Some of the nation’s largest insurers and pharmacy benefit managers (PBMs) impose coverage exclusions and other restrictions on birth control products, contrary to an Affordable Care Act (ACA) requirement, according to a House investigation.
Under the ACA, health plans must cover Food and Drug Administration-approved contraceptive products without cost-sharing. But a staff report from the Democrats on the House Oversight and Reform Committee found insurers and PBMs required patients to pay some of the cost or otherwise limited coverage of more than 30 birth control products.
The investigation also found that companies denied many exception requests.
“In the wake of the extreme Supreme Court decision to overturn Roe v. Wade, the ability to decide if and when to become pregnant has never been more important,” House Oversight and Reform Committee Chairwoman Carolyn Maloney (D-N.Y.) said in a statement. “I urge the Administration to further update their guidance to address the concerns identified in this report.”
The law requires each plan or issuer to cover without cost-sharing at least one form of contraception in each of the 18 categories of Food and Drug Administration-approved contraceptive methods, as well as methods deemed medically appropriate by a health provider.
Patients seeking to access contraceptive products that are either excluded from coverage or subject to cost-sharing requirements must submit claims through an exceptions process so that the company can evaluate whether to waive patient cost-sharing or the coverage exclusion.
The investigation found the majority of companies reported denying an annual average of at least 40 percent of exception requests for contraceptive products from 2015 through 2021.
For patients who need to use a different contraceptive product, the 2015 guidance stated that plans and issuers must have “an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual or a provider.”
Committee staff looked at five of the nation’s largest health insurers and four of the largest pharmacy benefit managers, the drug middlemen who handle claims for big insurers and help negotiate drug prices with manufacturers.
The investigation identified 34 different contraceptive products that the majority of companies exclude from coverage or require cost-sharing on at least one plan or formulary. The investigation also showed that insurers and PBMs excluded or imposed cost-sharing requirements on about half of contraceptive products approved by the Food and Drug Administration (FDA) after 2011.
Many contraceptive products approved after 2011 reflect recent innovations and provide alternatives to traditional contraceptives, including long-term effectiveness and products with lower hormone levels and different estrogen formulations to help mitigate side effects and negative medication interactions.
The report found that of the 17 products for which health plans and PBMs reported having cost-sharing requirements or formulary exclusions — none of which have therapeutic equivalents — at least five “provide particular clinical benefit to patients with distinct health care needs.”
Four of these products are non-pill methods, which are disproportionately used by non-white patients and patients with less income. There are generally fewer products available in non-pill contraceptive categories, and the investigation found that many of those non-pill methods are excluded from coverage or require cost-sharing.
In addition to raising barriers to access specific products, exclusions and cost-sharing requirements undermine efforts to ensure equitable access to convenient contraception. Research indicates that Black and Hispanic individuals are less likely to use birth control pills for contraception than white individuals, and people with incomes below the federal poverty level use implants at higher rates.
The staff report recommended that the administration issue guidance clarifying that all FDA-approved contraceptive products that do not have a generic equivalent should be covered without cost-sharing as part of every plan or formulary. It also recommended making exceptions automatic at the point of prescribing.
