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Coverage of Contraceptive Services: A Review of Health Insurance Plans in Five States

Coverage of Select Contraceptive Methods

Vaginal Ring

Vaginal RingThe vaginal ring is a hormonal contraceptive method in the form of a small, flexible ring that is inserted vaginally by a woman once every three weeks, and then removed and discarded for the remaining week each month. Currently, the NuvaRing is the only FDA-approved vaginal ring. The NuvaRing functions by releasing estrogen and progestin, the same hormones in the combination birth control pill. The NuvaRing is effective for three weeks, and has a typical use failure rate of 9%, meaning the percentage of women who experience an unintended pregnancy within the first year of using the contraceptive method. One NuvaRing (which lasts for 30-days) costs between $15 to $80 per month.

Findings
  • Twelve carriers of the 20 we reviewed cover NuvaRing, placing no RMM limitations or no cost-sharing requirements to policyholders (Table 2). One additional carrier does not require cost-sharing, but applies step therapy; the member must have tried or experienced intolerance to at least two generic oral contraceptives in the previous 180 days and provide documentation for why an oral contraceptive cannot be used.
  • Three carriers cover NuvaRing, but charge cost-sharing. One of these carriers specified the rationale for the decision was that they have determined that contraceptives with the same progestin are equivalent to each other without regard to the delivery method. The carrier covers a birth control pill with no cost-sharing, and therefore charges cost-sharing for the NuvaRing, which has the same chemical composition as some birth control pills. One additional carrier requires both cost-sharing and prior authorization to show medical necessity on why formulary oral contraceptives are not suitable before they will cover the NuvaRing. One carrier does not cover NuvaRing at all.
Table 2: Carriers Covering NuvaRing by Cost-Sharing Requirement and RMM Limitations
NuvaRing Coverage NuvaRing
Covered with no RMM limitations and no cost-sharing 12
Covered with prior authorization and no cost-sharing
Covered with step therapy and no cost-sharing 1
Covered with cost-sharing but no RMM limitations 3
Covered cost-sharing unknown 1
Covered with prior authorization/step therapy and cost-sharing 2
Not covered 1
NOTE: 20 carriers were reviewed.
Contraceptive Patches

Contraceptive PatchesBirth control patches are applied topically and stick directly on the skin, releasing estrogen and progestin into the bloodstream. A new patch is applied once a week for three weeks, followed by one patch-free week. The patch may be less effective for overweight women, and though the typical use failure rate is 9%, it may be higher for women whose weight is at or over 198 pounds.1

Three patches (a 30-day supply) costs about $15 to $80. Until recently, OrthoEvra was the only patch available. The generic patch, Xulane, became available in April,2014. Since we started this study, Janssen Pharmaceuticals, the manufacturer of the OrthoEvra patch has discontinued production of the patch. Going forward, the generic alternative will be the only patch available.

Findings

We found that birth control patches are not covered by some carriers who use the rationale that it is the same chemical composition also available in generic birth control pills that are less expensive; some carriers use the same rationale to limit coverage of the NuvaRing.

  • OrthoEvra: Seven carriers cover the OrthoEvra patch with no RMM limitations and no cost-sharing (Table 3). Another carrier covers the OrthoEvra patch with no cost-sharing and requires prior authorization. Five carriers cover OrthoEvra with no RMM limitations but require cost-sharing. Five carriers do not cover OrthoEvra.
  • Generic patch (Xulane): We found that 14 carriers cover the generic patch with no RMM limitations and no cost-sharing. Three carriers cover the generic patch with no RMM limitations but require cost-sharing. One carrier does not cover the generic patch.
  • Six carriers cover both the generic and brand patches with no cost-sharing and no RMM limitations. Nine carriers cover either the generic or brand patch with no cost-sharing and no RMM limitations. In total, 15 carriers cover at least one type of patch without cost-sharing or RMM limitations.
Table 3: Carriers Covering Patches by Type, Cost-Sharing Requirement and RMM Limitations
Patch Coverage Xulane (Generic) OrthoEvra
Covered with no RMM limitations and no cost-sharing 14 7
Covered with prior authorization and no cost-sharing 1
Covered with step therapy and no cost-sharing
Covered with cost-sharing and no RMM limitations 3 5
Covered cost-sharing unknown 1 1
Covered with prior authorization/step therapy and cost-sharing
Not covered 1 5
Unknown* 1 1
NOTE: 20 carriers were reviewed. *Individuals participating in interviews were unable to respond or information was not included in plan documents.
Injections

Medication SyringeThe birth control injection is a shot administered typically in the arm by a clinician in a clinic or out-patient setting once every three months. The shot releases the hormone DMPA, a progestin, to prevent pregnancy. The typical use failure rate for the injection is 6%. The brand-name Depo-Provera is an intramuscular injection, while Depo-subQ Provera 104 is a newer, brand-name subcutaneous injection. The formulation for the Depo subQ Provera 104 injection provides slower and more sustained absorption of the progestin than intramuscular Depo-Provera. This enables a lower dose of progestin (104 mg versus 400 mg) and reduces peak blood levels by half, but with the same duration of effect as conventional intramuscular Depo-Provera. In addition to the lower dose, subcutaneous administration can be less painful than intramuscular injection. There is a generic equivalent for Depo-Provera, but not Depo-subQ Provera 104. One injection lasts for three months and costs $35 to $100 (excluding office exam fees).

Findings
  • Depo-Provera: Six carriers cover brand Depo-Provera with no RMM limitations and no cost-sharing (Table 4). One additional carrier requires a prior authorization. Three carriers cover Depo-Provera with cost-sharing and no RMM limitations. Eight carriers do not cover Depo-Provera. Three of the carriers that do not cover Depo-Provera, or cover it with cost-sharing, indicated that the generic is covered with no cost-sharing.
  • Generic for Depo-Provera: Sixteen carriers cover the generic Depo-Provera without cost-sharing. One carrier covers the generic Depo-Provera with cost-sharing and without RMM limitations, while another carrier covers it but requires cost-sharing as well as prior authorization.
  • Eighteen carriers cover either Depo-Provera or its generic, without cost-sharing or RMM limitations.
  • Depo-subQ Provera 104: Seven carriers cover Depo-subQ Provera 104 with no RMM limitations and cost-sharing. Five carriers cover it with cost-sharing. Another six carriers do not cover Depo-subQ Provera .
  • Overall, three carriers cover all three injections and six carriers cover the brand-name or generic Depo-Provera, as well as Depo-subQ Provera 104.
Table 4: Carriers Covering Injections by Type, Cost-Sharing Requirement, and RMM Limitations
Injection Coverage Generic Depo-Provera Depo-Provera Depo-subQ Provera 104
Covered with no RMM limitations and no cost-sharing 16 6 7
Covered with prior authorization and no cost-sharing 1
Covered with step therapy and no cost-sharing
Covered with cost-sharing and no RMM limitations 1 3 5
Covered cost-sharing unknown 2 1 1
Covered with prior authorization/step therapy and cost-sharing 1
Not covered 8 6
Unknown* 1 1
NOTE: 20 carriers were reviewed. *Individuals participating in interviews were unable to respond or information was not included in plan documents.
Implants

ImplantA contraceptive implant is a thin, plastic hormone- releasing rod that is inserted under the skin of a woman’s arm by a health care provider. Implanon and Nexplanon, the brand name implants, are each effective for three years and work by releasing progestin into the body. Nexplanon is newer than Implanon and is designed to be visible through x-ray, CT scan, ultrasound scans, or MRI, and has a different applicator. Both implants are long-acting reversible contraceptives and have the lowest typical use failure rate of all FDA-approved contraceptives at .05%. After use, implants must be removed by a provider in a clinic or outpatient setting. Implants cost $400 to $800 (excluding exam fees).

Findings
  • Eleven carriers cover Implanon and 10 cover Nexplanon with no RMM limitations and no cost-sharing (Table 5). One additional carrier requires prior authorization for both Implanon and Nexplanon. Four carriers do not cover Implanon and three carriers do not cover Nexplanon.
  • Ten carriers cover both implants with no cost-sharing and no RMM limitations. One carrier covers only one implant with no cost-sharing and no RMM limitations. In total, 11 carriers cover at least one implant. Two carriers do not cover either Implanon or Nexplanon even with cost-sharing. For four carriers, we were unable to ascertain coverage for either implant.
Table 5: Carriers Covering Implants by Type, Cost-Sharing Requirement, and RMM Limitations
Implant Coverage Implanon Nexplanon
Covered with no RMM limitations and no cost-sharing 11 10
Covered with prior authorization and no cost-sharing 1 1
Covered with step therapy and no cost-sharing
Covered with cost-sharing and no RMM limitations
Covered cost-sharing unknown 2
Covered with prior authorization/step therapy and cost-sharing
Not covered 4 3
Unknown* 4 4
NOTE: 20 carriers were reviewed. *Individuals participating in interviews were unable to respond or information was not included in plan documents.
Intrauterine Devices (IUD)

IUDAlong with implants, intrauterine devices (IUDs) fall under the category of long-acting reversible contraceptives (LARCs). IUDs are plastic T-shaped contraceptives that are inserted into the uterus by a health care provider. There are two types of IUDs available in the United States, hormonal and copper. Currently, there are two hormonal IUD’s on the market – Mirena and Skyla – and a third hormonal IUD Liletta was approved by the FDA in February 2015. While both Mirena and Skyla release progestin, Mirena releases slightly more progestin per day into the body, is slightly larger, and is effective for up to five years compared to Skyla, which is effective for up to three years. The typical use failure rate for Mirena is .2%, and .9% for Skyla.

The copper IUD is non-hormonal and goes by the brand name ParaGard. It prevents pregnancy by preventing sperm from reaching and fertilizing the egg, and possibly by preventing the egg from attaching in the uterus. It is effective for up to 10 years, has a typical use failure rate of .8% and can be used as emergency contraception up to five days after unprotected sex or contraceptive failure. All IUD’s must be removed by a health care provider in a clinic or outpatient setting. IUDs cost between $500 and $1,000 (excluding exam fees).

IUDs are typically inserted in a physician’s office or other outpatient setting. One carrier noted that IUDs can be expensive for doctors to purchase and stock in their offices. Doctors who do not stock IUDs can obtain them “on demand” from a specialty pharmacy, but this may require that women come back to the provider for a second visit.

Findings
  • Hormonal IUDs, Mirena and Skyla: Thirteen carriers cover Mirena with no RMM limitations and no cost-sharing (Table 6). One additional carrier requires prior authorization and no cost-sharing. Ten carriers cover Skyla with no RMM limitations and no cost-sharing. One additional carrier requires prior authorization and no cost-sharing. Three carriers do not cover Skyla. Ten carriers cover both hormonal IUDs, Mirena and Skyla, with no cost-sharing and no RMM limitations. Three carriers cover either Skyla or Mirena, but not both hormonal IUDs.
  • Copper IUD, ParaGard: Fourteen carriers cover ParaGard with no RMM limitations and no cost-sharing. One carrier does not cover ParaGard, which is the only non-hormonal IUD available to women.
  • Ten carriers cover all three IUDs and four carriers cover one IUD with no RMM limitations and no cost-sharing. In total, 14 carriers cover at least one IUD with no cost-sharing and no RMM limitations and we were unable to ascertain coverage from four carriers.
Table 6: Carriers Covering IUDs by Type, Cost-Sharing Requirement, and RMM Limitations
IUD Coverage Mirena Skyla ParaGard
Covered with no RMM limitations and no cost-sharing 13 10 14
Covered with prior authorization and no cost-sharing 1 1
Covered with step therapy and no cost-sharing
Covered with cost-sharing and no RMM limitations
Covered with cost-sharing unknown 2 2 1
Covered with prior authorization/step therapy and cost-sharing
Not covered 3 1
Unknown* 4 4 4
NOTE: 20 carriers were reviewed. *Individuals participating in interviews were unable to respond or information was not included in plan documents.
Emergency Contraceptive Pills

Emergency Contraceptive PillsEmergency contraception (EC) is used to prevent pregnancy after unprotected sex or contraceptive failure. There are several methods of EC that are available in the U.S. including progestin-based pills, ulipristal acetate, and copper IUDs. Unlike the copper IUD, EC pills are not intended for use as a regular contraceptive method.

The Plan B formulation (progestin-based) is also available in generic forms, known as Take Action, Next Choice One Dose, and My Way. Progestin-based EC pills are effective up to three days after unprotected sex. Take Action, Next Choice One Dose and My Way are approved for sale over the counter (OTC). There are other generic brands available, but the FDA has not approved their OTC availability and thus they remain “behind the counter” requiring the pharmacist to dispense the pills. The cost of OTC emergency contraceptive pills varies from $30 to $60.

Ulipristal acetate, marketed as ella, was approved by the FDA in 2010 for sale and use in the U.S. Ella is a single-dose pill that is effective in preventing pregnancy up to five days after unprotected intercourse, giving women a longer timeframe to prevent unintended pregnancy than Plan B. Unlike progestin-based EC, a prescription is required for ella.

Recent studies have raised questions about the effectiveness of EC pills in preventing unintended pregnancy in overweight and obese women. While these studies do not conclusively establish specific weight or body mass index (BMI) thresholds for progestin-based EC pills or ella, it is suggested that women with BMI thresholds greater than 25 take ella rather than a progestin-based formulation.2 However, the effectiveness of ella appears to diminish at BMI thresholds above 35.3

Findings
  • ella: Eleven carriers cover ella with no RMM limitations and no cost-sharing. Six carriers cover ella, but charge cost-sharing, and two carriers do not cover ella at all
  • Plan B: Five carriers cover Plan B with no RMM limitations and no cost-sharing. Ten carriers do not cover Plan B. One of the carriers’ coverage of the Plan B varies by product line. For this carrier, Plan B is covered within the individual and Small Employer Plans available on the Marketplace with cost-sharing, but it is not covered in the large group product lines. In table 7, this carrier is included twice to indicate its separate coverage policies.
  • Generic EC pills: Nineteen carriers cover generic progestin-based EC pills with no cost-sharing. We were not able to determine the cost-sharing from plan documents for one carrier, although it appears that they cover generic EC pills. At least one carrier covers OTC purchases from a network pharmacy when the policy holder has prescription. Another carrier makes reimbursement forms available at network pharmacies for policyholders purchasing EC pills OTC, that is, it is covered if they don’t have a prescription from a clinician.
Table 7: Carriers Covering Emergency Contraception by Type, Cost-Sharing Requirement, and RMM Limitations
Emergency Contraception Coverage Ella Generic Plan B Plan B1,2
Covered with no RMM limitations and no cost-sharing 11 19 5
Covered with prior authorization/ step therapy and no cost-sharing
Covered with cost-sharing and no RMM limitations 6 5
Covered with cost-sharing unknown 1 1 1
Covered with prior authorization/step therapy and cost-sharing
Not covered 2 10
NOTE: 20 Carriers were reviewed.
1 One carrier’s coverage varies by product line and as result the responses to this item total 21.
2  Two carriers cover the one pill dose (Plan B One-Step) and not the two pill dose of Plan B.
Permanent Forms of Female Sterilization

Regardless of the setting in which it is performed, sterilization is performed by a clinician and requires ancillary services and follow-up care. There are different procedures to achieve sterilization. Surgical sterilization closes the fallopian tubes by being cut, tied, or sealed. This stops the eggs from going down to the uterus where they can be fertilized. The surgery can be done a number of ways: laparoscopic, hysteroscopic, and mini laparotomy. Essure is the first non-surgical method of sterilizing women. A thin tube is used to thread a tiny spring-like device through the vagina and uterus into each fallopian tube. The device works by causing scar tissue to form around the coil. This blocks the fallopian tubes and stops the egg and sperm from joining. Coverage of this sterilization was more complicated to ascertain than other methods.

Findings
  • We were able to confirm that 10 carriers cover female sterilization with no RMM limitations and no cost-sharing. Three carriers cover female sterilization, but cost-sharing is unknown (Table 8).
  • One carrier mentioned that cost-sharing may sometimes apply depending on how the physician bills and/or how system edits are applied. One carrier indicated that coverage is restricted to members at least 21 years of age.
  • Seven carriers’ coverage of female sterilization is unknown because the information was not included in plan documents. Sterilization is a medical benefit and the publically available plan documents related almost entirely to pharmacy benefits.
  • Carriers were asked about three female sterilization procedures: laparoscopic, hysteroscopic, and mini laparotomy. The five carriers responding to these questions cover all three procedures with no cost-sharing. One reason cited for the lack of specificity about coverage of specific procedures is that the method selected is at the discretion of the physician, meaning that any procedure performed under the category of female sterilization is covered.
  • Five carriers cover ancillary services, including anesthesia and supplies, and follow-up care with no cost-sharing. One carrier, however, does not cover these services. Of the remaining carriers, one indicates that only anesthesia and supplies require cost-sharing and another indicates that anesthesia and supplies are covered with no cost-sharing but notes that follow-up care is not a covered benefit.
Table 8: Female Sterilization Coverage by Cost-Sharing Requirement and RMM Limitations
Covered with no RMM limitations and no cost-sharing 10
Covered with no RMM limitations, cost-sharing unknown 3
Covered with step therapy and no cost-sharing
Covered with cost-sharing and no RMM limitations
Covered with prior authorization / step therapy and cost-sharing
Not covered
Unknown* 7
NOTE: 20 carriers were reviewed. * Individuals participating in interviews were unable to respond or information was not included in plan documents.
Defining “Reasonable” Medical Management Related Coverage Issues

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