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For Physicians

Insurance Information

Insurance Carrier

Network Participation

PCP Referral Required

Authorization Required

Covered Procedure Codes

Aetna Health Plan

Yes

Yes

No

99406 & 99407

BCBS of Massachusetts

Yes

Yes

No

99406 & 99407

BMC Healthnet

Yes

No

No

99406 & 99407

Cigna Health Plan

Yes

Yes

No

99406 & 99407

Fallon Healthcare

No

Yes

No

99406 & 99407

HPHC

Yes

Yes

No

99406 & 99407

Masshealth

Yes

Yes

No

99407 only

Medicare

Yes

No

No

99406 & 99407

Minuteman Health

No

Yes

No

99406 & 99407

Neighborhood Health Plan

Yes

Yes

No

99406 & 99407

Sr. Whole Health

Yes

Yes

No

 

Tricare

No

No

Yes

99406 & 99407

Tufts Health Plan HMO & PPO

Yes

Yes

No

99406 & 99407

United Health Care

Yes

No

Yes

99406 & 99407

  • 99406: 3-10" counseling
  • 99407: > 10" counseling

MassHealth and Commonwealth Care

  • Medications: All FDA-approved medications, two 90-day treatment regimens per year.

Co-payments of $1 are required for generic medications, and co-payments of $3 are required for brand name medications. Prior authorization is required for the NRT nasal spray and inhaler, and if the patient wants to extend treatment duration past 90 days (24 weeks for varenicline).

  • Counseling: Up to 16 face-to-face counseling sessions per 12-month cycle.

Counseling sessions must be = > 10 minutes to be covered. Mass Health (Medicaid) covers the 99407 (>10” counseling) but not the 99406 (3-10”).

Prior authorization is also required if number of quit attempts exceed 2 per year. Group and individual counseling sessions are limited to 16 per year.

Medicare

  • Medications: Covers nicotine nasal spray, nicotine inhaler, bupropion and varenicline.

Does not cover over the counter medications such as nicotine patch and gum.

  • Counseling: Two cessation attempts per year; each attempt includes a maximum of four intermediate or intensive sessions, up to 8 sessions in a 12-month period.

Outpatient and hospitalized beneficiaries who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease; who are competent and alert at the time that counseling is provided; and whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

If you have Original Medicare, you no longer pay coinsurances or deductibles for smoking cessation counseling if you have not been diagnosed with an illness that is caused or complicated by smoking (see table).

For Medicare patients who have been diagnosed with a disease or condition caused by smoking, Medicare will pay 80 percent of the approved amount for smoking cessation counseling after the deductible is met.

CPT

Diagnosis

Patient annual deductible will be applied (99406/99407)

99406

Code disease impacted by tobacco

Smoking and tobacco cessation counseling; symptomatic pt >3-10" (intermediate)

99407

Code disease impacted by tobacco

Smoking and tobacco cessation counseling; symptomatic pt >10" (intensive)

State Health Insurance Exchanges

  • Will cover the unemployed, self-employed and those not provided with employer-sponsored insurance in 2014.
  • Coverage of comprehensive tobacco cessation treatment has not yet been defined.

Employer Sponsored Plan

  • All new plans must cover tobacco cessation treatment, but coverage varies widely plan to plan.
  • Blue Cross and Blue Shield (BCBSMA) covers smoking cessation/medications but may be dependent on the patient’s employee contract

Private Health Insurance Plans

  • This state does not require private health insurance plans to cover cessation treatments.
  • Cessation coverage in private health insurance plans varies by employer and/or plan.

Resources

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