CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

FDA-Approved Prescription Contraceptive Drugs and Devices (Rhode Island mandate)

Defines state-mandated coverage guidelines for FDA-approved prescription contraceptive drugs and devices for BCBSRI products (applicable to plans that do not include Preventive Services), including coverage for BlueCHiP Commercial and included for BlueCHiP for Medicare in this policy. Notes variations by benefit booklet and self-funded groups.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFDA-Approved Prescription Contraceptive Drugs and Devices (Rhode Island mandate)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2001

Next Review Date

Key ActionPrior authorization review is not required for FDA-approved prescription contraceptive drugs and devices under this policy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes noted in this release.

FDA-approved prescription contraceptivesCovered Indications

EC age <=17EC Covered (<=17)

EC age >=18EC Not Covered (>=18 OTC)

Foam, condoms, spongesOTC Supplies Denied

Coverage Summary

This policy implements Rhode Island General Law 27-20-43 requiring coverage of FDA-approved prescription contraceptive drugs and devices for health plans that provide prescription coverage and are delivered, issued for delivery, or renewed in Rhode Island. It applies only to plans that do not include Preventive Services and notes that benefits may vary by benefit booklet, Evidence of Coverage, or subscriber agreement.

The policy covers FDA-approved prescription contraceptives for BlueCHiP Commercial members and, notwithstanding that state mandated benefits generally do not apply to BlueCHiP for Medicare, this policy includes coverage for BlueCHiP for Medicare. It also states that self-funded groups may choose whether to follow the state mandate, so contract-level variations and exceptions can occur.

Key Stats

Covered IndicationsFDA-approved prescription contraceptives

OTC Supplies DeniedFoam, condoms, spermicidal cream/jelly, sponges

Emergency Contraception CoveredEC age <=17 (requires prescription, covered under pharmacy benefit)

Emergency Contraception Not Covered (OTC)EC age >=18 (OTC, not covered)

Coverage Criteria (mandated conditions & exclusions)

General Coverage Criteria per Rhode Island Mandate

Covered when ALL of the following are met:

ALL of the following

Product is FDA-approved contraceptive drug or device that requires a prescription
Member's plan provides prescription coverage and is delivered, issued for delivery, or renewed in Rhode Island

Emergency Contraception (EC)

Age-based coverage

EC is covered under pharmacy benefit for individuals 17 years of age and under and requires a prescription
Examples: Plan B and Next Choice; covered under member's pharmacy benefit
EC is not covered for individuals 17 years of age and older as it is an over-the-counter (OTC) product
Not covered under this policy for >=18

Over-the-counter Contraceptive Supplies

Foam, condoms, spermicidal cream/jelly, and sponges are denied coverage as they are OTC purchases

Religious Employer Exemption

Religious employers may exclude coverage for prescription contraceptive methods which are contrary to the religious employer's bona fide religious tenets

Religious employers invoking exemption must provide written notice to prospective enrollees prior to enrollment listing contraceptive services refused

Coding

Covered CPT/HCPCS/J-codes (BlueCHiP for Medicare and Commercial)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 IUS (Kyleena), 19.5 mg (New Code Effective 1/1/2018)
J7297	Levonorgestrel-releasing IUS, 52mg, 3 year duration (Liletta)

1–10 of 16

1/2

Not separately reimbursedHCPCSNot Covered

A4264

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

Covered under Pharmacy BenefitmixedCovered

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

Coding guidancemixed

S4981/S4989

Providers should file with the appropriate CPT or HCPCS J-code instead of S4981 and S4989

Provider Actions & Billing Rules

Prior Authorization

Prior Authorization Not Required

Prior authorization review is not required for FDA-approved prescription contraceptive drugs and devices under this policy.

Billing Rule

File appropriate CPT/HCPCS/J-code

Providers should file with the appropriate CPT or HCPCS J-code instead of S4981 and S4989. Certain contraceptive items (for example S4993, J7303, J7304) are covered under the pharmacy benefit and should be billed accordingly.

S4981
S4989
S4993
J7303
J7304

Documentation Required

Religious employer notice requirement

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

Background

Rhode Island General Law 27-20-43 requires every individual or group health insurance contract, plan, or policy that provides prescription coverage and is delivered, issued for delivery, or renewed in Rhode Island to provide coverage for FDA-approved contraceptive drugs and devices requiring a prescription. The statute explicitly states that nothing in the subsection shall be deemed to mandate coverage for the prescription drug RU-486 (mifepristone).

The law also permits a religious employer exemption: a medical service corporation may issue to a religious employer an individual or group health plan that excludes coverage for prescription contraceptive methods contrary to the employer’s bona fide religious tenets. Any religious employer that invokes this exemption must provide written notice to prospective enrollees prior to enrollment listing the contraceptive services the employer refuses to cover. The policy notes that benefits may vary by group/contract and that self-funded groups may or may not follow the state mandate. Additionally, prior authorization is not required for FDA-approved prescription contraceptive drugs and devices under this policy.

Definitions