It has been a struggle for Stephanie Force to find a method of contraception she likes and can get without paying out of pocket, even though the Affordable Care Act promises free contraception for women and adolescent girls in most health plans.
The 27-year-old doctor-recruiter in Roanoke, Virginia, was perfectly happy with the NuvaRing, a flexible vaginal ring that women use monthly to release hormones to prevent pregnancy. But their insurer, Anthem, discontinued coverage of the branded product and switched to a generic version in early 2020. Force said the new product left her with a headache and a feeling of irritability and fussiness.
After speaking to her gynecologist, Force tried an IUD. But it made her feel worse: She had bad cramps, gained 10 pounds, and developed severe hormonal acne. She was also billed $ 248 for an ultrasound that her doctor used to guide the insertion of the device, a fee she successfully tackled.
Force also looked at some of the contraceptives approved in recent years: a non-hormonal vaginal gel called Phexxi and a vaginal ring called Annovera that can be used for a year. But Phexxi isn’t covered by her employer’s health insurance, and she would owe a $ 45 copayment for Annovera.
Despite the ACA’s guarantees of free contraception, Force’s experience shows that even for women whose health plans are regulated by law, getting the right product for free can be a chore. New types of contraception are not automatically added to the state list of required methods that insurers use to make coverage decisions. Additionally, some health plans continue to discourage the use of even long-established methods such as IUDs by requiring providers to obtain approval of the plan before prescribing it.
Consumer advocates who have looked into the issue say that federal regulations provide a procedure for women to get the contraceptive they need, but far too few people know it is an option.
Despite the ACA’s guarantees of free contraception insurance, Stephanie Force found firsthand that getting the right product for free can be a chore. Force says she was not aware of any method she could have used to cover the NuvaRing at no cost. Neither her doctor nor the insurer mentioned the possibility.(Stephanie Kraft)
Ultimately, despite the side effects she continues to experience, Force reverted to the generic version of the NuvaRing. She would prefer to be on the branded NuvaRing, which didn’t cause her any problems, and method-to-method ping-ponging left her exhausted and angry.
“I can’t believe the tires I had to overcome between September 2020 and June 2021,” Force said, “between switching from the generic NuvaRing to the IUD and then back to battle my insurance and the obstetrician’s office over the ultrasound fee. ”
In a statement, Anthem said, “Anthem’s health plans include 222 contraceptives at a cost of $ 0 on our ACA preventive list. We cover at least one product in each of the 18 contraceptive categories that are FDA cleared.
Contraception is a very personal choice, and what meets one woman’s needs cannot meet another. If avoiding pregnancy is a top priority for a woman, a practically fail-safe method like an IUD may be the solution. But for someone considering getting pregnant soon, an easily reversible method like birth control pills might be the best option. Side effects should also be considered, as women react differently to the hormones in different contraceptives.
Before the ACA required free birth control, researchers estimated that up to 44% of women’s health care expenses were spent on contraceptives. The ACA required most commercial health plans to cover a comprehensive list of FDA-approved methods without charging women. Church plans and religious non-profit organizations as well as employers and schools that reject contraception are exempt from the coverage requirement. Plans that existed according to the law are also excluded. Even uninsured women do not benefit from the mandate.
But federal regulations don’t require health plans to cover every contraceptive. Following the adoption by the Court of Auditors in 2010, the Federal Administration for Health Resources and Services developed guidelines for the prevention of women. These guidelines state that women should have free access to a list that includes the 18 FDA-approved methods, including oral contraceptives, vaginal rings and cervical caps, IUDs, implantable rods, and sterilization. According to federal regulations, health insurance must cover at least one product in each category.
But neither the HRSA guidelines nor a birth control table published by the FDA address newer methods, including the Phexxi gel, which regulates the acidity of the vagina to reduce the chances of a sperm reaching an egg. It was approved by the FDA last year.
They also don’t include fertility detection mobile apps that the FDA has approved in recent years, such as Natural Cycles, which track a woman’s temperature and menstrual cycle to help prevent pregnancy.
“There is a real need for new guidelines that keep up with new practices,” said Mara Gandal-Powers, director of birth control access at the National Women’s Law Center.
Many insurers have shied away from insuring Phexxi, said Rameshwari Gupta, director of strategic markets at Evofem Biosciences, which markets Phexxi. A box of 12 disposable applicators – consumers use one before sex – costs $ 267.50 without insurance, she said.
“When I started talking to the payers, they all said, ‘Where are you on this FDA card?'” She said.
According to an FDA spokesman, birth control is for consumer education purposes only and “was not created with the intent to make decisions about coverage.” The agency is in the process of updating it.
In a statement, HRSA said it is reviewing the evidence of contraception and expects to complete its review later this year. If it chooses to revise it, it will publish draft recommendations to update the guidelines for women prevention services. These are finalized after a public comment period and come into force one year later.
At this point, health plans are viewing Phexxi as a spermicide and only need to cover one type of spermicide at no cost, said Kristine Grow, senior vice president at AHIP, a health insurance trading organization.
“If Phexxi is indeed seen as a new ‘method’ of contraception, both the FDA and HRSA would need to make this clear,” she added.
The vaginal ring Annovera, which was approved by the FDA in 2018, is usually covered by health insurance, according to Grow, although it may not be available free of charge. The average sales price according to GoodRx is $ 2,457 per year.
Plans have made it difficult for women to access certain contraceptives, even if they are on the list of approved methods, by requiring their providers to first get approval from the insurer, often by providing evidence that the product is medically necessary.
For example, according to UnitedHealthcare’s insurance policy for Phexxi, members must have documented reasons for not being able to use eight other methods of contraception, including oral contraceptives, the contraceptive patch, a vaginal ring, injections, and spermicides, prior to approval of coverage. Providers must also confirm that they advised patients that Phexxi is less effective at preventing pregnancy than some other methods.
In a statement, UHC said it covers “a wide range” of generic and brand name options and that it is following scientific evidence to develop its list.
However, according to a report by the National Women’s Law Center, consumers have a way to get the drug that is most suitable for them.
If a doctor or other health care provider determines that a patient needs a particular contraceptive even if it is not on the list of approved devices for the patient plan, federal regulations require the insurer to put in place an appropriate process for finding the patient for a waiver.
“It’s not up to the insurance company whether they cover this method; it’s up to the provider, ”said Adam Sonfield, senior editor, policy analysis at the Guttmacher Institute, a research and advocacy organization focused on women’s reproductive health.
But, according to the National Women’s Law Center report, many insurers, patients, and their providers are unaware of the requirement, and government agencies are not enforcing these so-called exemptions.
When patients are having trouble getting the method they want, “we usually recommend filing a complaint with their health insurance company,” said Gretchen Borchelt, vice president of reproductive rights and health at the National Women’s Law Center.
Stephanie Force said she was not aware of any procedure that would allow her to cover the NuvaRing at no cost. Neither her doctor nor the insurer mentioned the possibility.
She recently had an appointment with a new vendor that she hopes will make a better lawyer for her.
Michelle Andrews:
andrews.khn@gmail.com, @ mandrews110
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