Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 01|01|2007 POLICY LAST UPDATED: 08|16|2023

OVERVIEW This is an administrative policy to document Rhode Island General Laws (RIGL) 27-20-53 Tobacco cessation programs. This law, enacted January 1, 2007, mandates coverage for nicotine replacement therapy and smoking cessation counseling treatment as stated below.

The state mandate for Smoking Cessation is applicable in conjunction with a federal preventive services mandate under the Affordable Care Act. For coverage requirements applicable to services covered as Preventive according to the Federal mandate, please refer to the Preventive Services for Commercial and Preventive Services for Medicare Advantage Plans policies.

This policy is applicable to Commercial products as State Mandates do not apply to Medicare Advantage Plans. Self-funded groups may or may not choose to follow state mandate(s).

MEDICAL CRITERIA Not applicable

PRIOR AUTHORIZATION Prior authorization review is not required.

POLICY STATEMENT Commercial Products Smoking cessation treatment is covered and includes the following:

Nicotine Replacement Products: • A required written prescription from a physician for all smoking cessation medications, including over-the-counter nicotine replacement products (e.g., nicotine patch, gum, lozenges).

• Members are encouraged to contact Customer Service to verify approved nicotine replacement prescription products.

• Nicotine replacement therapy and smoking cessation prescription drugs are not covered when purchased at a mail order pharmacy.

Counseling Services: • Counseling services may be provided by a physician, nurse practitioner, nurse midwife, physician assistant, as well as a mental health and chemical dependency provider. Counseling services may be provided at a hospital facility.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for the applicable “Smoking Cessation Programs” and pharmacy benefit coverage.

Payment Policy | Smoking Cessation Mandate

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

Rhode Island-mandated benefits do not apply to Medicare Advantage Plans. However smoking cessation services are covered for Medicare Advantage Plan members. Please refer to the Preventive Services for Medicare Advantage Plans policy.

Self-funded groups may or may not choose to follow state mandates.

BACKGROUND § 27-20-53 Tobacco cessation programs. (a) Every individual or group health insurance contract, plan or policy delivered, issued for delivery or renewed in this state on or after January 1, 2010, which provides medical coverage that includes coverage for physician services in a physician's office, and every policy which provides major medical or similar comprehensive-type coverage, shall include coverage for smoking cessation treatment, provided that if such medical coverage does not include prescription drug coverage, such contract, plan or policy shall not be required to include coverage for FDA approved smoking cessation medications.

(b) As used in this section, smoking cessation treatment includes the use of an over-the-counter (OTC) or prescription US Food and Drug Administration (FDA) approved smoking cessation medication when used in accordance with FDA approval, for not more than two (2) courses of medication for up to fourteen (14) weeks each, annually, when recommended and prescribed by a prescriber who holds prescriptive privileges in the state in which they are licensed, and used in combination with an annual outpatient benefit of sixteen (16) one-half (1/2) hour evidence-based smoking cessation counseling sessions provided by a qualified practitioner for each covered individual. Smoking cessation treatment may be redefined through regulation promulgated by the health insurance commissioner., in accordance with the most current clinical practice guidelines sponsored by the United States department of health and human services or its component agencies. (See Special Note below regarding limits.)

(c) Health insurance contracts, plans, or policies to which this section applies, may impose copayments and/or deductibles for the benefits mandated by this section consistent with the contracts', plans' or policies' copayments and/or deductibles for physician services and medications. Nothing contained in this section shall impact the reimbursement, medical necessity or utilization review, managed care, or case management practices of these health insurance contracts, plans or policies.

(d) This section shall not apply to insurance coverage providing benefits for: (1) hospital confinement indemnity; (2) disability income; (3) accident only; (4) long-term care; (5) Medicare supplement; (6) limited benefit health; (7) specified disease indemnity; (8) sickness or bodily injury or death by accident or both; and (9) other limited benefit policies.

SPECIAL NOTE: The Office of the Health Insurance Commissioner (OHIC) OHIC redefined, through Regulation 14 - Tobacco Cessation Treatment Coverage, the smoking cessation treatment in regards to RIGL 27-20-53 to be consistent with the current clinical practice guidelines sponsored by the United States Department of Health and Human Services, "Treating Tobacco Use and Dependence: A Clinical Guideline." Consequently, the limits previously placed on the number of treatment courses and counseling sessions have been removed.

Smoking cessation treatments include: • Nicotine replacement therapy, that include the patch, gum, lozenges, and inhalers, and bupropion HCL, can assist by decreasing cravings for nicotine and reducing signs and symptoms of withdrawal.

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

• Varenicline (Chantix™) is a smoking cessation medication which helps reduce withdrawal symptoms and cravings caused by the loss of nicotine from cigarettes. In addition, it works by blocking the pleasant effects of nicotine (from smoking) in the brain.

CODING Commercial Products The following code is covered: 99407 Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes

The following code is covered but not separately reimbursed:
99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10

minutes

NOTE: An evaluation and management visit filed in conjunction with one of the services above requires modifier -25. Based on coding requirements, services filed with modifier -25 must be separately identifiable.

RELATED POLICIES Coding and Payment Guidelines
Preventive Services for Commercial Members
Preventive Services for Medicare Advantage Plans

PUBLISHED Provider Update, October 2023 Provider Update, January 2022 Provider Update, August 2019 Provider Update, September 2018 Provider Update, June 2017 Provider Update, June 2016

REFERENCES

1. Office of the Health Insurance Commissioner (OHIC). Amendment of Regulation14 Tobacco Cessation Treatment Coverage. http://www.ohic.ri.gov/Regulation14Tobacco.php

2. http://webserver.rilin.state.ri.us/Statutes/TITLE27/27-20/27-20-53.HTM

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.

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