Benefit Payment Guideline
Contraceptives and Contraceptive Services
__________________________________________________________
Benefit Policy Statement:
In the "Coverage of preventive health services" regulation, women must be provided with preventive care and
screenings recommended by the Heath Resources and Services Administration ("HRSA") without cost-sharing 45 C
F R § 147 130(a)(1)(iv) The HRSA included all FDA approved contraceptive methods and sterilization procedures
and counseling in its preventive services guidelines(http://www.hrsa.qov/womensquidelines/) .
The HRSA Guidelines ensure women’s access to the full range of FDA-approved contraceptive methods including, but
not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and
counseling, as prescribed by a health care provider. Plans and issuers may use reasonable medical management
techniques to control costs and promote efficient delivery of care For example, plans may cover a generic drug without
cost-sharing and impose cost-sharing for equivalent branded drugs. However, in these instances, a plan or issuer must
accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate, as
determined by the individual’s health care provider, by having a mechanism for waiving the otherwise applicable costsharing for the branded or non-preferred brand version. This generic substitution approach is permissible for other
pharmacy products, as long as the accommodation described above exists. If, however, a generic version is not
available, or would not be medically appropriate for the patient as a prescribed brand name contraceptive method (as
determined by the attending provider, in consultation with the patient), then a plan or issuer must provide coverage
for the brand name drug in accordance with the requirements of the interim final regulations (that is, without costsharing, subject to reasonable medical management)
Exemptions are available for a group health plan sponsored by a religious employer or other eligible organization.
______________________________________________________________________________________________________________________
Benefit Policy Guidelines:
Contraceptives:
Contraceptives are only covered under the member’s Rx plan, including over-the–counter products.
HCT covers the following contraceptive methods at no cost to the member when provided or prescribed by a
participating provider and obtained at a participating pharmacy as noted below:
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting
Intrauterine devices (IUDs): device provided by the practitioner
•
•
Hormonal IUD – This releases a small amount of hormone to prevent pregnancy. It’s sometimes
called an intrauterine system (IUS).
Copper IUD – This releases a small amount of copper to prevent pregnancy.
Hormonal methods
•
•
•
•
•
Implant (tiny tube put under the skin) – device provided by the practitioner
Depo-Provera (injectable contraceptive)
Birth control pills – Formulary driven.
Patch - Obtained at pharmacy – Formulary driven.
Ring - Obtained at pharmacy – Formulary driven.
Barrier methods
•
•
Female condoms - Obtained at pharmacy
Diaphragm or cervical cap - Obtained at pharmacy
Over-the-Counter
•
•
Spermicides
Sponges
Emergency contraception
• Emergency contraception pills (ECP or “the morning after pill”) such as Plan B and Ella (Ulipristal) Obtained at pharmacy
Sterilization Procedure
• Essure Hysteroscopic (CPT 58565) and the Essure Confirmation Test (58340 and 74740)
• Tubal Ligation
• Permanent implantable contraceptive intratubal occlusion device(s) and delivery system (A4264)
Members must have a prescription from a participating provider for any over-the-counter contraceptives in order
to be covered with no cost share, even if a prescription is not required to obtain the item, spermicides, sponges, etc.
A member is still able to buy them without a prescription, but they will have to pay for them out of pocket; they
would receive no benefit.
Quantity Limits:
• Spermicides (e.g., vaginal gel/foam/film/suppositories) – Quantity limit of 12 units (or days’ supply for
gel/foam) per month
• Female condoms – Quantity limit of 12 units per month
• Sponges - Quantity limit of 12 units per month
• Emergency contraceptives – generics only; exclude branded products; not eligible for 90-day supply
• Oral Contraceptives – Quantity limit of 1 tab per day applies to all products
- Monophasic, Biphasic, Triphasic, Extended Cycle – generics only; exclude branded products;
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting
•
•
•
- Four-phasic – only brand product available within drug class
Contraceptive Patch – only brand product available within drug class (Ortho-Evra); quantity limit of 3
patches per month
Injectable Contraceptives – generics only; exclude branded products#; quantity limit of 1 injection per 90
days
Cervical caps – Quantity limit of 1 unit per year
Contraceptive (birth control) Counseling
Patient education and counseling, as prescribed by a health care provider for women with reproductive capacity
(not including abortifacient drugs) are covered without cost-share to the member.
LOB:
Commercial – On exchange and off exchange
HSA and Non-HSA plans
☒Large group
☒Small group
☒Individual
Examples of Claim Adjudication Scenarios:
1. Member is seen by a non-participating provider and has an IUD inserted. The member is not entitled to $0
cost-share because of the provider’s status. Cost share, according to the member’s benefit plan, would
apply.
2. Member brings a prescription for birth control pills to the pharmacy, but the drug is not on the formulary.
The claim rejects at the pharmacy. The member’s provider would need to change her prescription to a
formulary drug (typically a generic) or file an appeal with our PBM with evidence that the member cannot
tolerate the formulary drug.
Member Cost-Sharing: Copay/deductible according to benefit summary
1. Contraception as described above must be covered for women without a copayment, coinsurance or
deductible. However, birth control pills can be managed by a formulary plan that limits coverage to a
generic drug without cost-sharing and impose cost-sharing for equivalent branded drugs (see benefit
policy for exceptions).
2. The member may be responsible for an office visit copay/deductibles that are applicable per their benefit
plan, if the visit is not coded by the practitioner as preventive.
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting
Provider Guidelines:
1. Providers are responsible for giving their patients a prescription for any over-the-counter contraceptives in
order to be covered at no cost (even if a prescription is not required to obtain the item, such as
spermicides).
Coding
Contraceptive (birth control) counseling
Comments
Diagnosis codes to be billed with preventive counseling codes or preventive E&M codes
ICD.9 (for DOS prior to 10/01/15)
Description
V25.01
General counseling for prescription of oral contraceptives
V25.02
General counseling for initiation of other contraceptive measures
V25.03
Encounter for emergency contraceptive counseling and prescription
V25.04
Counseling and instruction in natural family planning to avoid pregnancy
V25.09
Other general counseling and advice for contraceptive management
V25.49
Surveillance of other contraceptive method
ICD.10 (for DOS 10/01/15 & after)
Description
Z30.011
Encounter for initial prescription of contraceptive pills
Z30.013
Encounter for initial prescription of injectable contraceptive
Z30.014
Encounter for initial prescription of intrauterine contraceptive device
Z30.018
Encounter for initial prescription of other contraceptives
Z30.019
Encounter for initial prescription of contraceptives, unspecified
Z30.012
Encounter for prescription of emergency contraception
Z30.09
Encounter for other general counseling and advice on contraception
CPT/HCPC Codes
Description
99385-99387, 99395-99397 &
99401-99404
Preventive counseling and E&M codes
81025
Urine pregnancy test, by visual color comparison methods
Contraceptive Services
Comments
The CPT/HCPC codes listed are considered preventive when billed with one of the ICD.9 or ICD.10 codes listed
below
ICD.9 (for DOS prior to 10/01/15)
V25.02
Initiation of other contraceptive measures
V25.11-V25.13
Encounter for insertion or removal of intrauterine contraceptive device
V25.40-V25.43
Surveillance of previously prescribed contraceptive methods
V25.49
Surveillance of other contraceptive method
V25.5
Insertion of implantable subdermal contraceptive
V25.9
Unspecified contraceptive management
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting
V45.51
V45.52
V72.41
ICD.10 (for DOS 10/01/15 & after)
Z30.013-Z30.019
Z30.4-Z30.9
Z32.02
Z97.5
CPT/HCPC Codes
S4989
S4993
A4261
A4266
A4268
A4269
11976
11981
11982
11983
57170
58300
58301
96372
81025
J1050
J7300
J7301
J7302
J7303
J7304
J7306
J7307
Intrauterine contraceptive device
Subdermal contraceptive implant
Pregnancy test negative
Description
Encounter for initial prescription of contraceptives
Encounter for surveillance of contraceptives or Encounter for contraceptive
management
Encounter for pregnancy test, result negative
Presence of (intrauterine) contraceptive device
Description
Contraceptive intrauterine device (e.g. progestacert iud), including implants
and supplies
Contraceptive pills for birth control
Cervical cap for birth control
Diaphram for birth control
Contraceptive supply, condom, female, each
Contraceptive supply, spearmicide (e.g., foam gel), each
Removal, implantable contraceptive capsules
Insertion, non-biodegradable drug delivery implant
Removal, non-biodegradable drug delivery implant
Removal with reinsertion, non-biodegradable drug delivery implant
Diaphragm or cervical cap fitting with instructions
Insertion of intrauterine device (IUD)
Removal of intrauterine device (IUD)
Therapeutic, prophylactic, or diagnostic injection (specify substance or
drug); subcutaneous or intramuscular
Urine pregnancy test, by visual color comparison methods
Injection, medroxyprogesterone acetate, 1 mg
Intrauterine copper contraceptive
Levonorgestrel-releasing intrauterine contraceptive system, 13.5 mg
Levonorgestrel-releasing intrauterine contraceptive system, 52 mg
Contraceptive supply, hormone containing vaginal ring, each
Contraceptive supply, hormone containing patch, each
Levonorgestrel (contraceptive) implant system, including implants and
supplies
Etonogestrel (contraceptive) implant system, including implant and supplies
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting
Sterilization procedures
Comments
HealthyCT considers the following CPT codes preventive when billed with the following ICD.9 code V25.2Sterilization (for dos prior to 10/01/15) or ICD.10 code Z30.2-Encounter for sterilization (for dos 10/01/15 or after)
CPT/HCPCS Codes
Description
58565
Hysteroscopy, surgical; with bilateral fallopian tube cannulation to induce
occlusion by placement of permanent implants
OO952
Anesthesia for vaginal procedures; hysteroscopy and/or hysterosalpingography
58340
Catheterization and introduction of saline or contrast material for saline
infusion SIS or hysterosalpingography
OO851
74740
58600
58605
58611
58615
58670
58671
A4264
ICD 9
V25.2
ICD 10
Z30.2
**Essure confirmation test
Anesthesia for intraperitoneal procedures in lower abdomen including
laparoscopy; tubal ligation/transection
Hysterosalpingography, radiological and interpretation
Ligation or transection of fallopian tube(s), abdominal or vaginal approach,
unilateral or bilateral
Ligation or transection of fallopian tube(s), abdominal or vaginal approach,
postpartum, unilateral or bilateral, during same hospitalization (separate
procedure)
Ligation or transection of fallopian tube(s) when done at the time of cesarean
delivery or intra-abdominal surgery (not a separate procedure) (List separately
in addition to code for primary procedure)
Occlusion of fallopian tube(s) by device (eg, band, clip, Falope ring) vaginal or
suprapubic approach
Laparoscopy, surgical; with fulguration of oviducts (with or without
transection)
Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or
Falope ring)
Permanent implantable contraceptive intratubal occlusion device(s) and
delivery system
Description
Sterilization
Description
Encounter for sterilization
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting
Exclusions/Limitations
1. Preventive Services rendered by a non-participating provider will be applied to the member’s cost share
requirements in their benefit plan
2. The following are covered with member cost share as applicable:
• Contraception services/devices ordered or provided by non-participating practitioners (i.e.: IUDs)
• Contraceptives obtained from a non-network pharmacy
• Male sterilization
• Coverage of abortifacient drugs (abortion pills) such as Mifeprex® (mifepristone-generic)
Excluded:
• Male contraception such as condoms.
References
https://www.healthcare.gov/what-are-my-preventive-care-benefits/#part=2
http://healthfinder.gov/HealthTopics/Category/health-conditions-and-diseases/hiv-and-other-stds/choose-the-rightbirth-control
Document History
8/8/2014
3/31/2015
04/29/2015
11/05/15
Initial Version
Added HCPC code A4264-Permanent implantable contraceptive intratubal occlusion devise(s)
and delivery system.
Added-and Contraceptive Services to policy name
Added contraceptive services section to policy
Reformatted coding section
Removed codes 99144 & 99145.
Added codes J7306, V25.01, V25.5, V72.41
Proprietary and Confidential
Benefit Guidelines are developed by HealthyCT to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This
Guideline may contain only a partial, general description of plan or program benefits and does not constitute a contract. This Guideline may be updated and
therefore is subject to change.
Contraceptives: Approved at 5/4/2015 PCP committee meeting