REQUIRED ENDORSEMENT

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Russell Toal DEPUTY SUPERINTENDENT Jennifer A. Catechis Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2021-029 December 17, 2021 TO: ALL ISSUERS OF FULLY INSURED HEALTH INSURANCE IN NEW MEXICO RE: REQUIRED ENDORSEMENT The Office of Superintendent of Insurance (“OSI”) is committed to consumer protection which includes assuring that issuers supply accurate and understandable information that explains health insurance rights and benefits. In recent weeks, OSI has received correspondence indicating that carriers may not be in compliance with statutes and regulations concerning enrollees’ rights to certain contraception services and supplies, and their cost-sharing responsibilities for those services and supplies. To ensure enrollees are fully and accurately informed about such rights and benefits, the OSI is issuing the endorsement attached to this bulletin. All subject issuers shall issue this endorsement to each enrollee under a plan that went into effect on or after July 1, 2021. Questions concerning this Bulletin should be directed to viara.ianakieva@state.nm.us. ISSUED this 17th day of December, 2021. SUPERINTENDENT OF INSURANCE _________________________________ RUSSELL TOAL CONTRACEPTIVE COVERAGE SUMMARY ENDORSEMENT [NUMBER/IDENTIFIER] THIS ENDORSEMENT CHANGES YOUR AGREEMENT WITH US This endorsement summarizes the contraception coverage benefits you are entitled to, and replaces any part of your insurance agreement with us that provides less favorable contraception benefits: Contraception Coverage You are entitled to receive certain covered contraception services and supplies without cost sharing and without prior approval from us. This means that you do not have to make a co-payment, coinsurance, satisfy a deductible or pay out-of-pocket for any part of contraception benefits listed in this summary if you receive them from an in-network provider. You may be required to pay a copay, coinsurance, and/or a deductible if you receive a contraception service or supply from an out-of-network provider if the same service or supply is available in-network. You may also owe cost sharing if you receive a brand-name contraceptive when at least one generic or a therapeutic equivalent is available. Covered Contraceptive Methods Your plan covers these contraceptive methods: Method Sterilization Surgery for Women Sterilization Surgery for Men IUD Copper IUD with Progestin Implantable Rod Shot/Injection Oral Contraceptives (The Pill) (Combined Pill) Oral Contraceptives (Extended/Continuous Use) Oral Contraceptives (Mini Pill – Progestin Only) Patch Vaginal Contraceptive Ring Diaphragm with Spermicide Sponge with Spermicide Cervical Cap with Spermicide Male Condom Female Condom Spermicide Emergency Contraceptive – “Plan B” Emergency Contraceptive – “Ella” Long Acting Reversible Contraceptives The Long Acting Reversible Contraceptives (LARCs), including Intrauterine Devices (IUDs) covered without cost-sharing by your plan are listed here: [insert website for Cost Sharing Free Covered Contraceptives Summary]. Coverage with no cost-sharing also applies to IUD insertion and removal, including surgical removal, and to any related medical examination when services are obtained from an in-network provider. Coverage of LARCs with no cost-sharing also includes (pre-discharge) postpartum clinical services. Oral Contraceptives The oral contraceptives covered by your plan are listed here: [insert website for Cost Sharing Free Covered Contraceptives Summary]. Six Month Dispensing You are entitled to receive a six-month supply of contraceptives, if prescribed and self-administered, when dispensed at one time by your pharmacy. To receive this benefit, your provider must specifically prescribe the six-month supply. If you need to change your contraceptive method before the six-month supply runs out, you may do so without cost-sharing. You will not owe cost sharing for any related contraceptive counseling or side-effects management. Brand Name Drugs or Devices Your plan may exclude or apply cost sharing to a name-brand contraceptive if a generic or therapeutic equivalent is available within the same category of contraception. Please see the table of contraceptive categories above. Ask your provider about a possible equivalent. If your provider determines that a brand-name contraceptive is medically necessary, your provider may ask us to cover that contraceptive without cost-sharing. If we deny the request, you or your provider can submit a grievance to contest that denial. Vasectomies and Male Condoms [FOR NON-HSA PLANS - This plan covers vasectomies and male condoms. No prescription or cost sharing is required for coverage of male condoms. Please see the section below on Coverage for Contraception Where a Prescription Is Not Required for instructions on reimbursement for condoms.] [INSERT FOR HSA PLANS - Once you have met your deductible, this plan will cover vasectomy and male condoms cost-sharing free. Please see the section below on Coverage for Contraception Where a Prescription Is Not Required for instructions on reimbursement for condoms.] Sexually Transmitted Infections Your plan covers, and no cost sharing applies to, contraception methods that are prescribed for the prevention of sexually transmitted infections. Coverage for Contraception Where a Prescription Is Not Required Your plan covers contraception with no cost sharing even when a prescription is not required. Contraceptive methods such as condoms or Plan B may fall into this category. You will not have to pay upfront for contraceptives that do not require a prescription when obtained through an in-network pharmacy. For all other purchases, you may submit a request for reimbursement as follows: • Within 90 days of the date of purchase of the contraceptive method, • [Provide the receipt with the item name and amount, your name, address, plan ID number, to the following: [INSERT ADDRESS HERE] Or [INSERT FAX OR HIPAA COMPLIANT ELECTRONIC METHOD HERE]] OR • [Provide the receipt with the reimbursement form available at [insert form citation], to the following: [INSERT ADDRESS HERE] Or [INSERT FAX OR HIPAA COMPLIANT ELECTRONIC METHOD HERE]] If you submit your complete request for reimbursement electronically or by fax, we will reimburse you within 30 days of receiving the request. If you submit your complete request for reimbursement by U.S. mail, we will reimburse within 45 days. Failure to submit a complete request may lead to delays in reimbursement. Availability of Out-of-Network Coverage [FOR HMOs - Under your plan, use of an out-of-network provider to prescribe or dispense contraceptive coverage is not a covered benefit.] or [FOR PPOs - Under your plan, use of an out-of-network provider to prescribe or dispense contraceptive coverage is a covered benefit. Please refer to [insert section of out-of-network description section the plan] to learn more about your out-of-network benefit.] This endorsement is retroactive to the effective date of your coverage with us. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply.