Understanding Insurance Coverage For Nexplanon: A Guide To Billing With Bcbsnc

Nexplanon is a prescription birth control medication for women. It is covered by most healthcare plans and can be covered as either a medical benefit or a pharmacy benefit. If you are a Blue Cross and Blue Shield of North Carolina (BCBSNC) insurance holder, you can check your coverage by calling the customer service number on the back of your health insurance card. You can also visit a Blue Cross NC location to get insurance support.

Nexplanon as a medical benefit

Nexplanon is a prescription medication for the prevention of pregnancy in women. It is a physician-administered birth control drug that is inserted under the skin in a woman's upper arm. It is covered by most health care plans and can be covered as either a medical benefit or a pharmacy benefit.

To find out if you have coverage for Nexplanon as a medical benefit, call the customer service number for your insurance provider. This number should be listed on the back of your health insurance card. Inform the representative that Nexplanon is a physician-administered birth control drug and that your physician will order Nexplanon for you and insert it during an office visit. Ask if Nexplanon is covered by your insurance. If the answer is no, then ask if you have coverage for Nexplanon in your pharmacy benefit.

If Nexplanon is covered, you will want to verify some information with your insurance company to better understand your costs. Ask if Nexplanon and the procedure are 100% covered. If not, ask about any out-of-pocket costs. You should also confirm the coverage and out-of-pocket costs for removal.

If Nexplanon is not covered, you may have some other options. Ask if there are "Medical Exceptions" available. Some policies have medical exception clauses that allow your healthcare professional to authorize a specific treatment. If a "Medical Exception" is not available, ask your healthcare professional if they have any payment plans available to offset the cost.

Nexplanon as a pharmacy benefit

Nexplanon is a prescription medication for the prevention of pregnancy in women. It is a small, thin plastic rod that is inserted under the skin to prevent pregnancy. The rod slowly releases etonogestrel into the body over a 3-year period. Nexplanon is covered by most health care plans and may be covered as a medical benefit or a pharmacy benefit.

If Nexplanon is covered as a pharmacy benefit, this means that the drug is covered separately from the procedure. After the pharmacy benefit is determined, a specialty pharmacy can deliver Nexplanon to the practice. The specialty pharmacy will bill the insurance plan for Nexplanon and ship the patient-specific Nexplanon to the office. The office will then schedule the patient for the procedure. Once the procedure takes place, the practice will bill the insurance carrier for the procedure.

It is important to verify each patient's insurance coverage as insurance coverage varies from patient to patient. To determine if Nexplanon is covered by your insurance, call the customer service number listed on the back of your health insurance card. Inform the representative about Nexplanon and ask if it is covered by your insurance. If the answer is no, ask if you have coverage for Nexplanon in your pharmacy benefit.

If Nexplanon is covered, verify some information with your insurance company to better understand your costs. Ask if Nexplanon and the procedure are 100% covered. If not, ask about any out-of-pocket costs. You should also confirm the coverage and out-of-pocket costs for removal.

Specialty distributors

Specialty pharmaceuticals are typically defined by their high cost, high complexity, or high touch nature. These drugs often require specialized handling, limited distribution networks, and unique storage and transportation requirements. As a result, specialty distributors must adhere to stringent quality standards and regulations to ensure the integrity and efficacy of the products they supply.

One of the most common forms of coverage for specialty pharmaceuticals is through specialty distributors or specialty pharmacies, known as the "buy and bill" method. In this model, healthcare providers purchase specialty drugs, such as Nexplanon, from specialty distributors to maintain an in-office inventory. They then bill the patient's insurance carrier for both the drug and the procedure, which are usually covered under the same benefit. This approach simplifies the distribution process and allows providers to offer a wider range of treatment options to their patients.

The role of specialty distributors is evolving due to the increasing complexity of the healthcare landscape. With the rise of specialty pharmaceuticals and the shift towards patient-administered specialty drugs, distributors are adapting their business models. They are investing in innovative technologies, such as sophisticated ordering platforms and inventory management systems, to enhance the efficiency and accuracy of their distribution processes. Additionally, specialty distributors are expanding their service offerings to include reimbursement support, patient assistance programs, and data collection services.

In conclusion, specialty distributors play a critical role in the healthcare industry by ensuring the timely and reliable distribution of specialty pharmaceuticals to physician practices, hospitals, and clinics. By maintaining high standards of product integrity and adhering to regulatory requirements, specialty distributors contribute to improving patient care and outcomes. As the healthcare industry continues to evolve, specialty distributors will need to remain agile and responsive to meet the changing needs of healthcare providers and their patients.

Rebate program

Nexplanon is covered by most healthcare plans and can be covered as either a medical benefit or a pharmacy benefit.

The Commercial Coverage Assurance Program for Nexplanon is intended to help customers who are reimbursed less than their acquisition cost for Nexplanon on eligible patient claims for dates of service between February 1, 2024, and October 31, 2024. To be eligible for the rebate program, you must have purchased Nexplanon at the wholesale acquisition cost (WAC), not at a manufacturer-discounted or contracted price. Only patient claims under commercial insurance plans are eligible for this program.

If your request meets all the criteria, you will receive a rebate check for the difference between the total reimbursement amount received for that unit from the plan and from patient cost-sharing amounts, and the acquisition cost for Nexplanon. The maximum amount of the rebate check is $200 per claim.

To request a rebate, you must submit the following documentation:

• Completed Rebate Request Form, either via fax or email
• Invoice from your distributor showing the price paid for Nexplanon (invoice must be dated between February 1, 2024, and October 31, 2024)
• An Explanation of Benefits (EOB) with the amount paid by the insurance plan for the unit. Please remove/black out all patient information and patient health information (PHI) to maintain HIPAA compliance. The patient date of service/insertion must be between February 1, 2024, and October 31, 2024.

Possible billing codes

Nexplanon is covered by most healthcare plans and can be covered as either a medical benefit or a pharmacy benefit. To accurately bill and obtain reimbursement, it is important to know which billing codes to use to describe Nexplanon and any procedures related to it.

The insertion and/or removal of the implant are reported using one of the following CPT® codes:

• 11981 Insertion, non-biodegradable drug delivery implant
• 11982 Removal, non-biodegradable drug delivery implant
• 11983 Removal with reinsertion, non-biodegradable drug delivery implant

The diagnostic coding will vary, but usually will be selected from the Encounter for Contraceptive Management code series - V25 in ICD-9-CM or Z30 in ICD-10-CM. These codes are:

• V25.5 Encounter for contraceptive management, insertion of implantable subdermal contraceptive or
• Z30.018 Encounter for initial prescription of other contraceptives in ICD-10-CM
• V25.43 Surveillance of previously prescribed contraceptive method; implantable subdermal contraceptive or
• Z30.49 For checking, reinsertion, or removal of the implant in ICD-10-CM
• Z30.017 Insertion
• Z30.46 Surveillance

The CPT procedure codes do not include the cost of the supply. Report the supply separately using a HCPCS code:

J7307 Etonogestrel [contraceptive] implant system, including implant and supplies

Effective October 1, 2019, two additional ICD-10 codes were added to the LARC DRG reimbursement retroactive date of October 1, 2018. Providers must bill with the following HCPCS code, and the appropriate ICD-10 PCS code on the inpatient hospital claim to receive the LARC DRG reimbursement:

• OJHD3HZ Insertion of Contraceptive Device into Right Upper Arm
• OJHF3HZ Insertion of Contraceptive Device into Left Upper Arm

Frequently asked questions