CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Contraceptive Drugs and Devices Mandate

States Rhode Island-mandated coverage requirements for FDA‑approved prescription contraceptive drugs and devices and how BCBSRI applies them across product lines; affects members and providers for plans that do not include Preventive Services.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyContraceptive Drugs and Devices Mandate

Policy CodePolicy N/A

Change TypeNo material change

Effective Date2019

Next Review DateN/A

Key ActionDo not require prior authorization for contraceptive drugs and devices.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365 daysmax days' supply (no restriction)

All FDA‑approvedrequired contraceptive types

Not requiredprior authorization

Not coveredOTC emergency contraception (17+)

Coverage Requirements

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Mandate coverage conditions: The health insurance contract, plan, or policy provides prescription coverage.

Applies to individual or group coverage delivered, issued for, or renewed in Rhode Island.

Mandate coverage conditions: The contract, plan, or or policy is delivered, issued for, or renewed in Rhode Island.

See Rhode Island General Law 27-20-43.

Mandate coverage conditions: The contraceptive drug or device is FDA‑approved and requires a prescription.

Covered device types include IUDs (including hormonal‑releasing IUDs), diaphragms/cervical caps, vaginal rings, hormonal implant systems, oral and injectable contraceptives, and contraceptive patches.

Mandate coverage conditions: Religious employer exemption: a religious employer may be issued a contract, plan, or policy that excludes coverage for prescription contraceptive methods contrary to its bona fide religious tenets.

A religious employer invoking the exemption must provide written notice to prospective enrollees specifying the contraceptive services it will not cover.

Dispensing quantity requirement

Days' supply reimbursement requirement: Insurers shall not restrict reimbursement for dispensing a covered prescription contraceptive for up to 365 days at a time beginning with the first day of each plan year after April 1, 2019.<= 365 days

Applies to issuers offering group or individual coverage that covers prescription contraception.

Emergency contraception (EC) is covered under this policy only when obtained by prescription for individuals 17 years of age and under and is processed through the member's pharmacy benefit. EC obtained over‑the‑counter is not covered for individuals 17 years and older.

Over‑the‑counter contraceptive supplies — including foam, condoms, spermicidal creams/jellies, and sponges — are not covered under the prescription benefit because they are available OTC and should be denied as non‑prescription purchases.

Rhode Island law permits a religious employer exemption: a medical service corporation may issue an individual or group health insurance contract, plan, or policy that excludes coverage for prescription contraceptive methods that are contrary to the employer's bona fide religious tenets. A "religious employer" is defined consistent with federal tax law (church or qualified church‑controlled organization).

An employer that invokes this exemption must provide written notice to prospective enrollees prior to enrollment specifying which contraceptive health care services the employer refuses to cover for religious reasons.

Coding and Billing Codes

Covered CPT/HCPCS/J CodesmixedCovered

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, 3 year duration (Liletta) 52mg

1–10 of 15

1/2

Covered S-codes (file with J/CPT)HCPCSCovered

S4981	Use with appropriate CPT or HCPCS J-code (file accordingly)
S4989	Use with appropriate CPT or HCPCS J-code (file accordingly)

Not separately reimbursedHCPCSNot Covered

A4264

Permanent implantable contraceptive intratubal occlusion device and delivery system (not separately reimbursed)

Pharmacy benefit / supply codesmixedCovered

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

Provider Guidance and Actions

Prior Authorization

No Prior Authorization Required

Prior authorization review is not required for FDA‑approved prescription contraceptive drugs and devices. Providers do not need to submit prior authorization for these contraceptive medications and devices when coverage criteria are met.

Note

Coverage and Benefits May Vary by Contract

Benefits and covered services for contraceptives may vary by group, contract, or subscriber agreement. Always verify member coverage in the applicable Benefit Booklet, Evidence of Coverage, or Subscriber Agreement; services or devices outside a subscriber agreement or not included in a member's benefits may be denied.

Step Therapy

No Explicit Step Therapy Requirement Stated

There are no explicit step therapy requirements stated in this policy. However, benefit design (including any step therapy or other utilization management) may vary by group or self‑funded plan, so confirm applicable plan-level requirements before prescribing or dispensing.

Note

Religious Employer Exemption and Notice Requirement

Rhode Island law permits a religious employer exemption allowing an issuer to exclude contraceptive coverage that conflicts with the employer's bona fide religious tenets. A religious employer that invokes this exemption must provide written notice to prospective enrollees prior to enrollment specifying which contraceptive health care services the employer refuses to cover.

Religious employer definition: per statute (church or qualified church‑controlled organization).
Written notice to prospective enrollees is required prior to enrollment.

Denial Risk

OTC Emergency Contraception Coverage Risk

Denial risk: Over‑the‑counter emergency contraception (OTC EC) is not covered for individuals 17 years of age and older under the pharmacy benefit per this policy. EC is covered as a prescription for individuals 17 and under.

EC covered when prescribed for members age ≤17 and billed to pharmacy benefit.
OTC EC for members age ≥18 may be denied under this policy.

Definitions

Religious employer — definition and effect

DefinitionAn employer that is a 'church' or a 'qualified church-controlled organization' as defined in 26 U.S.C. §3121.

Exemption effectMay be issued an individual or group health insurance contract, plan, or policy that excludes coverage for prescription contraceptive methods contrary to the employer's bona fide religious tenets.

Notice requirementA religious employer invoking the exemption must provide written notice to prospective enrollees prior to enrollment specifying the contraceptive health care services the employer refuses to cover for religious reasons.

Background and Scope

Rhode Island General Law 27‑20‑43 requires that any individual or group health insurance contract, plan, or policy that provides prescription coverage and is delivered, issued for, or renewed in Rhode Island must provide coverage for FDA‑approved prescription contraceptive drugs and devices that require a prescription. The statute specifically allows religious employer exemptions and requires that, 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.