The implant is designed to be effective for up to three years, at which point it must be removed or replaced by a healthcare provider. While the removal procedure is a minor, in-office procedure involving a small incision and local anesthetic, the question of whether insurance covers the cost often arises due to variable health plan policies. Fortunately, in the vast majority of cases, the removal of this long-term contraceptive is covered by insurance with no out-of-pocket expense to the patient.
Federal Requirements for Contraceptive Coverage
Federal law mandates that most private health insurance plans must cover a range of preventive services for women, and this coverage includes all Food and Drug Administration (FDA)-approved methods of contraception. This requirement specifically extends to the necessary services associated with these methods, such as the initial consultation, insertion, and ultimate removal of the device.
For individuals covered by compliant plans, the procedure for Nexplanon removal should be provided without any cost-sharing, meaning there are no copayments, coinsurance, or deductibles applied. This zero-cost coverage is only guaranteed when the procedure is performed by a provider or facility that is considered in-network with the patient’s insurance plan. The removal is treated as an essential part of the preventive care benefit, ensuring access to the entire contraceptive process.
This broad coverage standard applies to most employer-sponsored plans and those purchased through the Health Insurance Marketplace. Ensuring the provider codes this service correctly on the claim is a significant factor in guaranteeing the no-cost benefit.
Exceptions to Coverage Mandates
Despite the federal mandate, certain types of health plans are legally permitted to bypass the requirement to cover contraceptives without cost-sharing. One common exception is known as a “grandfathered” plan, which existed before the federal health law was enacted and has not substantially changed its terms since then. These older plans are generally not required to comply with the preventive service mandate, although they are becoming increasingly rare.
Another set of exceptions involves plans sponsored by religious employers or those with moral objections to covering contraception. Group health plans for churches and houses of worship are fully exempt. The law also allows certain non-governmental employers, including private for-profit entities, to claim an exemption based on sincerely held religious beliefs or moral convictions.
The third significant exception involves short-term, limited-duration insurance plans, which are not considered minimum essential coverage under federal law. These plans typically have lower premiums but do not adhere to the same comprehensive coverage requirements as standard plans, often excluding contraceptive services entirely. Patients relying on one of these three types of exempt plans should expect to pay for the removal unless their specific policy voluntarily includes the benefit.
Actionable Steps to Confirm Coverage
Before scheduling the removal procedure, the most effective step is to directly contact the insurance provider to verify coverage specifics and prevent a surprise bill. The patient should call the number on the back of their insurance card and ask targeted questions to the representative. It is important to confirm that the specific clinic and healthcare provider are in-network for the procedure.
A crucial detail to verify is how the insurer covers the Current Procedural Terminology (CPT) code used for the removal. The common CPT code for a routine Nexplanon removal is 11982, and the patient should ask if this code is covered as a preventive service with zero cost-sharing. Asking for this specific code can help the representative confirm the exact benefit.
In the event the implant has migrated or is difficult to locate, the removal may be coded differently, often using a more complex surgical code such as 24200 or 24201. The patient should ask about coverage for a complex removal, as this may trigger a different billing process. This process potentially requires pre-authorization, where the provider obtains approval from the insurance company before the service is rendered.
Financial Options If Coverage is Not Available
If a patient determines their insurance plan will not cover the removal, several alternative financial pathways exist to access the procedure at a reduced cost. Federally funded centers, such as Title X family planning clinics and local health departments, often provide contraceptive services, including Nexplanon removal, on a sliding fee scale based on the patient’s income. This structure allows low-income individuals to receive the service for free or at a significantly discounted rate.
Organizations like Planned Parenthood also operate on similar principles, accepting most insurance plans while offering services at a reduced cost for uninsured or underinsured patients. Additionally, some pharmaceutical manufacturers offer patient assistance programs that may cover the cost of the removal procedure. Uninsured cash prices for a routine Nexplanon removal typically range from $100 to $300, depending on the clinic and geographic location.