Under health reform, most health plans must cover FDA-approved contraceptive methods prescribed by an in-network medical provider without cost-sharing (such as copayments, deductibles, and coinsurance) as part of preventive services (www.healthcare.gov).
Most plans that include prescription drugs must provide the same level of coverage for prescription contraceptives (leg.wa.gov) as they do for other prescribed drugs and devices including:
- Contraceptives on your plan's drug list (also called formulary), if they use a formulary for other covered prescriptions.
- All medical services associated with prescribing, dispensing, delivering, distributing, administering and removing prescription contraceptives, just as they do for other covered outpatient services.
- FDA-approved emergency contraception when prescribed by a medical provider.
As of Jan. 1, 2018, in addition to the coverage requirements under health care reform, individual/family and certain group health plans in Washington state are required to cover a 12-month refill of birth control pills rather than 12 separate 30-day refills (leg.wa.gov). The prescriptions are provided to consumers at no cost. That means you will receive a 12-month supply of birth control pills in one visit to the pharmacy without paying out of pocket. However, you can request a smaller supply. Your doctor can also prescribe a smaller amount if needed.
If you get your coverage from certain religious employers, your plan may provide the contraception through a special accommodation.
Health plans cannot:
- Deny coverage for prescribed FDA-approved contraceptive methods (including prescribed over-the-counter contraceptive methods.)
- Charge a copayment or coinsurance for an FDA-approved contraceptive method.
- Limit you to certain contraceptives, such as generics only, without allowing you to ask for a waiver if your provider says your preferred contraceptive is medically appropriate.
- Restrict, exclude, or reduce coverage or benefits on the basis of gender.
- Impose benefit-waiting periods, limits or restrictions on prescription contraceptives they don't impose on other covered prescribed drugs and devices.
What you pay
If you have a grandfathered plan not covered by health reform, you may be responsible for any copayments, deductibles and coinsurance for prescription contraceptives and associated services, just as you are for other prescription drugs, devices, and/or services.