Women’s Health

When can plans limit coverage of particular contraceptives?

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There are a number of ways that plans or employers can limit contraceptive services.  Federal law requires that ACA-compliant plans must cover at least one form of each the 18 FDA-approved contraceptive methods for women when prescribed. However, a plan may apply reasonable medical management techniques such as prior authorization or requiring you to try an alternative prescription first (step-therapy), and require cost-sharing for certain contraceptive drugs or devices to encourage use of specific services or items within a chosen FDA-approved contraceptive method. However, the plan must have a process in place to ensure that your particular contraceptive service or product is covered without cost sharing when your specific provider recommends it based on medical necessity.  In addition, you must get your contraceptive care from an in-network provider.  Insurers may require cost sharing if you go to an out-of-network provider for contraceptive care.

In addition, if your employer has a religious or moral objection to contraception, they can exclude coverage of all contraceptives or limit the types of contraceptives they will cover based on their religious or moral objections.  There is ongoing litigation about which employers are exempt and can exclude contraceptive services.

Short-term health insurance policies do not have to provide benefits required by the ACA and may not cover preventive services including contraceptive services.  Health care sharing ministries, which are membership groups usually affiliated with a religion that help members pay for health care (not insurance), are also not subject to ACA benefit requirements, including contraception.

While we have made every effort to provide accurate information in these FAQs, people should contact the health insurance Marketplace or Medicaid agency in their state for guidance on their specific circumstances.

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