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New FDA-Approved Opill Puts Spotlight Back On Health Insurance’s Limited Coverage for Contraception

Does Health Insurance Cover Contraception?

Most health insurance plans cover contraception. Specifically, all health insurance plans available in the Healthcare Marketplace must cover contraception as prescribed by a physician. The Affordable Care Act (ACA) requires these plans to cover 100% of in-network contraceptive services and counseling costs, regardless of whether a person has met their deductible. 

Common methods of FDA-approved birth control covered by ACA plans include birth control pills, implants, and Plan B. Most plans also offer sterilization procedures for women, such as tubal ligation, at no cost. Sterilization procedures for men, such as vasectomies, may only be partially covered. Hysterectomies are only covered when medically necessary and not for birth control.

Is Birth Control Available Without a Prescription?

Historically, you need a prescription for the most potent birth control methods, including “the pill,” an oral contraceptive proven up to 99% effective in preventing pregnancy; however, the need for a prescription often hinders access to the medication. 

To broaden accessibility, the FDA approved the first-ever non-prescription birth control pill, Opill, in 2023. 

Opill will be the only non-prescription birth control pill on pharmacy shelves when released in 2024. Its closest relatives still require an online or mail-order prescription for similar products. While FDA-approved Opill is technically over-the-counter, some insurers may still require a prescription to cover it under the ACA contraceptive care mandate.

What Contraception Does Health Insurance Cover?

The ACA mandates that any plan purchased on the Marketplace must cover prescribed contraception at no additional out-of-pocket cost to the insured. Covered contraceptive methods include:

  • Hormonal methods of contraception, including birth control pills and vaginal rings
  • Barrier methods of contraception, including sponges and diaphragms
  • Implants, such as Nexplanon, and intrauterine devices, or IUDs
  • Sterilization methods, such as tubal ligation or vasectomy
  • Emergency contraception, including Plan B or the “morning after” pill
  • Birth control education and counseling

What Contraception Does Health Insurance Not Cover?

Some forms of contraception, such as a vasectomy, are not mandated to be covered by health insurance since they may limit male reproductive ability but do not personally affect a woman’s reproductive capacity. The ACA does not consider male sterilization a preventive healthcare procedure and does not recognize it as a covered form of contraception.

ACA plans at the federal level are also not required to cover medications used to induce abortions; however, some plans in certain states may choose to include this option. Additionally, the ACA does not consider a hysterectomy a form of birth control and covers the procedure only if medically necessary for an unrelated condition.    

Circumstances Where Contraception Is Not Covered

Under the ACA, group plans offered through exempt religious organizations such as churches, synagogues, or mosques are not required to cover contraception. In this case, the employee would likely need to go outside their network and pay out of pocket for contraceptive care.

The ACA also allows exempt nonprofit religious organizations to deny contraceptive coverage. Examples include hospitals and universities with religious affiliations or sponsorship. You may owe a copay or coinsurance and be required to seek third-party care for contraception through such an organization.

Is Abortion Covered?

Abortion is not recognized under federal law as a means of contraception and is not widely covered by ACA plans. States now govern their own levels of limitations or restrictions regarding abortions, ranging from offering full access to eliminating them altogether. Coverage may also vary by exception, for example if the pregnancy is life-threatening or the result of rape or incest.

How Much Does Contraception Cost?

The ACA’s effort to guarantee access to women’s reproductive healthcare services also aims to make contraception more affordable nationwide. 

Insured individuals with a prescription for the following FDA-approved forms of contraception can pay as little as $0 for these products and services; however, the ranges listed below reflect variations in costs for things such as medical supplies, device removal, and pharmacy copays. 

Birth Control Method
With a Prescription
Without a Prescription
Diaphragm
$0-$200
N/A (must be fitted by a physician)*
Birth Control Pill or Vaginal Ring
$0-$50
$50
Nexplanon or IUD
$0-$200
$1,300
Plan B 
$0-$50
$10-$50
Permanent Sterilization Procedure
$0-$1,000
$350-$5,000

*Some retailers offer barrier-based birth control products online without requiring a traditional prescription but do require customers to submit a proprietary “Rx” as part of their order. These products are one-size-fits-all and not fitted by a physician.  

Will Opill Be Covered in the Future?

While experts tout the benefits of Opill to broaden access to birth control for women everywhere, details around its cost and coverage remain unclear. Research suggests the ACA is headed toward adding Opill to its list of covered contraceptives since Opill is FDA-approved. Still, it would set a precedent for including a non-prescription medication.

Similar to the controversy surrounding Plan B when it first became available over the counter, history suggests that even insurers who may be reluctant to cover Opill without a prescription could eventually get on board. Insurance companies have yet to decide whether to fully cover Opill if required by the ACA, still require a prescription, or charge a partial payment such as a copay fee.   

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