Payers interpret contraception mandate differently

Now that the contraception provision mandated under the reform law has been in effect for almost a month, some confusion remains about how exactly insurers should cover birth control and other contraceptives.

Insurers could offer $0 copays for only generics or for both generic and single-source brand oral contraceptives, or they could allow utilization management through step edits or cost sharing for birth control pills with a generic alternative. Most insurers have chosen to address the law's ambiguity by providing some combination of these two interpretations--offering $0 copays on all contraceptives with some step therapy or utilization management requirements, reported AIS Health.

Regardless of the option chosen, the contraception mandate is forcing insurers to undergo "a paradigm shift from a healthcare system built on diagnostic treatment of disease toward a foundation of disease prevention and wellness promotion," said Paula Johnson, chief of the women's health division at Brigham and Women's Hospital in Boston, FierceHealthPayer previously reported.

WellPoint, for example, requires members with a new prescription for an oral contraceptive to step through two generic contraceptive medications before it will authorize the prescribed drug. But members who began taking one of the brand medications 180 days prior to WellPoint's change aren't subject to the step edit.

At HealthPlus of Michigan, all oral contraceptives, device contraceptives and over-the-counter items are covered at no cost to members. The insurer also has some step edits in place, including requiring failure on generic oral contraceptives before allowing members to receive devices or branded oral contraceptives.

Blue Cross Blue Shield of North Carolina covers all oral generic contraceptives and generic injectables, diaphragms, NuvaRing, cervical caps, IUDs and implantable contraceptives at no cost to members. However, it hasn't changed its requirement that brand oral contraceptives are subject to a copay and/or coinsurance, depending on the plan, AIS Health noted.

Despite the upheaval in contraception coverage, some payers see the new mandate as an opportunity to avoid much higher costs later on. Maternity and neonatal care, for example, cost significantly more than contraceptives. "When we were looking at it, when you take the cost of one unplanned pregnancy and a neonatal stay for a preterm birth, you've paid for your whole plan for oral contraceptives," Jennifer Szumowicz, director of pharmacy operations at HealthPlus, told AIS Health.

To learn more:
- read the AIS Health article (registration required)