Will Insurance Cover Over-The-Counter Contraceptive Pills?

Consumers who want to purchase Opill — an FDA-approved over-the-counter oral contraceptive — may experience insurance coverage challenges, according to experts.

The recent FDA approval of Opill — the first over-the-counter (OTC) birth control pill in the United States — will offer a new contraceptive option for people when it hits store shelves in 2024.

However, according to experts, health insurance coverage of Opill may be hit or miss.

In a KFF webinar on September 15, a panel of experts discussed the current approaches to covering OTC oral contraception without a prescription, as highlighted in their recent Women's Health Policy report.

According to Laurie Sobel J.D., associate director for KFF's Women's Health Policy program, although the manufacturer has not yet announced Opill's price, a recent Tampa Women's Health Survey found that many people are interested in using OTC oral contraception but that will depend in large part on affordability as well as insurance and Medicaid coverage.

"The Affordable Care Act (ACA) requires most plans to cover without cost-sharing all FDA approved contraceptives for women, but currently requires a prescription even when the product or drug is sold over the counter," Sobel said. "So, for example, for an insurer to cover Plan B or emergency contraception, the policyholder needs to have a prescription of some sort."

Still, some states have passed laws requiring coverage of over-the-counter contraception without a prescription.

Research to investigate state policies

To dive into this further, KFF conducted a study to look further into policies and strategies.

"We conducted 35 interviews with nearly 80 experts and key players," said Michelle Long, M.P.H., senior policy analyst for Women's Health Policy at KFF. "We focused our study on seven states that already require private plans or Medicaid to cover OTC contraception without a prescription, including Illinois, New Jersey, New York, Oregon, New Mexico, Utah, and Washington, as well as national stakeholders."

KFF found that in the states where OTC coverage is required, consumers will likely need to purchase their OTC contraception at the pharmacy counter so the pharmacist can bill insurance.

"That's true for both Medicaid and private insurance," Long added. "We did hear from some health plan interviewees that it is possible to pay for OTC contraception at the regular checkout counter with your other products that you're buying and submit a receipt and request a claim from your plan."

However, the billing protocols for OTC contraception vary widely by specific insurance plan and Medicaid program — which has led to confusion for some pharmacists about how to bill insurance for OTC contraceptive purchases.

Still, if coverage requires a prescription, pharmacists in some states can prescribe medications, which has become a new approach for expanding access to OTC contraceptives and bridging the coverage gap. But this strategy comes with its own set of challenges.

"Two years ago, I had students in my pharmacy reproductive health group survey local pharmacies in Washington state trying to bill for OTC emergency contraception and found that most pharmacists had to resort to prescribing the contraception in order to get insurance coverage," said Don Downing, a clinical professor at the University of Washington School of Pharmacy and endowed chair of the Institute for Innovative Pharmacy Practice.

"This means that the consumer who decided themselves to purchase the OTC product now has become a patient, and the pharmacist now has become a prescriber with inherent provider liabilities," he adds.

Although Downing says this has helped fill the prescribing gap, he doesn't believe it should continue moving forward.

Instead, Downing says, standardizing OTC drug coverage and the consumer experience will help make purchasing OTC contraceptives like Opill more streamlined and efficient, opening accessibility to those who want this birth control option.

Until the process is simplified, obtaining Opill may require a prescription from a healthcare provider or qualified pharmacist for insurance coverage. However, in some states, a person may be able to get Opill covered if they purchase the pills directly from a pharmacist or submit a receipt to their insurance carrier after buying them at the checkout counter.

Still, when the new over-the-counter birth control pill becomes available, individuals should contact their insurance carrier to determine the type of over-the-counter drug coverage they offer for Opill.

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