Health Insurance

Health Insurance Coverage for Birth Control

Health Insurance Coverage for Birth Control

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The Patient Protection and Affordable Care Act, popularly known as Obamacare, requires health insurers to cover preventive health services with no co-pays, deductibles or other cost-sharing. Shortly after the passage of the law, a panel of medical experts recommended including contraceptives as preventive care, and the Obama administration agreed. This led to a common expectation that all birth control would be free under the new law. Once the contraceptive mandate took hold, the reality was somewhat different, with many women discovering they still had to pay out-of-pocket for their contraception, and some options were not covered at all.

Is Birth Control Covered by Insurance?

Yes, certain categories of birth control and contraceptives have at least one option covered for free. After reports from women’s health advocates, including the Kaiser Family Foundation and the National Women’s Law Center, the Obama administration issued additional guidance in May 2015, clarifying that at least one type of contraception in each of the FDA-approved methods must be offered to women at no cost.

As of May 2015, the methods of contraception health insurers had to cover with at least one free option within 60 days included the following:

  • Sterilization surgery
  • Surgical sterilization implant
  • Implantable rod
  • IUD copper
  • IUD with progestin
  • Shot/Injection
  • Oral contraceptives (combined pill)
  • Oral contraceptives (progestin only)
  • Oral contraceptives (extended/continuous use)
  • Patch
  • Vaginal contraceptive ring
  • Diaphragm
  • Sponge
  • Cervical Cap
  • Female condom
  • Spermicide
  • Emergency contraception (Plan B/Plan B One Step/Next Choice)
  • Emergency contraception (Ella)

The interpretation appeared in headlines like this one from Time.com: “Now You Can Really Get Free Birth Control Under Obamacare.”

Many women still will not.

The Cost of Birth Control in Health Insurance

The May 15 guidance from the federal government reiterated that “plans and issuers may use reasonable medical management techniques to control costs and promote efficient delivery of care, such as covering a generic drug without cost sharing and imposing cost sharing for equivalent branded drugs.” In other words: they can still require women to pay for some, or even all, of the costs of their contraception, if the type they use is not among those the plan covers cost-free.

As mentioned above, insurance plans must cover at least one type of birth control in each of the methods listed above for free, but for some methods, notably oral contraceptives, more than a hundred different versions are available. In theory, a plan could comply with the law by covering just one option in each oral contraceptive method (combined birth control pill, progestin only, extended/continuous use).

We examined various insurance plans’ coverage of oral contraceptives and found that they generally offered far more than one zero-cost option within each method (when there were many available types). But there were significant differences from one plan to the next.

For example: Among silver plans available to residents of Houston, through the Texas health insurance exchange:

Community Health Choice plans cover 23 different oral contraceptives with no cost sharing. Blue Cross Blue Shield of Texas plans cover 33 for free. United Healthcare plans offer 51. Aetna plans waive costs for 72. Molina and Cigna plans offer more than 100 each.

Another example: for the silver plans available to consumers living in San Francisco, CA, through Covered California, the state-run health insurance exchange:

Kaiser Permanente’s formulary (that is, their list of covered drugs) offers nine options, all generic versions of popular oral contraceptives. Health Net covers all generics for free. The Chinese Community plan includes 23 types of oral contraceptives. Both Anthem BlueCross and Blue of California cover more than 100 versions.

Generics of the Most Common Pills Are Typically Covered

The most popularly prescribed oral contraceptive formulations were typically covered by all plans, at least in a generic form. According to data from IMS Health, the most prescribed oral contraceptives and pills in the U.S. in 2014 were:

  • Sprintec 28; 5.6 million prescriptions
  • Tri-Sprintec 28; 4.5 million prescriptions
  • Lo Loestrin FE; 3.3 million prescriptions
  • Trinessa-28; 3.1 million prescriptions
  • Ortho-Tri-Cyclen Lo; 2.9 million prescriptions
  • Gildess FE; 2.9 million prescriptions
  • Microgestin FE ½; 2.7 million prescriptions
  • Minastrin 24 FE; 2.6 million prescriptions
  • Norgestimate/Ethinyl Estradiol; 2.6 million prescriptions

An additional 66 million prescriptions were written for women for other hormonal contraceptives in 2014, including those delivered other ways such as through a ring or a patch, for a total of nearly 97 million such prescriptions.

After the contraceptive coverage mandate went into effect, in late 2012, thousands of women did stop paying copays for their contraception. Before its implementation, about 85 percent of privately insured women using a contraceptive pill had out-of-pocket costs. By the spring of 2013, just 60 percent still had to chip in, according to research by the Guttmacher Institute, a non-profit which covers reproductive health.

At that point, more than half of women using those kinds of contraception (who make up about 28 percent of all female contraceptive users, according to Guttmacher) were still paying out of pocket.

How to Get Your Contraception Fully Covered

Since the specifics of insurance coverage vary wildly from state to state and plan to plan, you need to call your insurer, using the number on the back of your card, and ask if your preferred contraception is covered with no cost-sharing. If it’s not, ask which types are.

Next, make an appointment with your prescribing doctor to discuss the options. You may be able to get a different generic version of your desired contraception covered with no hassle, because it’s already on your insurer’s formulary with zero cost-sharing.

But, if you want to use a type that isn’t offered for free, perhaps because you’ve been on it for years with no problems and don’t want to switch, try the following approach.

Your insurance company must also cover, at no cost to you, any contraception your doctor deems medically necessary for you. This could be because other types cause severe side effects, are more or less permanent or reversible, or are harder for you to adhere to. The catch is: your doctor must communicate your medical need to the insurance company which is required to offer an easy way for the doctor to do so. Ultimately, the doctor’s decision determines the coverage.

In short: your doctor has to go to bat for you.

Keep in mind that your insurer must also cover, without a copay, all the medical visits you need to get your contraception and any follow-up care. However, you must use in-network doctors and pharmacies to ensure they’ll pay up.

If you opt to use one of the covered methods of contraception which happens to be available over the counter, such as spermicide or female condoms or some types of emergency contraception, you must still get a prescription for it from your doctor if you want insurance to pay for it. That’s how the law is written. Though you could walk into a pharmacy and pick up any of these OTC options on a moment’s notice, you will have to pay for it out of pocket and won’t be reimbursed by your insurance company.

Despite your most diligent efforts, you could still end up paying for your birth control if you fall through one of the remaining cracks in the contraceptive mandate (like if your health insurance is from an employer with a religious exemption). But, if it’s important to you to avoid out-of-pocket costs, take the time to find out about your insurance company’s coverage and take the steps required to get your contraception for free.

Sterling Price

Sterling Price is a research analyst at ValuePenguin specializing in health and life insurance. He graduated from Syracuse University with a bachelors degree in Finance and Accounting and has previous experience as a licensed life insurance representative.

Editorial Note: The content of this article is based on the author’s opinions and recommendations alone. It has not been previewed, commissioned or otherwise endorsed by any of our network partners.