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Contraception is free for women, except when it is not

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For Stephanie Force, finding a birth control method she likes and can get without paying out of pocket has been a struggle, despite the Affordable Care Act’s promise of free birth control. for women and adolescent girls in most health plans.

The 27-year-old medical recruiter from Roanoke, Virginia, was perfectly happy with the NuvaRing, a flexible vaginal ring that women insert monthly to release hormones and prevent pregnancy. But her insurer, Anthem, stopped covering the brand name product and switched it to a generic version in early 2020. Force said the new product left her with headaches and she felt irritable and short-tempered.

After speaking with her OB-GYN, Force tried an IUD. But that made her feel worse: she had severe cramps, gained 10 pounds, and developed severe hormonal acne. Additionally, they charged him $ 248 for an ultrasound that his provider used to guide insertion of the device, a charge he successfully fought for.

Force also considered a couple of birth control products 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 is not covered by your employer’s health plan, and you would have a $ 45 copay for Annovera.

Despite the ACA’s guarantees of free contraception coverage, Force’s experience illustrates that even for women whose health plans are subject to the law’s requirements, getting the right product at no cost can be onerous. New types of birth control are not automatically added to the federal list of required methods that insurers use to guide coverage decisions. Additionally, some health plans continue to discourage the use of even long-established methods, such as IUDs, by requiring providers to obtain plan approval before prescribing them.

Consumer advocates who have studied the issue say that federal rules establish a process for women to obtain the contraceptive they need, but very few people know that it is an option.

portrait selfie of Stephanie Force
Despite the ACA’s guarantees of free contraception coverage, Stephanie Force discovered first-hand that getting the right product at no cost can be expensive. Force says it was not aware of any process it could have used to cover the NuvaRing without cost sharing. Neither his healthcare provider nor the insurer mentioned the possibility.(Stephanie’s strength)

Eventually, Force went back to the generic version of the NuvaRing, despite the side effects that it continues to experience. She would rather be on the branded NuvaRing, which gave her no problems, and the ping-pong from one method to another has left her exhausted and furious.

“I can’t believe the hurdles I had to go through between September 2020 and June 2021,” Force said, “between switching from the generic NuvaRing to the IUD and then coming back, fighting my insurance and the OB-GYN office over the charge of ultrasound. “

In a statement, Anthem said: “Anthem health plans cover 222 contraceptive products at a cost sharing of $ 0 on our ACA Prevention List. We cover at least one product ”in each of the 18 FDA-approved contraceptive categories.

Contraception is a very personal choice, and what meets the needs of one woman may not meet the needs of another. If avoiding pregnancy is a woman’s top priority, a virtually fail-safe method like an IUD may be the right solution. But for someone considering getting pregnant soon, an easily reversible method like a birth control pill might be the best option. Side effects are also important to consider, as women respond differently to hormones in various birth control products.

Before the ACA required no-cost birth control coverage, researchers estimate that as much as 44% of women’s out-of-pocket spending on health care went to contraceptives. The ACA required that most commercial health plans cover a full list of FDA-approved methods without charging women. Church plans and religious non-profit organizations, as well as employers and schools that oppose contraception, are exempt from the coverage requirements. Plans that were protected by law are also exempt. Uninsured women also do not benefit from the mandate.

But federal rules don’t require health plans to cover all contraceptives. Following the approval of the ACA in 2010, the Health Resources and Services Administration developed guidelines for preventive services for women. Those guidelines say that women should have access without cost sharing to a list that covers the 18 FDA Approved Methods, including oral contraceptives, vaginal rings and cervical caps, IUDs, implantable rods, and sterilization. Under federal rules, health plans must cover at least one product in each category.

But neither the HRSA guidelines nor a birth control chart published by the FDA addresses newer methods, including Phexxi gel, which regulates vaginal acidity to reduce the chances of a sperm reaching an egg. It was approved by the FDA last year.

They also do not incorporate mobile fertility awareness apps that the FDA approved in recent years, such as Natural Cycles, which tracks the temperature and menstrual cycle to avoid pregnancy.

“There is a real need for a new guide that keeps up with the new methods,” said Mara Gandal-Powers, director of access to birth control at the National Center for Women’s Law.

Many insurers have refused to cover Phexxi, said Rameshwari Gupta, director of strategic markets at Evofem Biosciences, which markets Phexxi. A box of 12 single-use applicators (consumers use one before having sex) costs $ 267.50 without insurance, he said.

“When I started talking to payers, they all said, ‘Where are you on this FDA chart?'” He said.

According to an FDA spokesperson, the birth control chart is for consumer educational purposes only and “was not created with the intent of making coverage decisions.” The agency is in the process of updating it.

In a statement, HRSA said it is reviewing the evidence on contraceptives and expects to complete its review by the end of this year. If you choose to review, it will post draft recommendations to update the preventive services guidelines for women. These will be finalized after a public comment period and will go into effect one year later.

At this point, health plans consider Phexxi a spermicide and must cover only one type of spermicide with no cost sharing, said Kristine Grow, senior vice president of AHIP, a commercial health insurance organization.

“If Phexxi is truly considered a new ‘method’ of contraception, both the FDA and HRSA I would have to make this clear, ”he added.

The Annovera vaginal ring, approved by the FDA in 2018, is generally covered by health plans, according to Grow, although it may not be available without cost sharing. The average retail price is $ 2,457 a year, according to GoodRx.

One way that plans have made it difficult for women to access certain contraceptives, even those on the list of approved methods, is to require their providers to first obtain approval from the insurer, often by providing documentation that the product is medically necessary.

Under UnitedHealthcare’s coverage policy For Phexxi, for example, before coverage is authorized, members must have documented reasons why they cannot use eight other methods of contraception, including oral contraceptives, the contraceptive patch, a vaginal ring, injections, and spermicides. Providers must also attest that they have counseled patients that Phexxi is less effective in preventing pregnancy than some other methods.

In a statement, UHC said it covers “a wide range” of generic and brand-name options, and is following scientific evidence to develop its list.

However, consumers have a way of obtaining the specific drug that is most appropriate for them, depending on a report by the National Center for Women’s Law.

Under federal rules, if a doctor or other healthcare provider determines that a patient needs a particular contraceptive, even if it is not on the list of approved products for the patient’s plan, the insurer must have a timely process for the patient seek a waiver.

“It doesn’t depend on the insurance company if they cover that method; it depends on the provider, ”said Adam Sonfield, executive editor for 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 state agencies do not enforce these so-called exception policies.

If patients are having trouble getting the method they want, “we usually recommend filing an appeal with their insurance provider,” said Gretchen Borchelt, vice president for reproductive rights and health at the National Center for Women’s Rights.

Stephanie Force said she was not aware of any process that she could have used to cover the NuvaRing without cost sharing. Neither his healthcare provider nor the insurer mentioned the possibility.

She recently had an appointment with a new provider, who she hopes will be a better advocate for her.

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