Tobacco Cessation Benefit Clarification
May 27, 2011

One of the sources for the Patient Protection and Affordable Health Care Act’s mandated first-dollar preventive services came from recommendations made by the United States Preventive Services Task Force (USPSTF).

Regence recently conducted a close review of the USPSTF recommendations concerning tobacco cessation services and have concluded that 1) tobacco counseling and 2) associated prescription drug medications should be included within the first-dollar preventive benefits. 

The USPSTF recommendations are not specific in identifying what prescriptions should be covered.   We will limit the first-dollar tobacco cessation coverage to generic medications only; over-the-counter medications will not be covered.

In addition, if a group is subject to the Mental Health Parity and Addiction Equity Act (MHPAEA) and provides benefits for treatment of a substance use disorder (such as tobacco cessation), the benefit must be provided at parity with the medical benefits in all classifications (inpatient in- and out-of-network, outpatient in- and out-of-network, emergency care, and prescription drugs). 

While at this point the MHPAEA doesn’t apply to plans of employers of 50 or fewer employees or to individual coverage, we would be required to pay for the first-dollar preventive tobacco cessation benefits in these products pursuant to Federal Reform (unless grandfathered). 

After evaluating the two laws, we are altering our benefits in the following manner:

• Non-grandfathered group plans (regardless of size):
  • We will add tobacco cessation treatment to the preventive benefit at existing Category 1, 2 and 3 levels or at existing preventive care category levels.  Tobacco counseling is already included in the preventive benefit.  
  • We will add tobacco cessation generic medications to the preventive benefit when dispensed from participating pharmacies.
  • Other prescription medication benefits for tobacco cessation currently covered due to state mandate will remain unchanged. Clark County: For plans with a prescription drug benefit (either with Regence or an outside vendor), we will add non-generic tobacco cessation prescription medications from participating pharmacies and generic tobacco cessation medication from non-participating pharmacies to the regular pharmacy benefits.
    
• Grandfathered group plans (100+):
  • Oregon:
    • No changes are required due to the Oregon state mandate.
    • If a self-insured group did not take the Oregon mandate but has a Free and Clear or similar program or covers tobacco cessation drugs or benefits, we will create a tobacco cessation benefit that includes counseling and treatment at parity with medical benefits with no dollar limit. 
    • We will cover prescription tobacco cessation medications if the group has a pharmacy benefit through Regence. 
      
  • Clark County
    • These plans are not impacted by PPACA but are subject to the MHPAEA if the group has a Free and Clear or similar program or covers tobacco cessation drugs or benefits.  In those cases, we will add a tobacco cessation benefit with no dollar limit and add associated prescription medications if the group has pharmacy benefits through Regence.
    • If a grandfathered group does not have a Free and Clear or similar program and doesn’t cover tobacco cessation benefits or prescriptions, the group is not required to add the benefit.
    • We will also be seeking to identify groups that have a similar tobacco cessation benefit outside of Regence and adding benefits as appropriate.
      
• Non-grandfathered individual plans:
  • We will add tobacco cessation treatment to the preventive benefit at existing Category 1, 2 and 3 levels or at existing preventive care category levels.  Tobacco counseling is already included in the preventive benefit.  
  • Oregon: We will add tobacco cessation generic medications to the preventive benefit when dispensed from participating pharmacies.  Other prescription medication benefits for tobacco cessation currently covered due to state mandate will remain unchanged
  • Clark County: We will add tobacco cessation generic medications to the preventive benefit when dispensed from participating pharmacies.  There is no coverage for non-generic prescription tobacco cessation medications under the pharmacy benefit.

Administration

The following outlines the steps being taken to implement tobacco cessation benefits:

• Regence has reprocessed any medical claims impacted by the change retroactive to October 1, 2010, or when reform changes became effective.
• Oregon:  We are currently updating our system to allow coverage at 100% for tobacco cessation generic prescription drug claims submitted by a pharmacy.  Regence will reprocess any generic prescription drug claims that were not paid at 100%, retroactive to October 1, 2010, or when reform changes became effective.
• Clark County:  We are currently updating our system to allow coverage for tobacco cessation prescription drug claims submitted by a pharmacy.  Until we have the system updated, members will need to purchase the prescription themselves and submit the claim to Regence for reimbursement.  If a member has already purchased a tobacco cessation prescription drug, they may submit the claim to Regence for reimbursement.
• We are evaluating our contract language to ensure it is consistent with the described tobacco cessation benefits.
• We strongly encourage all self-funded groups to adopt our same approach; however, their plans bear the ultimate liability if they fail to comply with the MHPAEA.  If they do not choose our approach, these plans will need to send written confirmation (an email will suffice) to their Regence sales executive, indicating that they have been notified of our interpretation but have chosen not to implement the recommended changes.

Please contact your Regence Sales Executive if you have any questions.

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