Thanks to the health care law (Affordable Care Act) most health insurance plans should be covering your birth control without out-of-pocket costs. But what happens when a plan is covering birth control but not your specific pill or IUD? We know you’ve got questions about birth control coverage and the healthcare law, so here is the first in our three-part series, “Tips from the CoverHer Hotline”.
You go to your health care provider’s office for your well woman visit and walk out of there with a shiny new prescription for your new birth control pill. You’ve tried a million different pills with as many side-effects but you and your provider have decided this is the right pill for you. Plus you’ve got awesome health insurance thanks to the Affordable Care Act and birth control should be covered without co-pays, so you’re golden. #thxbirthcontrol #ThanksObamacare
But your happy dance comes to a screeching halt when you pick up your prescription from the pharmacy and are charged $170 for one month worth of pills, even with your insurance. You call your plan and they tell you they “only cover generic birth control pills” without a copay. They send you a list of covered pills and your awesome new brand-name pill is not on it.
Shouldn’t my birth control be covered without a co-pay?
In short, yes. Here is a little background about how the birth control benefit works. Health insurance plans have to cover at least one type of birth control in each of the method categories for women listed on this FDA birth control guide without out-of-pocket costs.
For method categories with only one product on the market, like the contraceptive ring or the copper IUD, plans have to cover the one product on the market in that category (i.e. the NuvaRing or Paragard) without out-of-pocket costs. But for other method categories with a lot of different options on the market, like birth control pills, it is not so simple. The government has said that health insurance plans do not have to cover every single pill on the market. Plans can decide which pills to cover as long as they are covering some pills in each of the three categories – combined, progestin only, and continuous/extended. This means that plans don’t have to automatically cover that brand-name pill you need.
Luckily, plans must have a “waiver” or “exception” for situations just like yours. If you and your healthcare provider decide that a specific birth control medication (it can be a brand or generic) is medically appropriate, you should get coverage for it, without a co-pay. Insurance companies must provide an easy, clear, and quick process that doesn’t require too much work for you or your health care provider that gives you coverage of your medication without out-of-pocket costs, just as if it were on the covered list.
(This isn’t just about the pill. It applies to progestin IUDs, too, since there are three progestin IUDs on the market. Plans can choose which of the three they want to cover as long as there is a wavier process for a woman to get coverage of the others if she and her healthcare provider decide it’s the right one for her).
How do I get a waiver or exception?
You or your healthcare provider will need to talk with your plan. Often your plan will need some information from your health care provider to apply a waiver or exception for out-of-pocket costs. If possible it is best to have your provider call your plan directly to get the process started. If this isn’t possible, you can call the plan directly and ask what you need to do to get a waiver or exception for your medication so that you can get it without a co-pay. If you get the run-around about the waiver or your plan says they don’t have a waiver, keep pushing. Ask to talk with a supervisor and document everything your insurance company says or sends you. Persistence often pays off, literally.
If you are denied a waiver or exception, or have other issues with coverage of birth control, contact the CoverHer hotline for further assistance at firstname.lastname@example.org or 1-866-745-5487