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


The selection of the health insurance carriers included in this study was established through a multi-step process. Five states were selected as areas of focus: California1, Georgia, Michigan, New Jersey, and Texas. These states were chosen because they reflect geographic and political diversity and include a representation of a mix of federal, partnership and state-based Marketplaces. Some of the selected states had contraceptive coverage mandates in place prior to the ACA and expanded Medicaid coverage under the ACA, and others did not. We then compiled a master list of health insurance carriers operating in each state based on public filings with state insurance agencies and other sources. Six carriers per state were selected for inclusion in the study from that list to cover the largest market share across lines of business (large group and Marketplace plans). If a carrier declined to participate in the study, an additional carrier was selected from the state.

In total, 24 insurance carriers, many of which operate in multiple states, were invited to participate in the study. The findings presented represent interviews and/or plan document reviews for 20 different carriers and were conducted between August and October of 2014. If a national carrier operates in more than one state in the study, but the coverage is the same in multiple states, their coverage is counted once. We were able to interview plan officials including medical directors, pharmacy care managers, public policy executives, attorneys and others for nine unique carriers. We then reviewed publically available carrier documents for an additional 11 carriers. In total, the interviews and document review represent well over 200 different lines of business across the nation, including many of the largest carriers in the nation. Carriers were assured that their responses would remain anonymous. Most of the national carriers we reviewed have standard coverage policies that apply to all (non-Medicaid) lines of business and states in which the carrier operates. We found little variation in the application of RMM limitations by plan type (large employer, Individual/Family and Small Employer Plans on and off the ACA Marketplaces). Because Medicaid coverage rules are established by state policies, the findings presented do not apply to plans that are serving Medicaid beneficiaries.

This study focuses on 12 contraceptive methods (Table 1). Some of these contraceptives are covered under plans’ pharmacy benefit and others are covered under the medical benefit. The ACA contraceptive requirement does not specify the exact types of contraceptives that should be covered, only that all plans must cover FDA-approved contraceptives “as prescribed” without cost-sharing. This has been interpreted by some to mean that they should cover contraceptive methods that are available over-the-counter (OTC) when the consumer has a prescription from a provider.

This study did not review the medical management approaches used by plans to limit the coverage of oral contraceptives because of the vast number of different formulations, brands and generics that are available.

Table 1: Female Contraceptive Methods Addressed in this Study
Method Benefit Category Brand Generic Cost Duration Typical Use Failure Rate*
Ring Pharmacy NuvaRing Not available $15-80 3 weeks 9%
Patch Pharmacy OrthoEvra Xulane, norelgestromin/
ethinyl estradiol
$15-80 1/ week for 3 weeks 9%
Emergency Pill Pharmacy ella Not available $45-70 1 time use n/a
Emergency Pill Pharmacy and OTC Plan B, Plan B One Step Levonorgestrel $35-60 1 time use n/a
Injection Medical and Pharmacy Depo-Provera Medroxyprogesterone acetate injection $35-100 3 months 6%
Injection Medical and Pharmacy Depo-SubQ Provera 104 Not available $35-160 3 months 6%
Implant Medical and Pharmacy Implanon Not available $400-800 3 years .05%
Implant Medical and Pharmacy Nexplanon Not available $400-800 3 years .05%
IUD –hormonal Medical and Pharmacy Mirena Not available $500-1000 5 years .2%
IUD – hormonal Medical and Pharmacy Skyla Not available $500-1000 3 years .9%
IUD – copper Medical and Pharmacy ParaGard Not available $500-1000 10 years .8%
Sterilization Medical n/a n/a Permanent .5%
NOTE: *Failure rate is defined as the percent of women who experience an unintended pregnancy within the first year of typical use.
SOURCE: CDC, Reproductive Health, Contraception, accessed April 1, 2015; Trussell J. Contraceptive failure in the United States. Contraception; ARHP, Facts About Intrauterine Contraception.
Introduction Defining “Reasonable” Medical Management

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