New methods of contraception may be more difficult to cover with insurance:
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For Stephanie Force, finding a contraceptive method that she loves and can get without paying out of pocket has been a struggle, despite the Affordable Care Act’s promise of free contraceptives for women and adolescents in most places. health plans.
The 27-year-old doctor recruiter in Roanoke, Va., Was perfectly happy with the NuvaRing, a flexible vaginal ring that women insert monthly to release hormones to prevent pregnancy. But her insurer, Anthem, stopped covering the branded product and replaced it with a generic version in early 2020. Force says the new product left her with headaches and feeling irritable and angry.
After talking to his OB-GYN, Force tried an IUD. But it made her feel worse: she had bad cramps, gained 10 pounds, and developed severe hormonal acne. Additionally, she was billed $ 248 for an ultrasound used by her provider to guide insertion of the device, a charge she successfully fought.
Force has also reviewed a few approved contraceptive products in recent years: a non-hormonal vaginal gel called Phexxi and a vaginal ring called Annovera that can be used for a year. But Phexxi is not covered by her employer’s health plan, and she is owed a $ 45 co-payment for Annovera.
Despite the Affordable Care Act guarantees for free contraceptive coverage, Force’s experience shows that even for women whose health plans are subject to legal requirements, getting the right product at no cost can be expensive. New types of contraceptives are not automatically included in the federal list of required methods that insurers use to guide coverage decisions.
In addition, some health plans continue to discourage the use of even long-established methods, such as IUDs, by requiring providers to obtain plan approval before prescribing them.
Consumer advocates who have studied the issue say there is a process set out in federal rules for women to get the contraceptives they need, but far too few people know that is an option. (For more on how to do this, see the last section below.)
In the end, Force returned to the generic version of NuvaRing, despite the side effects she continues to experience. She would rather be on the branded NuvaRing, which was okay with her, and the ping-pong method to method left her exhausted and furious.
“I can’t believe the hurdles I had to go through between September 2020 and June 2021,” Force said, “between switching from generic NuvaRing to IUD and then battling my insurance and the office of OB-GYN on ultrasound fees. “
In a statement, Anthem said, “Anthem’s health plans cover 222 cost-sharing $ 0 contraceptive products on our ACA preventive list.” The company went on to say that it covered “at least one product” in each of the 18 categories of FDA-approved contraceptive methods.
A policy aimed at reducing the costs of contraceptives
Contraception is a very personal choice, and what meets one woman’s needs may not meet another’s. If preventing pregnancy is a woman’s top priority, a nearly foolproof method like an IUD may be the answer. But for someone who is planning to get pregnant soon, an easily reversible method like a birth control pill might be the best option. Side effects are also important to consider, as women react differently to hormones in various contraceptive products.
Before the Affordable Care Act (ACA) required free birth control coverage, researchers estimate that up to 44% of women’s direct health care spending was on contraceptives. The ACA requires that most commercial health plans cover a full list of methods approved by the Food and Drug Administration without charging women anything.
Plans from church and nonprofit religious organizations, as well as employers and schools that oppose contraception, are exempt from coverage requirements. Plans which benefited from acquired rights under the law are also exempt. Uninsured women also do not benefit from the mandate.
But federal rules don’t require health plans to cover every contraceptive. After the adoption of ACA in 2010, the Federal Administration of Resources and Health Services (HRSA) developed guidelines for preventive services for women.
These guidelines say women should have cost-free access to a list that covers all 18 FDA-approved methods, including oral contraceptives, vaginal rings, cervical caps, IUDs, implantable rods, and sterilization. Under federal rules, health plans must cover at least one product in each category.
New products are left out
Neither the HRSA guidelines nor a birth control chart released by the FDA address newer methods, including Phexxi, a gel that regulates vaginal acidity to reduce the chances of a sperm reaching an egg. It was approved by the FDA last year.
They also don’t incorporate fertility awareness mobile phone apps approved by the FDA in recent years, such as Natural Cycles, which tracks a woman’s temperature and menstrual cycle to prevent pregnancy.
“There is a real need for new guidelines that follow new methods,” says Mara Gandal-Powers, director of access to birth control at the National Women’s Law Center.
Many insurers have been reluctant to cover Phexxi, says Rameshwari Gupta, director of strategic markets for Evofem Biosciences, which markets Phexxi. A box of 12 single-use applicators – consumers use one before having sex – costs $ 267.50 without insurance, she says.
“When I started talking to payers, they all said, ‘Where are you on that FDA chart? ” ” she says.
According to an FDA spokesperson, the birth control chart is for consumer education purposes only and “was not created with the intention of making coverage decisions.” The agency is updating it.
In a statement, the HRSA said it is reviewing the evidence on contraceptives and plans to complete its review later this year. If it chooses to make revisions, it will issue draft recommendations to update the guidelines on preventive services for women. These will be finalized after a public consultation period and will come into effect one year later.
At this point, health plans see Phexxi as a spermicide and should only cover one type of spermicide without cost sharing, says Kristine Grow, senior vice president of AHIP, a commercial health insurance organization.
“If Phexxi is indeed considered a new method of contraception, the FDA and HRSA should clarify,” she added.
Cost sharing and pre-approvals limit access to some methods
The Annovera vaginal ring, approved by the FDA in 2018, is generally covered by health plans, according to Grow, although it may not be available without cost sharing. The average retail price is $ 2,457 per year, according to GoodRx.
One of the ways the plans have made it difficult for women to access certain contraceptives, even those on the approved drug list, is to require their providers to first obtain approval from the insurer, often by providing documents certifying that the product is medically necessary.
Under UnitedHealthcare’s coverage policy for Phexxi, for example, before coverage is allowed, members must have documented reasons why they cannot use eight other contraceptive methods, including oral contraceptives, the patch contraceptive, a vaginal ring, injections and spermicides. Providers must also certify that they have informed patients that Phexxi is less effective in preventing pregnancy than some other methods.
In a statement, UnitedHealthcare says it covers “a wide range” of generic and branded options, and is following scientific evidence to grow its list.
Still, consumers have a way to get the specific drug that’s best for them, according to a report from the National Women’s Law Center.
How to get a birth control method covered
Under federal rules, if a doctor or other health care provider determines that a patient needs a particular contraceptive, even if they are not on the list of approved products for the patient’s plan, the The insurer is required to have a quick process for the patient to seek a waiver.
“It’s not up to the insurance company to cover this method – it’s up to the provider,” says Adam Sonfield, senior editor for policy analysis at the Guttmacher Institute, a research and advocacy organization focused on women’s reproductive health.
But according to the National Women’s Law Center report, many insurers, patients and their providers are unaware of this requirement, and state agencies are not enforcing these so-called exception policies.
If patients are having difficulty getting the method they want, “we usually recommend that you appeal to their insurer,” says Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center. .
Stephanie Force says she was not aware of any process she could have used to cover the NuvaRing without cost sharing. Neither his health care provider nor the insurer mentioned the possibility.
She recently had a date with a new supplier who she hopes will be a better advocate for her.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues.