Several large health insurers and pharmacy benefit managers (PBM) are limiting access to birth control medication, according to a report issued by the House Oversight and Reform Committee this week.
There are more than 30 birth control products that health insurers and pharmacy benefit managers are placing cost-sharing requirements on, the report found. In other words, these healthcare stakeholders are making patients pay to cover part of the prescription drug cost — or else restricting coverage.
The Affordable Care Act (ACA) requires that private health insurance plans cover birth control options that are approved by the Food and Drug Administration without asking for copays.
Among the 34 birth control products identified in the report, 12 don’t have equivalent options on the market.
Some of those cost-sharing requirements amounted to several hundred dollars per month out of the patient’s pocket, depending on the product. For non-pill contraception like Twirla, the cost was around $178 per month, or even up to $218 per month for certain pills.
Additionally, about 40% of exception requests submitted by patients for coverage were denied by insurers between 2015 and 2021.
Insurers and PBMs were also more likely to impose cost-sharing or restrictions on newer birth control products, doing so for about 50% of products approved by the FDA since 2011.
While the Biden administration has tried to put policies in place to protect access to abortion and contraception, advocates worry it’s not enough. In particular, the report highlights the oft-overlooked dynamic between insurers and PBM as one area that may contribute to a lack of access.
Reproductive health companies, meanwhile, have in some cases had to shift their messaging to hone in on payers rather than healthcare providers.
This is especially critical in light of the overturning of Roe. v Wade by the Supreme Court in June.
Evofem chief commercial officer Katherine Atkinson noted in a previous interview with MM+M that “When you take a look at the traditional model when you’re commercial and launching a product, ideally you wouldn’t have an issue with having to reason with payers or get politicians involved and affect policy. But that’s what we have to do to have a successful launch.”
House Oversight and Reform Committee Chairwoman Carolyn Maloney (D-NY) had also flagged the issue back in May, saying she was “deeply troubled” by signs that payers were “not fully complying with the ACA’s requirement to cover contraceptives at no cost.”
Maloney requested several large insurers including UnitedHealth, Anthem, Aetna, Cigna and Humana — as well as PBMs like CVS Caremark, Express Scripts and Prime Therapeutics — to provide information on their cost-sharing requirements. The results of this report are based on those companies’ cost-sharing practices.
Prime Therapeutics, for example, reported it had denied more than 77% of exception requests per year from 2015 to 2021, while Cigna reported denying only 5%.
The report outlined two ways the Biden administration could tweak its approach to the issue. The first would be by clarifying requirements around coverage of FDA-approved contraceptives, and the second would be by encouraging accessible, easy and quick exceptions.
“I urge the administration to further update their guidance to address the concerns identified in this report,” Maloney said in a statement this week.
