Committee Releases Report on Insurer and PBM Compliance with Affordable Care Act’s Birth Control Coverage Requirement

Washington, D.C. (Oct. 25, 2022)—Today, Rep. Carolyn B. Maloney, the Chairwoman of the Committee on Oversight and Reform, released a staff report entitled, Barriers to Birth Control: An Analysis of Contraceptive Coverage and Costs for Patients with Private Insurance. The report presents findings from the Committee's review of birth control coverage offered by five of the nation's largest health insurers and four of the largest pharmacy benefit managers (PBMs). The Affordable Care Act (ACA) requires issuers and health plans to cover Food and Drug Administration (FDA)-approved contraceptive products without cost-sharing.

On May 26, 2022, following reports that patients were facing barriers to accessing birth control without cost-sharing, Chairwoman Maloney sent letters to health insurers UnitedHealth, Anthem, Aetna, Cigna, and Humana and pharmacy benefit managers CVS Caremark, Express Scripts, OptumRx, and Prime Therapeutics, requesting information regarding zero-cost coverage of contraceptives and related services for individuals enrolled in private health plans, as required by the ACA.

The Committee's investigation identified more than 30 birth control products for which most health insurers and PBMs reviewed impose cost-sharing requirements or coverage exclusions. The investigation found that the processes established for patients seeking exceptions to cost-sharing and coverage restrictions can be burdensome for patients and providers, and that from 2015 to 2021, companies denied exceptions requests on average four or more times out of ten. These practices raise barriers to accessing birth control, contrary to Congress's goal in the ACA.

Chairwoman Maloney issued the following statement in releasing the new findings:

"In the wake of the extreme Supreme Court decision to overturn Roe v. Wade, the ability to decide if and when to become pregnant has never been more important. The Affordable Care Act protects access to no-cost contraceptives for millions of Americans. For the last five months, my Committee has been examining how health insurers and pharmacy benefit managers are complying with that law—and whether barriers are impeding Americans' access to birth control.

"Today, my Committee is releasing a new report revealing that health insurers and PBMs are imposing financial burdens on patients for dozens of birth control products, and that patients who seek exceptions to these restrictions face a bureaucratic process that often pushes care out of reach.

"Today's findings are a call to action. The Biden-Harris Administration recently issued important guidance to enhance contraceptive coverage under the ACA, and I urge the Administration to further update their guidance to address the concerns identified in this report. I am committed to working alongside my Democratic colleagues and the Administration to ensure that every American can access the birth control that works best for them, without unnecessary cost or delay."

This staff analysis, the first congressional report of contraceptive coverage in the private health insurance market, presents the findings of the Committee's investigation:

• Health Plans and PBMs Have Coverage Exclusions or Cost-Sharing Requirements for at Least 34 Different Contraceptive Products. The Committee identified 34 contraceptive products for which the majority of companies reported coverage exclusions or cost-sharing on at least one plan or formulary. Of these products, 12 have no equivalent product on the market. Half of the 34 products—six of which have no equivalent product on the market—are subject to exclusions or cost-sharing requirements by each of the companies surveyed. The companies reported cost-sharing obligations of up to $178 per month for certain non-pill contraceptives like the Twirla patch, and approximately $218 per month for certain birth control pills.

• Insurers and PBMs Disproportionately Impose Cost-Sharing or Coverage Exclusions for Newer Contraceptive Products. New products may reflect recent innovations and provide alternatives to traditional contraception. However, for approximately 50% the of contraceptive products examined by the Committee that were approved by the FDA after 2011, a majority of the companies imposed coverage exclusions or required cost-sharing.

• Many Contraceptive Products Used by Patients with Distinct Health Care Needs or Disproportionately Used by People with Lower Incomes are Subject to Cost-Sharing or Exclusions. At least five of the 17 products for which all companies require cost-sharing or have coverage exclusions provide particular clinical benefit to patients with distinct health care needs. Four of the 17 products are non-pill products, which are disproportionately used by patients with less income and non-white patients.

• Health Insurers and PBMs Deny an Average of at Least 40% of Exception Requests. The majority of companies surveyed reported denying an average of at least 40% of exception requests from individuals seeking coverage for contraceptive products from 2015 to 2021. One company denied more than 80% of requests each year.

• Exceptions Processes Are Inadequate. The Committee obtained documents showing the companies' processes for considering exceptions to cost-sharing or coverage exclusions are not sufficiently accessible, expedient, or transparent to be considered "reasonable" medical management under ACA guidance. One company reported a delay of up to 15 days to process exception requests, and two companies request that providers document prior medications a patient has unsuccessfully tried in order for that patient to receive an exception.

To address coverage gaps and better ensure that all people have access to the most appropriate contraceptive products without out-of-pocket payment obligations, the staff report recommends that the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury (collectively, the Tri-Departments) issue guidance clarifying that all FDA-approved contraceptive products that do not have a therapeutic equivalent should be covered without cost-sharing as part of every plan or formulary. The Chairwoman also recommends that the Tri-Departments encourage exceptions processes that are automatic at the point of prescribing.

Click here to read the Committee staff report.

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