CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Smoking Cessation Treatment and Nicotine Replacement Coverage (Rhode Island mandate)

Documents BCBSRI coverage for smoking cessation counseling and FDA‑approved nicotine replacement and prescription cessation medications per Rhode Island RIGL 27-20-53. Applies to commercial products issued in Rhode Island; does not apply to Medicare Advantage; self-funded groups may opt out.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySmoking Cessation Treatment and Nicotine Replacement Coverage (Rhode Island mandate)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2007

Next Review DateN/A

Key ActionProvide smoking cessation counseling and FDA‑approved nicotine replacement or prescription cessation medications per Rhode Island mandate, ensure prescriptions are written by a prescriber with state licensure and filled at an in‑network retail pharmacy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Covered counseling CPT codes listed

up to 16Statutory annual one-half hour counseling sessions (limits removed by regulation)

2Statutory medication courses per year (limits removed by regulation)

Smoking Cessation Coverage Rules (Rhode Island)

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Coverage for Smoking Cessation Treatment (Rhode Island mandate RIGL 27-20-53 and OHIC regulation)

Smoking cessation treatment is covered per state law and OHIC regulation when provided according to prescriber and counseling requirements:

ALL of the following

Use of an over-the-counter (OTC) or prescription FDA‑approved cessation medication when used in accordance with FDA approval
Medication must be recommended and prescribed by a prescriber who holds prescriptive privileges in the state of licensure
Counseling must be provided by a qualified practitioner and consist of evidence‑based outpatient sessions
Qualified practitioners include physicians, nurse practitioners, nurse midwives, physician assistants, mental health and chemical dependency providers; counseling may be provided at a hospital facility.
Medication and counseling may be used in combination
A required written prescription from a physician is required for all smoking cessation medications and over‑the‑counter nicotine replacement products when covered under the pharmacy benefit
Members are encouraged to contact Customer Service to verify approved nicotine replacement prescription products; nicotine replacement therapy and smoking cessation prescriptions are not covered when purchased from a mail‑order pharmacy.

Limitations and Exceptions (statutory and regulatory notes)

Statute listed certain limits that have since been redefined by OHIC regulation:

ANY of the following

Statute allowed up to two courses of medication for up to 14 weeks each annually (note: OHIC regulation removed these numeric limits)
OHIC Regulation 14 redefined smoking cessation treatment to align with current clinical practice guidelines and consequently removed the previous numeric limits on courses of medication.
Statute referenced an annual outpatient benefit of sixteen (16) one‑half (1/2) hour evidence‑based counseling sessions (note: OHIC regulation removed these numeric limits)
OHIC Regulation 14 redefined smoking cessation treatment to align with current clinical practice guidelines and consequently removed the previous numeric limits on counseling sessions.

Applicable Codes and Coding Notes

Covered CPT / HCPCS Codes for Smoking Cessation CounselingCPTCovered

99407	Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
99406	Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes (covered but not separately reimbursed)

Modifier / Coding NoteModifier

25	Modifier -25 required when E/M service is provided and billed in conjunction with counseling; services must be separately identifiable

Pharmacy / Medication Codesmixed

N/A	FDA‑approved nicotine replacement therapies (patch, gum, lozenges, inhalers) and prescription medications (bupropion HCl, varenicline/Chantix) are covered per mandate when prescribed; specific NDCs not listed

Required Actions, Billing Rules, and Denial Risks

Documentation Required

Prescription requirement for nicotine replacement products

A required written prescription from a physician is required for all smoking cessation medications and over-the-counter nicotine replacement products when covered under the pharmacy benefit; members should be advised to contact Customer Service to verify approved nicotine replacement prescription products.

Prior Authorization

Prior authorization not required

Prior authorization review is not required for smoking cessation treatments under this policy.

Denial Risk

Mail-order pharmacy exclusion

Nicotine replacement therapy and smoking cessation prescriptions are not covered when purchased from a mail order pharmacy; providers should ensure prescriptions are filled at an in‑network retail pharmacy to avoid denial.

Documentation Required

Billing E/M with counseling

If an evaluation and management visit is billed in conjunction with a smoking cessation counseling code, modifier -25 must be appended and the E/M must be separately identifiable in documentation.

99406
99407
25

Clinical and Regulatory Background

Rhode Island law RIGL 27-20-53 (enacted January 1, 2007) mandates coverage for tobacco cessation programs for individual and group commercial health contracts delivered, issued, or renewed in the state. The statute defines cessation treatment to include the use of an over‑the‑counter or prescription FDA‑approved cessation medication (when used in accordance with FDA approval) and an annual outpatient benefit of evidence‑based smoking cessation counseling provided by a qualified practitioner. The mandate applies to commercial products and does not apply to Medicare Advantage plans; self‑funded groups may opt out. [

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySmoking Cessation Treatment and Nicotine Replacement Coverage (Rhode Island mandate)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2007

Next Review DateN/A

SourceLink

On This Page

OpenPayer

Smoking Cessation Treatment and Nicotine Replacement Coverage (Rhode Island mandate)

Smoking Cessation Coverage Rules (Rhode Island)

Applicable Codes and Coding Notes

Required Actions, Billing Rules, and Denial Risks

Statutory Limits and Current Regulatory Status

Clinical and Regulatory Background

Defined Terms

Smoking Cessation Treatment and Nicotine Replacement Coverage (Rhode Island mandate)

Smoking Cessation Coverage Rules (Rhode Island)

Applicable Codes and Coding Notes

Required Actions, Billing Rules, and Denial Risks

Statutory Limits and Current Regulatory Status

Clinical and Regulatory Background

Defined Terms

Also See