CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

FDA‑Approved Prescription Contraceptive Drugs and Devices

State‑mandated coverage guidelines for FDA‑approved prescription contraceptive drugs and devices as applied by BCBSRI; affects members and providers under plans that do not include Preventive Services and generally applies to commercial and Medicare Advantage products as described.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFDA‑Approved Prescription Contraceptive Drugs and Devices

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateApr 1, 2022

Next Review DateN/A

Key ActionVerify member benefits and eligibility via the member's Evidence of Coverage/Benefit Booklet or the provider call center before billing.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

365Maximum days' supply allowable

CoveredPrescription contraceptives

Not requiredPrior authorization

DeniedOTC contraceptive supplies

IncludedMedicare Advantage

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Coverage Criteria for FDA-Approved Prescription Contraceptives

Statutory coverage mandate

Covered when the statutory conditions apply:

Mandated coverage conditions: Insurer provides prescription coverage AND the contraceptive is FDA‑approved and requires a prescription

Applies to individual or group health insurance contracts, plans, or policies delivered, issued for delivery, or renewed in Rhode Island per R.I. Gen. Law 27‑20‑43.

Emergency contraception

Emergency contraception coverage rules:

Emergency contraception (EC) is covered under the pharmacy benefit when prescribed for individuals 17 years of age and under; EC is not covered for individuals 17 years of age and older when available over‑the‑counter (OTC).age 17

Coverage for <=17 as prescription under the pharmacy benefit; OTC availability for >=18 is excluded from coverage per policy.

Religious employer exemption

Exemption rules:

Religious employer exemption: Religious employers may exclude coverage for prescription contraceptive methods that are contrary to bona fide religious tenets but must provide written notice to prospective enrollees prior to enrollment when invoking the exemption.

'Religious employer' is defined in the statute as a church or qualified church‑controlled organization (26 U.S.C. § 3121).

Claims for over‑the‑counter contraceptive supplies are not covered. Specifically, BCBSRI denies coverage for foam, condoms, spermicidal cream/jelly, and sponges because these items are available as OTC purchases.

Emergency contraception (EC) is handled by age: EC is covered when prescribed for individuals 17 years of age and under and will be paid under the member's pharmacy benefit when prescribed. EC is not covered for individuals 17 years of age and older when it is available over‑the‑counter.

Medical criteria: Not applicable. This policy does not specify additional medical necessity criteria for coverage of FDA‑approved prescription contraceptive drugs and devices.

Coding and Billing

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 Pharmacy Benefit CodesmixedCovered

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

Not separately reimbursedHCPCSNot Covered

A4264

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

Provider Actions, Billing Notes, and Exceptions

Prior Authorization

Prior authorization not required

Prior authorization review is not required for FDA‑approved prescription contraceptive drugs and devices.

Step Therapy

Step therapy / coding note

No step therapy requirements are specified in this document; submit claims using the appropriate CPT, HCPCS, or J‑codes listed in the coding section.

Documentation Required

Benefits verification

Verify member-specific benefits and eligibility using the member’s Evidence of Coverage/Benefit Booklet or by calling the provider call center; the subscriber agreement or employer agreement supersedes this policy for benefits determinations.

Background and Legal Authority

Rhode Island General Law 27‑20‑43 requires insurers to provide coverage for FDA‑approved prescription contraceptive drugs and devices for plans that provide prescription coverage. The statute permits a religious employer exemption allowing certain employers to exclude coverage for contraceptives contrary to bona fide religious tenets and requires written notice if the exemption is invoked.

Definitions

Religious employer — definition and applicability

Definition'Religious employer' means an employer that is a 'church or a qualified church‑controlled organization' as defined in 26 U.S.C. § 3121.

Permitted actionMay exclude coverage for prescription contraceptive methods that are contrary to the employer's bona fide religious tenets.

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

ApplicabilityApplies to individual or group health insurance contracts, plans, or policies delivered, issued for delivery, or renewed in Rhode Island under R.I. Gen. Law 27‑20‑43.

Relation to mandateThe exemption is an exception to the state mandate requiring coverage of FDA‑approved prescription contraceptive drugs and devices for plans that provide prescription coverage.