§ 4W — Outpatient services; hormone replacement therapy for peri and post menopausal women; contraceptive services; approved prescription contraceptive drugs or devises; exception

Section 4W. (a) Any subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within or without the commonwealth and that provides benefits for outpatient services shall provide to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth benefits for hormone replacement therapy services for peri and post menopausal women and outpatient contraceptive services under the same terms and conditions as for such other outpatient services. Outpatient contraceptive services shall mean consultations, examinations, procedures and medical services provided on an outpatient basis and related to the use of all contraceptive methods to prevent pregnancy that have been approved by the United States Food and Drug Administration.(b) Any subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within or without the commonwealth and that provides benefits for outpatient prescription drugs or devices shall provide to all individual subscribers and members within the commonwealth and to all group members having a principal place of employment within the commonwealth benefits for hormone replacement therapy for peri and post menopausal women and for outpatient prescription contraceptive drugs or devices which have been approved by the United States Food and Drug Administration under the same terms and conditions as for such other prescription drugs or devices, provided that in covering all FDA approved prescription contraceptive methods, nothing in this section precludes the use of closed or restricted formulary.(c) This section shall not apply to a subscription certificate under an individual or group medical service agreement delivered, issued or renewed under this chapter if that subscription certificate is purchased by an employer that is a church or qualified church-controlled organization, as those terms are defined in 26 U.S.C. section 3121(w)(3)(A) and (B).(d) A subscription certificate under an individual or group medical service agreement that is delivered, issued or renewed within or outside the commonwealth and that provides benefits for outpatient services shall provide to all individual subscribers and members in the commonwealth and to all group members having a principal place of employment in the commonwealth 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 contraceptive drugs 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, an individual or group medical service agreement shall not be required to include all such therapeutically equivalent version in its formulary as long as at least 1 is included and covered without cost-sharing and in accordance with this subsection;(B) if there is a therapeutic equivalent of a drug, device or other product for an FDA-approved contraceptive method, a medical service agreement 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, a medical service agreement shall provide coverage, subject to a plan'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 expedited grievance process under section 13 of chapter 176O;(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 furnished or dispensed all at once or over the course of the 12 months, regardless of whether the covered person was enrolled in the policy, contract or plan at the time the prescription contraceptive was first dispensed; provided, however, that a corporation shall not be required to provide coverage for 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.(e) (1) Coverage provided under subsection (d) 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 (d) or otherwise as required under federal law. Coverage offered under said subsection (d) shall not impose unreasonable restrictions or delays in the coverage, in accordance with the requirements of chapter 176O; 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 subsection (d) shall be the same for the enrollee's covered spouse and covered dependents.(f) A medical service agreement that is delivered, issued or renewed within or outside the commonwealth that is purchased by an employer that is a church or qualified church-controlled organization shall be exempt from subsection (d) at the request of the employer. An employer that invokes the exemption under this subsection shall provide written notice to prospective enrollees prior to enrollment with the plan and such notice shall list the contraceptive health care methods and services for which the employer will not provide coverage for religious reasons.(g) Nothing in subsection (d) 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 an enrollee or the enrollee's covered spouse or covered dependents.(h) The commissioner shall ensure compliance with this chapter.(i) Nothing in subsection (d) shall be construed to require a medical service agreement to cover experimental or investigational treatments.(j) For purposes of this section, the following words shall have the following meanings unless the context clearly requires otherwise:''Church'', a church, a convention or association of churches or an elementary or secondary school that is controlled, operated or principally supported by a church or by a convention or association of churches.''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.''Qualified church-controlled organization'', an organization described in section 501(c)(3) of the federal Internal Revenue Code, other than an organization that: (i) offers goods, services or facilities for sale, other than on an incidental basis, to the general public, other than goods, services or facilities that are sold at a nominal charge that is substantially less than the cost of providing such goods, services or facilities; and (ii) normally receives more than 25 per cent of its support from: (A) governmental sources; (B) receipts from admissions, sales of merchandise, performance of services or furnishing of facilities in activities that are not unrelated trades or businesses; or (C) both clauses (A) and (B).''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.