CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Smoking Cessation Mandate

Documents Rhode Island's statutory mandate and insurer implementation for coverage of smoking cessation medications and counseling for applicable commercial members; affects providers and members covered by applicable Rhode Island health plans (excludes certain limited plans and Medicare supplement).

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicySmoking Cessation Mandate

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateJan 1, 2007

Next Review DateN/A

Key ActionObtain a written physician prescription for all smoking cessation medications before dispensing; note that prior authorization is not required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2medication courses allowed

16half-hour counseling sessions (statute)

99407intensive counseling code

99406intermediate counseling code

2017-03-24OHIC regulation date

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Coverage Criteria

Covered services and applicability

Covered when the policyholder's plan is subject to Rhode Island statutory requirements and provides physician office services or major medical/comprehensive coverage; apply the conditions below.

Statutory applicability: Applies to individual or group health insurance contracts, plans, or policies delivered, issued for delivery, or renewed in Rhode Island on or after January 1, 2010 that provide coverage for physician services in a physician's office or provide major medical or similar comprehensive coverage; if the medical coverage does not include prescription drug benefits, the contract is not required to include coverage for FDA‑approved smoking cessation medications.

Source: RIGL §27-20-53 (a)

Covered services: Smoking cessation treatment includes FDA‑approved over‑the‑counter or prescription smoking cessation medications when used in accordance with FDA approval and outpatient evidence‑based counseling sessions; OHIC Regulation 14 aligned the definition with current clinical practice guidelines and removed prior numerical limits on courses and sessions.

See RIGL §27-20-53(b) and OHIC Regulation 14

Treatment components and typical limits (statute vs regulation): Statute described up to two courses of medication for up to 14 weeks each annually and sixteen 1/2‑hour counseling sessions annually when prescribed and combined with counseling; OHIC Regulation 14 revised the coverage definition to follow current clinical practice guidelines and removed the previous numeric limits.Statute: up to 2 courses (≤14 weeks each) annually; 16 half-hour counseling sessions annually (note: OHIC removed numeric limits)

Source: RIGL §27-20-53(b) and OHIC Regulation 14 special note

Qualified counseling providers and settings: Counseling may be provided by qualified practitioners (including physicians, nurse practitioners, nurse midwives, physician assistants, mental health and chemical dependency providers) and may be provided in outpatient or hospital facility settings consistent with the regulation and clinical guidelines.

Source: OHIC Regulation 14 and policy background

Prescription and purchase requirements: A written prescription from a physician is required for smoking cessation medications; nicotine replacement therapy and smoking cessation prescription drugs purchased through a mail‑order pharmacy are not covered.

Prescription requirement and mail‑order exclusion per policy and provider guidance

Cost‑sharing and utilization management: Plans subject to the statute may impose copayments and/or deductibles for these mandated benefits consistent with the plan's cost‑sharing for physician services and medications; prior authorization review is not required for smoking cessation treatments under this policy.

See RIGL §27-20-53(c) and prior authorization guidance

Plan exclusions: The statutory requirement does not apply to hospital confinement indemnity; disability income; accident‑only; long‑term care; Medicare supplement; limited benefit health; specified disease indemnity; sickness or bodily injury or death by accident or both; and other limited benefit policies.

Source: RIGL §27-20-53(d)

This section does not apply to the following plan types: hospital confinement indemnity, disability income, accident-only, long-term care, Medicare supplement, and limited benefit plans (including specified disease indemnity, sickness/bodily injury/death-by-accident plans, and other limited benefit policies).

Providers should confirm member coverage eligibility and plan type prior to ordering smoking cessation medications or counseling to ensure the member’s product is eligible under the Rhode Island statutory mandate.

Nicotine replacement therapy and prescription smoking cessation drugs are not covered when purchased through a mail-order pharmacy. Providers and members must obtain covered nicotine replacement products and prescription medications through channels permitted by the plan; a physician’s written prescription is required for all smoking cessation medications, including over-the-counter nicotine replacement products.

Coding and Quantities

Covered CPT CodesCPTCovered

99407

Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

Covered but not separately reimbursedCPTCovered

99406

Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

Modifiers/notesModifier

25	Modifier -25: significant, separately identifiable evaluation and management service

Covered CPT CodesCPTCovered

99407

Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

Covered but not separately reimbursedCPTCovered

99406

Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes

Modifiers/notesModifier

25	Modifier -25: significant, separately identifiable evaluation and management service

Modifiers/notesModifier

25	Modifier -25: significant, separately identifiable evaluation and management service

Medication courses and counseling sessions (statute)

Statutory medication-course limitUp to 2 courses of FDA‑approved smoking cessation medication per year, each course for up to 14 weeks when prescribed by a licensed prescriber (RIGL §27-20-53(b)).

Statutory counseling sessionsAnnual outpatient benefit of sixteen (16) one-half (1/2) hour evidence‑based smoking cessation counseling sessions per covered individual (RIGL §27-20-53(b)).

Regulatory change (OHIC Regulation 14)OHIC Regulation 14 redefined tobacco cessation treatment to align with current clinical practice guidelines and removed the prior numerical limits on treatment courses and counseling sessions (Special Note).

Provider Actions & Billing Notes

Prior Authorization

Prior authorization review is not required.

Documentation Required

Prescription Requirement

Providers should ensure a written prescription from a physician is obtained for all smoking cessation medications, including over-the-counter nicotine replacement products (e.g., nicotine patch, gum, lozenges). Members are encouraged to contact Customer Service to verify approved nicotine replacement prescription products.

Written prescription required for all smoking cessation medications, including OTC nicotine replacement products
Members should contact Customer Service to verify approved nicotine replacement prescription products

Background

Smoking cessation treatment includes FDA‑approved nicotine replacement therapies (NRT) — such as patch, gum, and lozenges — and prescription medications (for example, bupropion and varenicline). These therapies reduce cravings and withdrawal symptoms and are intended to be used in combination with outpatient, evidence-based counseling to support successful cessation.

Definitions

Varenicline (Chantix™)

DefinitionVarenicline (Chantix™) is a prescription smoking cessation medication that helps reduce withdrawal symptoms and cravings caused by nicotine loss from cigarettes and blocks the pleasant effects of nicotine in the brain.

Therapeutic effectReduces cravings and withdrawal symptoms and diminishes the reinforcing/pleasant effects of nicotine, supporting tobacco cessation efforts.

Nicotine replacement therapy

Forms includedNicotine replacement therapy (NRT) includes transdermal patch, gum, lozenges, and inhalers.

Intended effectNRT can assist smoking cessation by decreasing cravings for nicotine and reducing signs and symptoms of withdrawal.