Tobacco Cessation Preventive Service Coverage
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Requires coverage of tobacco cessation preventive services (screening, counseling, FDA‑approved medications) without cost-sharing or prior authorization for applicable Delaware non-grandfathered plans.
No material clinical or coverage changes in this revision.
Coverage Criteria for Tobacco Cessation
Tobacco cessation preventive services
Covered when ALL of the following are provided:
This bulletin applies to the following plans: private group plans (large and small) that are not grandfathered, individual private plans that are not grandfathered, and plans offered through State Health Insurance Marketplaces. The bulletin does not mandate coverage for grandfathered plans.
Provider Actions and Plan Requirements
No prior authorization required
Plans should not require prior authorization for tobacco cessation treatments; the bulletin states that “plans should not require prior authorization for any of these treatments.”
Step therapy not specified
The bulletin does not impose any step therapy or sequencing requirement for tobacco cessation services; no prior-step or medication-failure sequence is specified.
Document quit attempts and counseling
Document tobacco-use screening and support for up to two quit attempts per year, including counseling session details and medication prescriptions when provided.
- Record screening for tobacco use.
- For each quit attempt (up to two per year) document four counseling sessions (telephone, individual, or group) lasting at least 10 minutes each.
- Document prescriptions for FDA‑approved smoking cessation medications and the intended duration (up to 90 days per quit attempt).
Prior-authorization prohibition risk
If a plan were to impose prior authorization for any tobacco cessation treatment, that requirement would be inconsistent with this bulletin and its federal guidance.
Background
Tobacco cessation interventions are recognized as evidence-based preventive services under the ACA and include screening for tobacco use, counseling, and FDA-approved medications. Specifically, covered services include: screening for tobacco use; up to two quit attempts per year; each quit attempt comprising four sessions of telephone, individual, or group cessation counseling lasting at least 10 minutes each; and all FDA-approved medications for smoking cessation for up to 90 days per quit attempt when prescribed by a health care provider. The guidance also requires that plans not impose cost-sharing for these treatments and should not require prior authorization.
Definitions
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