Mass. Gen. Laws ch. 118E, sec. 10K — MA Code / Part I / Title XVII / Chapter 118E / Section 10K
Coverage for certain services and contraceptive methods
Status: in_force

Section 10K. (a) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall provide coverage for the following services and contraceptive methods: (i) Food and Drug Administration, FDA, approved contraceptive drugs, devices and other products; provided, however, that coverage shall not be required for male condoms or FDA-approved oral contraceptives that do not have a therapeutic equivalent; and provided further, that: (A) if the FDA has approved 1 or more therapeutic equivalents of a contraceptive drug, device or product, the division shall not be required to include all such therapeutically equivalent versions in its formulary as long as at least 1 is included and covered without cost-sharing and in accordance with this section; (B) if there is a therapeutic equivalent of a drug, device or other product for an FDA-approved contraceptive method, the division may provide coverage for more than 1 drug, device or other product and may impose cost-sharing requirements as long as at least 1 drug, device or other product for that method is available without cost-sharing; provided, however, that if an individual's attending provider recommends a particular FDA-approved contraceptive based on a medical determination with respect to that individual, regardless of whether the contraceptive has a therapeutic equivalent, the division shall provide coverage, subject to the division's utilization management procedures, for the prescribed contraceptive drug, device or product without cost-sharing; and (C) appeals of an adverse determination of a request for coverage of an alternative FDA-approved contraceptive drug, device or other product without cost-sharing shall be subject to the grievance process under section 47 of chapter 118E; (ii) FDA-approved emergency contraception available over-the-counter, whether with a prescription or dispensed consistent with the requirements of section 19A of chapter 94C; (iii) prescription contraceptives intended to last: (A) for not more than a 3-month period for the first time the prescription contraceptive is dispensed to the covered person; and (B) for not more than a 12-month period for any subsequent dispensing of the same prescription, which may be dispensed all at once or over the course of the 12-month period, regardless of whether the covered person was enrolled with the division at the time the prescription contraceptive was first dispensed; provided, however, that the insured may not fill more than one 12-month prescription in a single dispensing per plan year; (iv) voluntary female sterilization procedures; (v) patient education and counseling on contraception; and (vi) follow-up services related to the drugs, devices, products and procedures covered under this subsection including, but not limited to, management of side effects, counseling for continued adherence and device insertion and removal. (b) (1) Coverage provided under this section shall not be subject to any deductible, coinsurance, copayment or any other cost-sharing requirement, except as provided for in subclauses (A) and (B) of clause (i) of subsection (a) or as otherwise required under federal law. Coverage provided under this section shall not impose unreasonable restrictions or delays in the coverage; provided, however, that reasonable medical management techniques may be applied to coverage within a method category, as defined by the FDA, but not across types of methods. (2) Benefits for an enrollee under this section shall be the same for the enrollee's covered spouse and covered dependents. (c) Nothing in this section shall be construed to exclude coverage for contraceptive drugs, devices, products and procedures prescribed by a provider for reasons other than contraceptive purposes including, but not limited to, decreasing the risk of ovarian cancer, eliminating symptoms of menopause or providing contraception that is necessary to preserve the life or health of the enrollee or the enrollee's covered spouse or covered dependents. (d) Nothing in this section shall be construed to deny or restrict the division's authority to ensure its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan are in compliance with this chapter. (e) Nothing in this section shall be construed to require the division to cover experimental or investigational treatments. (f) For purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise: ''Provider'', an individual or facility licensed, certified or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice acting within the scope of their license. ''Therapeutic equivalent'', a contraceptive drug, device or product that is: (i) approved as safe and effective; (ii) pharmaceutically equivalent to another contraceptive drug, device or product in that it contains an identical amount of the same active drug ingredient in the same dosage form and route of administration and meets compendial or other applicable standards of strength, quality, purity and identity; and (iii) assigned the same therapeutic equivalence code as another contraceptive drug, device or product by the FDA.

Section 10K. (a) The division and its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan shall provide coverage for the following services and contraceptive methods:

(i) Food and Drug Administration, FDA, approved contraceptive drugs, devices and other products; provided, however, that coverage shall not be required for male condoms or FDA-approved oral contraceptives that do not have a therapeutic equivalent; and provided further, that:

(A) if the FDA has approved 1 or more therapeutic equivalents of a contraceptive drug, device or product, the division shall not be required to include all such therapeutically equivalent versions in its formulary as long as at least 1 is included and covered without cost-sharing and in accordance with this section;

(B) if there is a therapeutic equivalent of a drug, device or other product for an FDA-approved contraceptive method, the division may provide coverage for more than 1 drug, device or other product and may impose cost-sharing requirements as long as at least 1 drug, device or other product for that method is available without cost-sharing; provided, however, that if an individual's attending provider recommends a particular FDA-approved contraceptive based on a medical determination with respect to that individual, regardless of whether the contraceptive has a therapeutic equivalent, the division shall provide coverage, subject to the division's utilization management procedures, for the prescribed contraceptive drug, device or product without cost-sharing; and

(C) appeals of an adverse determination of a request for coverage of an alternative FDA-approved contraceptive drug, device or other product without cost-sharing shall be subject to the grievance process under section 47 of chapter 118E;

(ii) FDA-approved emergency contraception available over-the-counter, whether with a prescription or dispensed consistent with the requirements of section 19A of chapter 94C;

(iii) prescription contraceptives intended to last: (A) for not more than a 3-month period for the first time the prescription contraceptive is dispensed to the covered person; and (B) for not more than a 12-month period for any subsequent dispensing of the same prescription, which may be dispensed all at once or over the course of the 12-month period, regardless of whether the covered person was enrolled with the division at the time the prescription contraceptive was first dispensed; provided, however, that the insured may not fill more than one 12-month prescription in a single dispensing per plan year;

(iv) voluntary female sterilization procedures;

(v) patient education and counseling on contraception; and

(vi) follow-up services related to the drugs, devices, products and procedures covered under this subsection including, but not limited to, management of side effects, counseling for continued adherence and device insertion and removal.

(b) (1) Coverage provided under this section shall not be subject to any deductible, coinsurance, copayment or any other cost-sharing requirement, except as provided for in subclauses (A) and (B) of clause (i) of subsection (a) or as otherwise required under federal law. Coverage provided under this section shall not impose unreasonable restrictions or delays in the coverage; provided, however, that reasonable medical management techniques may be applied to coverage within a method category, as defined by the FDA, but not across types of methods.

(2) Benefits for an enrollee under this section shall be the same for the enrollee's covered spouse and covered dependents.

(c) Nothing in this section shall be construed to exclude coverage for contraceptive drugs, devices, products and procedures prescribed by a provider for reasons other than contraceptive purposes including, but not limited to, decreasing the risk of ovarian cancer, eliminating symptoms of menopause or providing contraception that is necessary to preserve the life or health of the enrollee or the enrollee's covered spouse or covered dependents.

(d) Nothing in this section shall be construed to deny or restrict the division's authority to ensure its contracted health insurers, health plans, health maintenance organizations, behavioral health management firms and third-party administrators under contract to a Medicaid managed care organization or primary care clinician plan are in compliance with this chapter.

(e) Nothing in this section shall be construed to require the division to cover experimental or investigational treatments.

(f) For purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:

''Provider'', an individual or facility licensed, certified or otherwise authorized or permitted by law to administer health care in the ordinary course of business or professional practice acting within the scope of their license.

''Therapeutic equivalent'', a contraceptive drug, device or product that is: (i) approved as safe and effective; (ii) pharmaceutically equivalent to another contraceptive drug, device or product in that it contains an identical amount of the same active drug ingredient in the same dosage form and route of administration and meets compendial or other applicable standards of strength, quality, purity and identity; and (iii) assigned the same therapeutic equivalence code as another contraceptive drug, device or product by the FDA.