Your Voice: Why can’t we get health plans and PBMS to comply with the affordable care act contraceptive requirements?

Dr. Komkwuan Paruchabutr, DNP, WHNP-BC, FNP-BC, CNM, FACNM, FNAP

Dear Editor,

Millions of women across the United States face well-documented unnecessary barriers when trying to access birth control despite clear requirements under the Affordable Care Act (ACA). In a most welcome development, on October 21, 2024, the Biden-Harris Administration proposed new rules that would continue building upon the Affordable Care Act (ACA) by expanding coverage of recommended preventive health services and tearing down many barriers to contraceptive care.¹

Several months ago, Rep. Jamie Raskin, ranking member of the Committee on Oversight and Accountability, sent letters to major health insurers and pharmacy benefit managers (PBMs),² demanding they comply with new federal guidance to improve no-cost access to birth control.

A 2022 House Oversight and Reform Committee investigation³ highlighted the extent of the problem: Insurers and PBMs routinely impose cost-sharing requirements or coverage exclusions on over 30 contraceptive products, directly violating the ACA. The investigation also revealed that the processes for seeking exceptions are often non-existent or so burdensome that they effectively deny women the care they need. Patients and providers are left frustrated and without options, undermining the very goals of the ACA.

To address this systemic non-compliance, the Committee recommended that the Biden Administration, consistent with its June 2023 Executive Order,⁴ require that insurance plans cover all contraceptive products without a therapeutic equivalent, a so-called “national therapeutic equivalent standard.” The Committee recognized that such a standard would be a game-changer. It would require health insurers and PBMs to cover at least one version of all FDA-approved contraceptive products without cost-sharing. By eliminating the confusing and time-consuming exception processes, plans that use this standard would ensure women receive the birth control they need without unnecessary hurdles.

The proposed new regulation adopts the Committee’s recommendation to require plans and issuers to cover all Food and Drug Administration (FDA)-approved, -cleared, and -granted birth control methods without cost-sharing that do not have a therapeutic equivalent. The proposed rule also requires, for the first time, most group health plans and health insurance issuers to cover over-the-counter (OTC) contraceptives without cost sharing or requiring a prescription. I commend the Biden-Harris Administration for issuing the new proposed rules that, if enacted and enforced, will eliminate many of the barriers women have faced for far too long regarding contraceptives.

As a health care provider, I see the impact of these barriers. Women go to clinics seeking medically appropriate contraceptive products, only to find out that they are either denied outright by health plans or PBMs or priced out of reach. The time we spend navigating these obstacles takes away from patient care and adds to the frustration and stress of those we serve.

Women must be able to make informed decisions about their reproductive health without financial constraints. The urgency of this issue cannot be overstated. In the wake of recent decisions impacting reproductive justice, ensuring comprehensive access to contraceptive products is more critical than ever.

The time to act is now. Women are being denied coverage of new, innovative products on the market. It’s time for insurers and pharmacy benefit managers (PBMs) to fully cover FDA-approved contraceptive products without barriers. To cover newer contraceptive products on the market—and stimulate the development of new products for women—the federal government must require all products without a therapeutic equivalent to be covered with no cost-sharing. Let your voice be heard—contact your representatives, the White House, and HHS to demand that new, innovative products are fully covered and affordable to all.

Sincerely,

Dr. Komkwuan Paruchabutr, DNP, WHNP-BC, FNP-BC, CNM, FACNM, FNAP

About the author:

Dr. Komkwuan Paruchabutr, DNP, WHNP-BC, FNP-BC, CNM, FACNM, FNAP, is the President of the National Association of Nurse Practitioners in Women’s Health. She is a triple board-certified advanced practice registered nurse and a passionate advocate for women’s health.

References:

1. Fact sheet: Biden-Harris Administration proposes rule to expand coverage of affordable contraception under the Affordable Care Act. The White House. October 19, 2024. https://bidenwhitehouse.archives.gov/briefing-room/statements-releases/2024/10/21/fact-sheet-biden-harris-administration-proposes-rule-to-expand-coverage-of-affordable-contraception-under-the-affordable-care-act/.

2. Raskin J. Ranking Member Raskin Urges Insurers and Pharmacy Benefit Managers to Follow New Guidance to Ensure Patients Have Access to No-Cost Birth Control. May 16, 2024. https://oversightdemocrats.house.gov/news/press-releases/ranking-member-raskin-urges-insurers-and-pharmacy-benefit-managers-follow-new

3. Committee on Oversight and Reform U.S. House of Representatives.Barriers to Birth Control: An Analysis of Contraceptive Coverage and Costs for Patients with Private Insurance. October 25, 2022. https://oversightdemocrats.house.gov/sites/evo-subsites/democrats-oversight.house.gov/files/2022-10-25.COR%20PBM-Insurer%20Report.pdf

4. Biden, Joseph. Strengthening Access to Affordable, High-Quality Contraception and Family Planning Services. June 23, 2023 https://www.federalregister.gov/documents/2023/06/28/2023-13889/strengthening-access-to-affordable-high-quality-contraception-and-family-planning-services