
J7304	Contraceptive supply, hormone containing patch, each (pharmacy benefit)

Provider Actions & Billing Rules

Documentation Required

Religious employer exemption notice

If a religious employer invokes the exemption, the employer must provide written notice to prospective enrollees prior to enrollment listing the contraceptive health care services the employer refuses to cover for religious reasons.

Written notice must be provided to prospective enrollees prior to enrollment.
Notice must list the contraceptive health care services the employer refuses to cover for religious reasons.

Billing Rule

Use CPT/HCPCS J-codes instead of S-codes when appropriate

Providers should file with the appropriate CPT or HCPCS J-code rather than filing S4981 and S4989; use pharmacy benefit codes where specified.

Affected codes: S4981
Affected codes: S4989
Affected codes: S4993
Affected codes: J7303
Affected codes: J7304

Billing Rule

Dispensing quantity reimbursement

Beginning on the first day of each plan year after April 1, 2019, issuers covering prescription contraception shall not restrict reimbursement for dispensing a covered prescription contraceptive up to 365 days at a time.

Do not restrict reimbursement for dispensing up to 365 days at a time.
Effective beginning the first day of each plan year after 2019-04-01.

Background

Rhode Island General Law 27-20-43 requires that every individual or group health insurance contract that provides prescription coverage shall provide coverage for FDA-approved contraceptive drugs and devices that require a prescription. The statute explicitly states that nothing in the subsection mandates coverage for the prescription drug RU-486 (mifepristone) and that coverage of RU-486 is not required under the mandate; for RU-486 coverage guidance, refer to the Termination of Pregnancy policy.

The law allows an exemption for religious employers: a medical service corporation may issue plans to a religious employer that exclude coverage for prescription contraceptive methods contrary to the employer's bona fide religious tenets. Any religious employer invoking this exemption must provide written notice to prospective enrollees prior to enrollment listing the contraceptive services the employer refuses to cover.

Federal women's preventive services guidelines adopted by HHS (effective for renewals on or after August 1, 2012) address contraception among other services and federal law can supersede state law where applicable.

Although Rhode Island mandated benefits generally do not apply to BlueCHiP for Medicare, this policy specifically includes coverage for FDA-approved prescription contraceptive drugs and devices for BlueCHiP for Medicare members, and notes that oral contraceptives are covered under Medicare Part D benefits.

Definitions

Religious employer (definition)An employer that is a 'church or a qualified church-controlled organization' as defined in 26 U.S.C. § 3121.