Coverage of Contraceptive Services: A Review of Health Insurance Plans in Five States

This analysis finds that there is variation in how the ACA’s contraceptive coverage requirement is being interpreted and implemented by health plans. While most carriers are complying with the spirit of the contraceptive coverage requirement, there are some exceptions that appear to be attributable to the carriers’ interpretations of the HHS regulations. In particular, some of the plans did not differentiate between similar hormonal formulations that had different delivery mechanisms, i.e., oral contraceptives, patches and vaginal rings. Because of this variation across plans, some women may not have coverage without cost-sharing to the contraceptive method of their choice. This practice does not support the current quality guidelines for family planning issued by the CDC and the federal HHS Office of Population Affairs.

The most commonly employed RMM limitation is offering preferred coverage of generics with no cost-sharing. Of the specific contraceptives studied for which a generic is available, the EC pill Plan B and the patch, carriers are less likely to also cover the brand version. Twice as many carriers cover the generic patch Xulane with no cost-sharing and no RMM limitations compared to the brand OrthoEvra patch. Xulane first became available in 2014, so it is possible that more plans will cover the generic in 2015 and, notably, in October 2014 the distribution of the OrthoEvra patch was discontinued. In addition, 16 carriers cover generic Depo-Provera injection with no cost-sharing and no RMM, but only 6 cover the brand Depo-Provera injection. While nearly all carriers (19 carriers) cover at least one generic progestin-based emergency contraceptive pill (equivalent to Plan B) with no cost-sharing, only five cover the brand Plan B.

When a generic alternative is not available, many carriers cover all the available alternatives, but some plans don’t. For example, at the time the study was conducted there were only three brand-name IUDs approved by the FDA. Ten of the carriers in the study cover all three IUDs with no cost-sharing. One carrier does not cover ParaGard at all which is the only non-hormonal IUD available to women. Similarly, 10 carriers cover both of the brand implants Implanon and Nexplanon with no cost-sharing and no RMM limitations, but two carriers do not cover either brand of implant even with cost-sharing.

Notably, NuvaRing is not available as a generic and seven of the carriers interviewed apply RRM limitations and/or cost-sharing to the NuvaRing. Their rationale is that the chemical compounds are the same as other covered forms of contraception that are covered with no RMM limitations and no cost-sharing. Essentially, these carriers do not consider different delivery mechanisms that use the same active ingredients to constitute a separate and distinct form of FDA-approved contraceptive. This can also limit coverage without cost-sharing to implants and contraceptive patches.

The ella emergency contraceptive pill does not have a generic equivalent. Six carriers do not make ella available without cost-sharing and two carriers do not cover ella at all. We were not able to determine one carrier’s cost-sharing for ella. This is of potential concern given recent findings that ella has a longer time window of effectiveness and may be a more preferable choice than Plan B or the generic equivalents to Plan B for women with higher BMIs.

All carriers interviewed reported that IUD and implant coverage includes the office visits necessary for insertion and removal with no cost-sharing. Likewise, carriers include the office visit for injections. However, this policy was not clearly reported or documented in all plan materials. In addition, there is considerable uncertainty about the extent to which ancillary services associated with female sterilization, such as anesthesia or follow up care, would be covered with no cost-sharing.

Despite significant national attention to the availability of a religious accommodation, the carriers reported that very few employers using their plans elected the accommodation. Carriers did not identify difficulties in implementing the accommodation and none of the carriers with self-funded lines of business anticipate seeking reimbursement through a reduction in the fees they pay the Federally Facilitated Marketplace.

One of the cross-cutting findings of this analysis was how difficult it is to ascertain the limits on contraceptive coverage used by different carriers. The contraceptive coverage policies used by health insurance carriers were not easily accessible. Many carriers we approached for this project were unwilling to participate in an interview; only 9 out of 24 carriers invited agreed to be interviewed. Furthermore, the individuals that did participate in interviews, such as medical directors, pharmacy care managers, public policy executives, attorneys and others, were sometimes unable to respond to the full range of contraceptive topics addressed in this study. This information is even more opaque in many of the plan materials available to policyholders. Many of the publicly available documents do not clearly identify plan coverage rules when it comes to how different contraceptive methods are covered and the limitations of the coverage. This makes it extremely difficult, if not impossible for women in some plans to ascertain their coverage options. This also makes it difficult for women to determine coverage while comparing plans during open enrollment.

The current regulations and FAQs subsequently issued by HHS do not specifically proscribe how plans should implement this coverage and allow plans to apply their own definitions of reasonable medical management. In response to concerns registered by women experiencing both coverage denials and cost-sharing for FDA-approved methods such as the contraceptive ring and patch, the California State Legislature passed the Contraceptive Coverage Equity Act of 2014 that was signed by Governor Jerry Brown in October 2014. This new law requires plans to cover prescribed FDA-approved contraceptives without cost-sharing. The law specifies that a plan does not have to cover more than one therapeutic equivalent of a contraceptive drug, device, or product, as long as at least one is covered without cost-sharing. Contraceptives with the same chemical formulation and delivery mechanism are therapeutically equivalent. Starting in January 2016, plans in California will be required to cover the vaginal ring, patch and birth control pills even if they have the same chemical formulation, because these methods have different delivery mechanisms. While plans must cover alternative methods/products without cost sharing, when a contraceptive product that is covered by the plan is not available or is deemed medically inadvisable by the enrollee’s provider, plans may apply utilization management (e.g. step therapy or prior authorization).

For many women, the ACA’s contraceptive coverage provision has reduced their health care out-of-pocket costs and given them the opportunity to use more effective but more costly methods of contraception that had been unaffordable to them in the past. This report finds that there is variation in how insurance carriers are interpreting the guidelines for contraceptive coverage issued by HHS, and that not all FDA-approved methods may be covered without cost-sharing to women policyholders. The CDC and the Office of Population Affairs have clearly stated that offering women the full range of FDA-approved contraceptive methods is an element of high quality family planning services and emphasizes the importance of contraceptive choice in reducing women’s risk of unintended pregnancy. For many women with private insurance, this range of options is now a reality, for some however, their choice of plan may still result in limitations of their contraceptive options.