Stymying access.....

A new House Oversight report found some big health insurers and benefit managers stymying access to no-cost birth control options.

Carolyn Maloney urged the administration to update their most recent guidance on contraceptive coverage.

Lauren Gardner

A new report by House Oversight Democrats found that some of the biggest health insurers and drug benefit managers engage in coverage restrictions and other practices that stymie access to no-cost birth control options, contrary to the Affordable Care Act's goal.

Federal law requires most private health plans to cover FDA-approved contraceptive methods with no copays, and the Biden administration has promised increased enforcement of the mandate. But the findings confirm many practices that contraceptive access advocates and drug manufacturers have said are widespread: Insurers and pharmacy benefit managers, known as PBMs, often impose cost-sharing requirements for dozens of products, meaning the patient has to pay a portion to help cover the cost of the drug, or otherwise limit coverage. Furthermore, those companies frequently deny exception requests.

“In the wake of the extreme Supreme Court decision to overturn Roe v. Wade, the ability to decide if and when to become pregnant has never been more important," Oversight Chair Carolyn Maloney said in a statement to POLITICO. The New York Democrat urged the administration to update their most recent guidance on contraceptive coverage to address the issues uncovered in the report.

What they found: Committee staff evaluated five of the country's largest health insurers and four of the biggest PBMs and found most had coverage exclusions or cost-sharing requirements for 34 products. Most of the companies imposed those limitations on about half of the contraceptive products that were approved by the FDA after 2011.

While newer products lack generic competition that can help bring down the drugs' sticker price — and which plans often try to steer consumers toward to save money — they can offer unique formulations that can help mitigate potential side effects or make them accessible to patients with underlying conditions who may not be able to take commonly prescribed contraceptives. Breast cancer patients, for example, are generally advised to avoid hormonal birth control options.

The panel identified 17 products for which all companies investigated require cost-sharing or impose coverage exclusions, with at least five that benefit patients with "distinct health care needs," such as people with certain conditions like high blood pressure or migraines. Four of those products aren't pills, and non-pill products are often used by low-income consumers and non-white patients, the committee said.

Limits and exceptions: Plans may limit zero-cost coverage to specific products as long as they cover at least one in each contraceptive method category outlined in federal guidelines. But they’re also required to defer to medical providers who recommend a specific product for a patient, and most of the companies investigated reported denying an average of at least 40 percent of exception requests annually from 2015 through 2021.

Recommendations: The committee recommended that the Biden administration clarify that all FDA-approved birth control products without generics should be covered on every plan and formulary, while continuing to allow plans and PBMs to encourage the use of generics whenever possible. It also suggested making the exceptions process automatic when the provider prescribes a medication.