CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

FDA-Approved Prescription Contraceptive Drugs and Devices Coverage Guidelines

Defines Rhode Island-mandated coverage for FDA-approved prescription contraceptive drugs and devices for Blue Cross & Blue Shield of Rhode Island products (applies to Commercial and Medicare Advantage Plans within BCBSRI unless group/plan exceptions apply). Excludes OTC contraceptive supplies and specifies pharmacy vs medical benefit coding and dispensing limits.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyFDA-Approved Prescription Contraceptive Drugs and Devices Coverage Guidelines

Policy CodePolicy N/A

Change TypeClarified dispensing limitprior authorization guidance

Effective DateApr 1, 2019

Next Review Date

Key ActionProviders must verify member benefits and whether the employer/plan is self-funded or a religious employer that may have contraceptive exclusions; refer to member's Evidence of Coverage/Benefit Booklet/Subscriber Agreement.

SourceLink

POLICY UPDATE CHANGES

Policy includes mandate language permitting dispensing up to 365 days at a time starting first day of plan year after April 1, 2019.

Prior authorization is not required for these contraceptive prescription drugs and devices.

11Listed covered medication/device code groups

1Code listed as not separately reimbursed

365Max days supply reimbursable at once

Coverage Summary & Scope

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

This policy implements Rhode Island General Law 27-20-43 requiring insurers that provide prescription coverage to cover FDA-approved prescription contraceptive drugs and devices. It applies to Blue Cross & Blue Shield of Rhode Island Commercial and Medicare Advantage Plans that provide prescription benefits, unless a group/plan exception applies. Self-funded groups may elect not to follow the state mandate, and religious employers may issue plans that exclude coverage for prescription contraceptive methods contrary to bona fide religious tenets. The policy became effective 04/01/2019.

Key thresholds and quick facts

Maximum dispensing quantityUp to 365 days supplied at one time

Effective date2019-04-01

Last review2022-02-16

Scope summary (lines covered)FDA‑approved prescription contraceptive drugs and devices for BCBSRI Commercial and Medicare Advantage Plans (unless group/plan exceptions apply)

Prior authorizationNot required for contraceptive prescriptions

Pharmacy vs Medical benefitCertain contraceptives (e.g., S4993, J7303, J7304) covered under pharmacy benefit; others billed with CPT/HCPCS J‑codes

General Coverage

Covered when ALL of the following are met:

ALL of the following

Product is an FDA-approved contraceptive drug or device that requires a prescription
Member is covered under a BCBSRI product that provides prescription coverage
Self-funded groups may opt out of state mandate; check benefit booklet/Evidence of Coverage/Subscriber Agreement

Operational note: Self-funded groups may elect not to follow the state mandate; verify group/contract benefits in the Benefit Booklet/Evidence of Coverage/Subscriber Agreement

Coverage Criteria

Emergency Contraception (EC)

Age-based coverage

EC for <=17: EC is covered under the pharmacy benefit when prescribed for individuals 17 years of age and under
Includes brand examples (Plan B, Next Choice); use pharmacy benefit codes where applicable
EC for >=18: EC is not covered when used by individuals 17 years of age and older because it is available over-the-counter
No prior authorization required

Prior authorization is not required for emergency contraception

Over-the-Counter Contraceptive Supplies

OTC supplies denied: Foam, condoms, spermicidal cream/jelly, and sponges are denied coverage because they are over-the-counter

Religious Employer Exemption

Religious employer exemption: Religious employers may issue plans that exclude coverage for prescription contraceptive methods contrary to bona fide religious tenets

Written notice requirement: Religious employers invoking the exemption must provide written notice to prospective enrollees prior to enrollment specifying contraceptive services refused for religious reasons

Dispensing Quantity Limit

Dispensing up to 365 days: Starting the first day of each plan year after April 1, 2019, issuers shall not restrict reimbursement for dispensing a covered prescription contraceptive up to 365 days at a timeUp to 365 days

Effective beginning first day of plan year after April 1, 2019

CPT / HCPCS / J-code Guidance

Covered CPT codes (procedures) and HCPCS/J-codes for Commercial and Medicare Advantage PlansmixedCovered

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 (Liletta) 52 mg

1–10 of 15

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 Benefit (Commercial and Medicare Advantage Plans)mixedCovered

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

Not separately reimbursedHCPCSNot Covered

A4264

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

Provider Actions & Billing Rules

Documentation Required

Verify benefit applicability and group/plan exceptions

Verify member-specific benefits before providing contraceptive drugs or devices. Check the member's Evidence of Coverage/Benefit Booklet/Subscriber Agreement to confirm coverage and any applicable limitations. Confirm whether the employer/plan is self-funded or a religious employer that may have elected an exemption from the state contraceptive coverage mandate; self-funded groups may opt out and religious employers may exclude coverage for contraceptive methods contrary to bona fide religious tenets (they must provide written notice to prospective enrollees).

Billing Rule

File appropriate CPT/HCPCS J-code rather than nonspecific codes

File claims using the specific procedure or HCPCS/J-codes listed for contraceptive services rather than nonspecific laboratory codes such as 84981 or 84989. Use the covered CPT/HCPCS/J-codes for insertion, removal, implants, IUDs, diaphragms, and injectable contraceptives as appropriate when billing.

11976
11981
57170
58300
58301
A4261
A4266
J1050
J7296
J7297
J7298
J7300
J7301
J7306
J7307

Billing Rule

Pharmacy benefit for certain contraceptives

Certain contraceptives, including emergency contraception for individuals 17 years of age and under, and some contraceptive supplies may be covered under the pharmacy benefit. When applicable, bill pharmacy benefit codes rather than medical procedure codes.

S4993
J7303
J7304

Background & Definitions

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 delivery, or renewed in Rhode Island shall provide coverage for FDA-approved contraceptive drugs and devices that require a prescription. 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.

Exemptions: the law permits a religious employer to be issued an individual or group health insurance contract, plan, or policy that excludes coverage for prescription contraceptive methods that are contrary to the religious employer's bona fide religious tenets. Religious employers invoking the exemption must provide written notice to prospective enrollees prior to enrollment specifying the contraceptive health care services the employer refuses to cover. Additionally, self-funded groups may choose not to follow the state mandate; benefits may vary between groups and members should refer to their Benefit Booklet / Evidence of Coverage / Subscriber Agreement.

Coding and benefit application notes: a list of covered procedure and HCPCS/J-codes for Commercial and Medicare Advantage Plans is specified in the policy, one code (A4264) is noted as not separately reimbursed for all BCBSRI products, and certain contraceptive products are covered under the pharmacy benefit (e.g., S4993, J7303, J7304).

Religious employer: an employer that is a church or a qualified church-controlled organization as defined in 26 U.S.C. § 3121; such employers may be issued plans that exclude coverage for prescription contraceptive methods contrary to their bona fide religious tenets and must provide written notice to prospective enrollees prior to enrollment.

Policy Changes & History

2019-04-01policy_effective

Beginning the first day of each plan year after April 1, 2019, issuers shall not restrict reimbursement for dispensing a covered prescription contraceptive up to 365 days at a time.

2019-04-01clarificationLatest

Policy clarifies that prior authorization review is not required for FDA-approved prescription contraceptive drugs and devices.