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It has been a struggle for Stephanie Force to find a method of contraception she likes and can get without paying out of pocket, even though the Affordable Care Act promises free contraception for women and adolescent girls in most health plans.
The 27-year-old doctor-recruiter in Roanoke, Virginia, was completely satisfied with the NuvaRing, a flexible vaginal ring that women use monthly to release hormones to prevent pregnancy. But their insurer, Anthem, discontinued coverage of the branded product and switched to a generic version in early 2020. Force says the new product left her with a headache, irritability, and fluffiness.
After speaking to her gynecologist, Force tried an IUD. But it made her feel worse: She had bad cramps, gained 10 pounds, and developed severe hormonal acne. She was also billed $ 248 for an ultrasound that her doctor used to guide the insertion of the device, a fee she successfully tackled.
Force also looked at some of the contraceptives approved 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 isn’t covered by her employer’s health insurance, and she would owe a $ 45 copayment for Annovera.
Despite the Affordable Care Act’s guarantees of free contraceptive insurance, Force’s experience shows that even for women whose health plans are regulated by law, getting the right product for free can be a chore. New types of contraception are not automatically added to the state list of required methods that insurers use to make coverage decisions.
Additionally, some health plans continue to discourage the use of even long-established methods such as IUDs by requiring providers to obtain approval of the plan prior to prescribing.
Consumer advocates who have looked into the issue say that federal regulations set a procedure for women to get the contraception they need, but far too few people know it is an option. (See the last section below for more information.)
Ultimately, despite the side effects she continues to experience, Force reverted to the generic version of the NuvaRing. She would prefer to be on the branded NuvaRing, which didn’t cause her any problems, and method-to-method ping-ponging left her exhausted and angry.
“I can’t believe the tires I had to overcome between September 2020 and June 2021,” says Force, “between switching from the generic NuvaRing to the IUD and then back to battle my insurance and the obstetrician’s office over the ultrasound fee. “
In a statement, Anthem said, “Anthem’s health plans cover 222 contraceptives at a cost of $ 0 on our ACA preventive list.” The company said it covered “at least one product” in each of the 18 FDA-approved categories of birth control methods.
A policy designed to reduce the cost of contraception
Contraception is a very personal choice, and what meets one woman’s needs cannot meet another. When avoiding pregnancy is a top priority, a practically fail-safe method like an IUD can be the solution. But for someone considering getting pregnant soon, an easily reversible method like birth control pills might be the best option. Side effects should also be considered, as women react differently to the hormones in different contraceptives.
Before the Affordable Care Act (ACA) made free birth control mandatory, researchers estimate that up to 44% of women’s self-expenditure on health care was used for contraception. The ACA requires most commercial health plans to cover a comprehensive list of methods approved by the Food and Drug Administration without charging women anything.
Church plans and religious non-profit organizations, as well as employers and schools that reject contraception, are exempt from coverage. Plans that existed according to the law are also excluded. Even uninsured women do not benefit from the mandate.
But federal regulations don’t require health plans to cover every single contraceptive. Following the adoption by the Court of Auditors in 2010, the Federal Administration for Health Resources and Services (HRSA) developed guidelines for preventive services for women.
These guidelines state that women should have free access to a list that includes the 18 FDA-approved methods, including oral contraceptives, vaginal rings, cervical caps, IUDs, implantable rods, and sterilization. According to federal regulations, health insurance must cover at least one product in each category.
New products are left out
Neither the HRSA guidelines nor a birth control table published by the FDA addresses newer methods, including Phexxi, a gel that regulates the acidity of the vagina to reduce the chances of a sperm reaching an egg. It was approved by the FDA last year.
They also don’t include any FDA-cleared fertility detection cell phone apps in recent years like Natural Cycles, which track a woman’s temperature and menstrual cycle to help prevent pregnancy.
“There is a real need for new guidelines that keep up with new practices,” said Mara Gandal-Powers, director of birth control access at the National Women’s Law Center.
Many insurers have shied away from insuring Phexxi, says Rameshwari Gupta, director of strategic markets at Evofem Biosciences, which markets Phexxi. A box of 12 disposable applicators – consumers use one before sex – costs $ 267.50 without insurance, she says.
“When I started talking to payers, everyone was like, ‘Where are you on this FDA card?’ ” She says.
According to an FDA spokesman, birth control is for consumer education purposes only and “was not created with the intent to make decisions about coverage.” The agency is in the process of updating it.
In a statement, HRSA said it is reviewing the contraceptive evidence and expects to complete its review by the end of this year. If it chooses to revise it, it will publish draft recommendations to update the guidelines for women prevention services. These are finalized after a public comment period and come into force one year later.
At this point, health insurers are viewing Phexxi as a spermicide and only need to cover one type of spermicide at no cost, says Kristine Grow, senior vice president at AHIP, a health insurance trading organization.
“If Phexxi is indeed seen as a new method of contraception, both the FDA and HRSA would have to make this clear,” she added.
Cost sharing and pre-approval limit access to some methods
The vaginal ring Annovera, which was approved by the FDA in 2018, is usually covered by health insurance, according to Grow, although it may not be available for free. The average sales price according to GoodRx is $ 2,457 per year.
Plans have made it difficult for women to access certain contraceptives, even if they are on the list of approved methods, by requiring their providers to get approval from the insurer first, often by providing evidence that the product is medically necessary.
For example, according to UnitedHealthcare’s insurance policy for Phexxi, members must have documented reasons for not being able to use eight other methods of contraception, including oral contraceptives, the contraceptive patch, a vaginal ring, injections, and spermicides, prior to approval of coverage. Providers must also confirm that they advised patients that Phexxi is less effective at preventing pregnancy than some other methods.
In a statement, UnitedHealthcare says it covers “a wide range” of generic and branded names, and it is following scientific evidence to develop its list.
However, according to a report by the National Women’s Law Center, consumers have a way to get the method that is most suitable for them.
How to cover a method of contraception
If a doctor or other health care provider determines that a patient needs a particular contraceptive even if it is not on the list of approved devices for the patient plan, federal regulations require the insurer to put in place an appropriate process for finding the patient for a waiver.
“It’s not up to the insurance company to cover this method – it’s up to the provider,” said Adam Sonfield, editor-in-chief of 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 the requirement, and government agencies are not enforcing these so-called exemptions.
When patients have difficulty finding the method they want, “we usually recommend filing a complaint with their health insurance company,” said 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 procedure that would allow her to cover the NuvaRing without paying the cost. Neither her doctor nor the insurer mentioned the possibility.
She recently had an appointment with a new vendor that she hopes will make a better lawyer for her.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health topics.