It has been well-established that long-acting and reversible methods of contraception like IUDs and the implant are a good option for many women. They provide the most effective coverage of all available contraceptive methods available, with failure rates of less than one percent; they can last up to a decade; and they can be easily removed when a women decides to become pregnant. There are also significant public health implications associated with an increased use of these methods, including decreased rates of unintended pregnancy, teen births, and abortions. Clinicians and public health advocates are increasingly recognizing the benefits, and efforts are underway across Northeast Ohio to educate women about the benefits of IUDs and the implant. However, despite some growth, these methods remain underutilized. More work is necessary to increase access and to understand the challenges women face when receiving family planning services.

For example, research shows that removing cost barriers is a key variable to increasing use of these methods. Fortunately, through provisions in the Affordable Care Act (ACA), insurance plans must cover all FDA-approved methods of birth control, including IUDs and implants, with no out-of-pocket costs. While there are some exceptions for “grandfathered plans,” or plans that were purchased before the health care law was signed into effect, and plans claiming religious exemptions, most plans must comply with the contraception mandate. This is significant, as prior to the ACA; some IUDs could cost as much as $1,000 out-of-pocket.

So—all plans must cover all birth controls, right? Well, not exactly. Plans are required to cover all of the types of methods[1] but not necessarily every brand.  In fact, plans can elect to only cover generic or low-cost versions of these products (there are currently no generic equivalents for IUDs and implants, but likely will be in the near future). And, evidence suggests that some plans have neglected to follow the law. A 2013 study from Guttmacher found that implementation of the mandate has not been “flawless,” and that some plans were still applying out-of-pocket costs to IUDs and implants or not covering all required methods.[2] The National Women’s Law Center issued a report in April 2015, which analyzed plans to evaluate compliance with the ACA, and found that two plans in the state were imposing cost-sharing[3] for IUDs, a major violation and a known barrier to choosing these methods.[4] In fact, the report found seven birth control related ACA violations in Ohio for the plans they reviewed in 2014, and 4 in 2015. Anecdotal information from women suggests that violations continue to occur.

We decided to do some quick research to find out how a woman could identify her covered contraceptive benefits. There was good news (many of the plans cover most IUD and implant products). However, in some cases, finding the answers proved more difficult than you’d think.

In order to research what a specific plan covers, one must first develop an understanding of how IUDs and implants actually get into the hands of the clinicians, and subsequently, to women. Even though these methods must be inserted by a clinician in a healthcare setting, they are sometimes listed as pharmacy benefits, much like an oral contraceptive, (“the pill”). The device must be ordered from a pharmacy with orders from a healthcare provider for delivery to the clinic prior to insertion, or in some cases, women must pick up their own device and bring it in to their appointments (another barrier!).  As a result, in order to try to find out what specific products each plan covers, we had to seek out their drug formularies, which are long lists of the prescription drugs that indicate what a plan covers. These are updated annually, and are typically available on an insurance company’s website.

In some cases, IUDs and the implant may be listed as a covered medical benefit, rather than a pharmacy benefit, however this is inconsistent from company to company (yet another complexity). As most contraceptive options are listed as a pharmacy benefit (including pills, patches, rings, and injectables), this exception may lead some women to believe that their IUD or implant is not covered, when, in fact, it may be. Consumers often must contact their insurance company directly to find out about covered medical benefits, as these vary significantly from plan to plan. As a result, it was more difficulty to gather information on covered medical benefits; however, we did receive this information about some plans.

We  recently scoured drug formularies for the major health insurance companies that cover Ohioans (including Ohio Medicaid’s five managed care plans[5]) searching for the most common IUD and implant products, Nexplanon, Liletta, Mirena, Skyla, and Paragard. It was more difficult to gather information on covered medical benefits, however we did receive this information about some plans. The results were mixed. While several companies had every product clearly listed as covered in their formularies (kudos!) others were much less straightforward.

Can we make this easier?

To start, the formularies were hard to find and difficult to navigate. They are often buried on a plan’s website, and are not consistently organized or categorized, which means that women must be aware of the specific product they are looking for when examining the list. A quick “Control F” helped to lighten the load on this exercise, but for those who are not computer savvy; this could be a real headache. Also, several companies’ websites have multiple links to different covered drug lists, adding to the confusion. For example, one of the plans provides three separate links that define the covered pharmaceutical benefits – one for drugs that require prior authorization, one for maintenance drugs, and another preferred drug list, or PDL. Each list includes dozens of drug names. Even as a researcher who is accustomed to sometimes tedious work, I grew discouraged trying to navigate and understand the formularies.  Drug “Tiers” and specialist pharmacy benefits create additional layers of complexity.  Some companies list these methods on a specialty drug list – typically reserved for drugs used to treat complex and/or rare conditions – so women could miss them entirely. Many women would no doubt feel similarly defeated and confused. And, as mentioned above, there are inconsistencies among companies as to whether the product is listed as a medical benefit or a pharmacy benefit, which can be misleading. While phone calls to insurance providers to discuss covered benefits are often an option, woman must first understand what specifically to ask for. And, who has time for phone calls? As Health Savings Accounts (HSAs) and high-deductible plans are becoming increasingly commonplace, more people are forced to make decisions on their own about health care options. Overcomplicated formularies and vague information on covered contraceptive benefits create major challenges and unnecessary work, and could act as a barrier to receiving care and making informed decisions about contraception.  Giving women simple and easy-to-find information on covered benefits reduces these barriers, and empowers women to make informed decisions using the available information.

Is my product covered?

Some of the companies’ formularies didn’t include all of the above mentioned products on their formularies. We did find that many of these plans have the implant and IUDs included as a medical benefit, however a lack of a standard method for classifying the coverage is problematic for women. As generic versions of the products are not currently available, in some cases, it’s possible that these products are not being covered at all. Plans should make certain that they are staying true to the law and covering all FDA-approved methods of birth control, including IUDs and the implant, and work make sure this information is easily-accessible for women.

Furthermore, prior authorization is required for some products under some plans, which means that your medical provider must obtain permission from your health plan to confirm that it will cover the device prior to insertion. This creates yet another barrier, and a time-lag, which can prohibit same-day insertion.

Healthcare providers can play a role.

In the face of an increasing emphasis on individuals taking charge of their healthcare, doctors and other healthcare providers can still play a role in helping women to understand their options and covered benefits. This includes understanding the new guidance that these methods are front-line for pregnancy prevention in any women of reproductive age and discussing the most effective options (IUDs and implants) first when providing guidance to women on contraception.  This simple paradigm shift could result in many more women learning about the benefits of IUDs and the implant. Then they may work with their providers to understand what specific products suit their needs and are covered under their plans.  More local providers are also stocking these methods, to avoid the barrier of a follow up appointment.

There are other significant barriers to access.

Insurance companies should certainly not shoulder all of the blame for low utilization rates and the headaches of consumers. In fact, a just-released informational bulletin from the Centers for Medicare and Medicaid Services (CMS) outlines some of the other existing barriers, including reimbursement and administrative challenges. CMS also describes strategies that states may use to reduce these barriers. This highly informational brief is available here. Specifically, the strategies identified by CMS that states may undertake to increase utilization include increasing reimbursement rates to incentivize use, or offering add-on payments to hospitals outside of the typical delivery fee for postpartum insertion (“unbundling” IUD or implant insertion from other labor and delivery costs). Also discussed are approaches to “remove administrative barriers,” such as preauthorization requirements, and methods to address stocking issues. The brief also includes details on innovative strategies that three states have successfully implemented to increase rates.

Progress has been made.

In spite of these complexities, progress has been made by insurance companies in recent months to expand IUD and implant coverage.  In fact, since we started monitoring the formularies and covered benefits in 2015, several plans have made updates. And the accomplishments of the ACA in assuring women have access to multiple contraceptive options cannot be overstated.  A wide range of stakeholders in Ohio have demonstrated their commitment to battling the state’s infant mortality crisis, with significant buy-in from insurance companies, including the Medicaid managed care plans, and increasing access to IUDs and the implant has been an important part of these efforts. For now, however, women may need to continue to be persistent when seeking information from their health insurance provider about covered products, particularly if they are told a product isn’t covered, as most plans must cover IUDs and implants without cost sharing.

While our analysis of this issue is far from scientific, it illustrates the challenges women face in learning about covered options, and obtaining the contraceptive option of their choice.  We will continue to monitor formularies and medical benefits to assess coverage of the products under different plans.  As IUDs and the implant are the most effective options available, and increasing access could lead to significant strides in public health, plans should actively advertise their coverage of this important benefit, and take the guess-work out for women.