An Insider’s Look at Why Some Contraceptives get Coverage, Others Don’t & How to Navigate

By: Craig Spears, Afaxys’ Senior Director Market Access

Sexual and reproductive healthcare is vast and complex with many regulations and constantly shifting variables that can make it intimidating to navigate when it comes to costs and insurance coverage. To help guide you on your healthcare journey, I’m pulling back the curtain on market access and giving you an inside look into the various factors influencing contraceptive coverage. 

Coverage Variability

With millions of U.S. women relying on private insurance coverage and an estimated 20.6 million U.S. women relying on publicly funded contraceptive services and supplies, it’s important to understand the variables that may impact coverage – and there are many.

Once a drug or device is clinically studied, created, approved by the U.S. Food and Drug Administration (FDA), and on the market, it’s up to insurance companies whether it gets covered or not. A few factors impacting this decision include:

• Safety and Efficacy – Insurance may cover the new product if it is more effective than currently available treatment options or features a better safety or side effect profile.
• Ease of Use and Flexibility of Choice – Since there is not one single contraceptive option that meets the needs of all women, insurance needs to cover multiple options.
• Cost to Patient, Provider, and Payer – An insurer may seek to obtain lower acquisition costs through the establishment of a rebate agreement with the product’s manufacturer.
• Pharmacy & Therapeutics (P&T) Committee Evaluations – An insurer’s P&T Committee is composed of doctors and pharmacists that evaluate clinical, safety, efficacy, and outcomes of therapies and pharmacy operations and manage the formulary system – the list of drugs covered by an insurance plan.

Additionally, the Affordable Care Act (ACA) stipulates that plans in the Healthcare Marketplace^®* must cover FDA-approved contraceptive methods and counseling. States across the U.S. interpret this law differently, which results in coverage variability. For example, one state may cover both the generic and branded version of a contraceptive product, while another may cover just the generic option.

*A place to obtain health insurance if you don’t have health insurance through an employer. In such a situation, a government program such as Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), or another source provides qualifying health coverage.

What to do if Your Contraception Isn’t Covered 

Due to the complicated nature of insurance coverage, you may find yourself in a situation where your preferred contraception isn’t covered by your insurer. If that happens, there are a few avenues you can take:

• Patient Assistance Programs – Many manufacturers offer patient assistant programs to help minimize out of pocket costs. Check out the manufacturer’s website or call them to see if you’re eligible for the program.
• Letter of Medical Necessity – Your doctor can write a letter of medical necessity and submit it to your insurer.
• Advocacy – You can also get involved with advocacy groups working toward greater contraceptive coverage.

No matter which option you choose, always consult with your doctor on any contraceptive-related matters first.

The Importance of Accessibility and Affordability

Guttmacher reported that the number of women who likely need public support for contraceptive care increased by 25% over the past 16 years, rising from 16.4 million women in 2000 to 19.1 million in 2010 and to 20.6 million women in 2016. The extent of the increase has varied over time, as well as across social and demographic groups.

Afaxys is deeply committed to our essential role as a leading provider of oral and emergency contraceptives to U.S. community and public health centers and the patients they serve. It is more important now than ever that contraception is accessible and affordable to all, regardless of race, sexuality, income, or zip code. Access to affordable sexual and reproductive care gives women control over if and when they become pregnant and affords them multifold and well-established benefits. It’s imperative that women across the U.S. have the information necessary to make the best decisions for their individual needs, allowing them to chart their own path, and gain control over their lives, including their personal and economic futures.