Insurance Coverage of OTC Oral Contraceptives: Lessons from the Field


In July 2023, the U.S. Meals and Drug Management (FDA) accredited the primary over the counter (OTC) day by day oral contraceptive tablet, Opill. In spite of years of OTC get entry to to birth control akin to Plan B and condoms, there was little analysis on how personal insurance policy or Medicaid techniques quilt non-prescribed OTC birth control and whether or not they achieve this with out cost-sharing. Recently, federal regulation calls for maximum personal medical health insurance plans and Medicaid enlargement techniques to hide, with out cost-sharing, the overall vary of FDA-approved contraceptive strategies. Well being plans typically require a prescription to suggest clinical necessity and cause protection, together with for ways that don’t require a prescription to buy. Conventional Medicaid techniques are required to hide circle of relatives making plans services and products with out cost-sharing, regardless that states have flexibility during which contraceptive strategies they quilt.

Previous this 12 months, the Biden management issued an executive order directing the U.S. Departments of Exertions, Well being and Human Products and services, and Treasury to believe new movements to reinforce get entry to to inexpensive birth control, which contains selling higher get entry to to and protection of OTC birth control at no prices to shoppers. Recently, the guidance from those 3 companies “encourages” personal plans to hide OTC contraceptives with out cost-sharing however does now not require it.

Six states, on the other hand, have handed regulations requiring state-regulated well being plans to hide, with out cost-sharing, positive OTC birth control with out a prescription and seven states use state-only finances to offer this protection for Medicaid enrollees. Twenty-seven states and D.C. have expanded pharmacist prescribing of no less than some contraceptive strategies, which might facilitate protection of OTC strategies however few pharmacists have coaching or time, and people who do, aren’t compensated for counseling sufferers.

This record is in accordance with 35 structured interviews carried out from January to August 2023, with just about 80 mavens and key gamers akin to pharmacists, well being plans, and state Medicaid officers concerned within the protection and provision of OTC birth control in seven states with a number of of those protection approaches (IL, NJ, NM, NY, OR, UT, and WA). It discusses the demanding situations and alternatives known by way of the interviewees that they have got skilled relating to protection beneath personal medical health insurance and Medicaid and critiques doable choices for operationalizing insurance policy of non-prescribed OTC birth control akin to Opill. Those stories also are knowledgeable by way of contemporary insurance policies that required plans to pay for OTC COVID exams and extra not too long ago by way of passion in increasing get entry to to Narcan, now to be had with out a prescription.

With the upcoming availability of Opill and the potential for a brand new OTC oral contraceptive tablet within the close to long term, the problem of protection has been raised by way of many stakeholders. Whilst some states have moved ahead with protection necessities for OTC contraceptives, operational problems and considerations akin to pharmacy and pharmacists’ capability to publish claims for OTC merchandise, a loss of uniformity and oversight of well being plans’ billing protocols, and coffee consciousness of those insurance policies stay as implementation demanding situations. Whilst required protection of OTC birth control with out a prescription and with out affected person cost-sharing would build up get entry to, it might additionally create a precedent for protection of alternative OTC therapies, elevating problems with charge for insurers and state Medicaid techniques.

Key Takeaways

  • Around the spectrum of stakeholders interviewed, there may be passion and engagement about the opportunity of an over the counter (OTC) contraceptive tablet to expand get entry to to contraceptive choices, however many raised considerations about demanding situations associated with affordability, implementation, and protection choices in accordance with stories in different states.
  • In states the place OTC strategies are recently lined with out a prescription by way of Medicaid or personal plans, shoppers normally want to download OTC birth control on the pharmacy counter, the place they are able to display proof of protection and get their pharmacy declare processed. In some personal well being plans, shoppers will pay for OTC birth control up entrance after which search repayment from the plan, however which may be financially and administratively burdensome for shoppers and isn’t used.
  • Interviewees indicated that there was little particular outreach about this lined receive advantages to pharmacies in states the place OTC birth control, akin to emergency birth control and condoms, is roofed with out a prescription in personal insurance coverage or for Medicaid enrollees. Well being plan interviewees reported that they obtain few claims for non-prescribed OTC birth control, which might be because of low consciousness of the convenience and how one can invoice for it. Few plans supply details about the convenience of their enrollee-facing data.
  • State Medicaid techniques want to publish a State Plan Modification (SPA) to the Facilities for Medicare & Medicaid Products and services (CMS) to hide OTC medicine and merchandise. After acquiring this authorization, states can decide which OTC medicine and merchandise their Medicaid techniques will quilt. Then again, federal Medicaid regulation calls for a prescription to hide all medicine, even the ones which can be to be had with out a prescription. A couple of states have selected to make use of their very own finances, with out federal matching bucks, to pay for OTC contraceptives for Medicaid enrollees with out a prescription. Federal finances will stay unavailable to hide OTC medicine with out a prescription except Congress amends the federal Medicaid regulation.
  • In states the place protection for OTC birth control is equipped with out a prescription, interviewees famous that billing protocols for OTC birth control range broadly by way of medical health insurance plan or even inside state Medicaid techniques, resulting in confusion for some pharmacists. States/state companies don’t typically decide the billing mechanism for use.
  • Some interviewees raised the significance of addressing amount limits for OTC birth control. Interviewed well being plans and a countrywide PBM prompt that amount limits have the prospective to keep an eye on fraud, waste, and abuse, which they cited as main to raised prices for insurers.
  • There was restricted communique about billing for non-prescribed OTC birth control between pharmacies, PBMs, well being plans, and state insurance coverage departments. Many interviewees from those sectors expressed that the mechanics of those state regulations and how one can operationalize them are unclear.
  • Whilst a number of interviewees expressed self belief that their present billing procedure for different non-prescribed OTC birth control can simply accommodate, maximum state-level discussions on insurance policy of this product are within the initial levels.
  • In some states, pharmacist prescribing performs an integral middleman position in get entry to to birth control the place a prescription is needed for protection by way of getting rid of the want to download a prescription from a doctor or different prescriber. Then again, demanding situations and shortcomings with this method persist, akin to pharmacist time constraints, coaching necessities, and coffee or no cost from well being plans for pharmacists’ services and products.
  • When interviewees have been requested what normal tips that they had for how one can best possible put in force protection for Opill with out a prescription, many stressed out the significance of getting a standardized billing procedure to lend a hand facilitate the transition to overlaying OTC birth control akin to with out a prescription in addition to the position of clearer federal steerage relating to what plans are required to hide.
  • Whilst state movements to extend get entry to to non-prescribed OTC birth control with out cost-sharing may also be significant for folks with personal insurance coverage, the succeed in of those movements is proscribed, largely for the reason that majority of the ones with personal medical health insurance are enrolled in self-funded employer plans, which aren’t matter to state insurance coverage necessities.
  • The level to which OTC contraceptive capsules can expand the supply of efficient contraceptives to people who search them is determined by many elements together with state and federal insurance policies, pharmacy engagement, pharmacy stocking and signage, spiritual refusals, affordability, and insurance policy, in addition to public consciousness and schooling.

This paintings was once supported by way of Arnold Ventures. KFF maintains complete editorial keep an eye on over all of its coverage research, polling, and journalism actions.


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