Can your health plan charge a co-pay for brand contraceptives? Maybe‼️

Generally speaking “free” contraceptives can be limited to generic versions of the pill and health plans can still require the normal copayment for the brand version.

However, recent Q and As from the DOL and HHS indicate that there can be exceptions. Apparently all it takes is for the attending physician to indicate that only the brand name can be prescribed. Health plans have long struggled with the patient who claims they can’t use the generic version of a drug, but usually the plan cost-sharing provisions prevail. That’s no longer true under Obamacare. The Q and As state:

20140701-064725-24445607.jpgIf utilizing reasonable medical management techniques within a specified method of contraception, plans and issuers must have an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual or a provider (or other individual acting as a patient’s authorized representative).

If an individual’s attending provider recommends a particular service or FDA- approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. 

Needless to say, this will only add more costs to a health plan, but then again there is absolutely no logical reason why contraceptives should be treated any differently from other prescription drugs.

From government Q and As

The HRSA Guidelines include a recommendation for all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity, as prescribed by a health care provider. On February 20, 2013, the Departments issued a FAQ stating that the HRSA Guidelines ensure women’s access to the full range of FDA- approved contraceptive methods including, but not limited to, barrier methods, hormonal methods, and implanted devices, as well as patient education and counseling, as prescribed by a health care provider.The FAQ further clarified that plans and issuers may use reasonable medical management techniques to control costs and promote efficient delivery of care, such as covering a generic drug without cost sharing and imposing cost sharing for equivalent branded drugs. However, in these instances, the FAQ stated that a plan or issuer must accommodate any individual for whom a particular drug (generic or brand name) would be medically inappropriate, as determined by the individual’s health care provider, by having a mechanism for waiving the otherwise applicable cost sharing for the brand or non-preferred brand version.1

If utilizing reasonable medical management techniques within a specified method of contraception, plans and issuers must have an easily accessible, transparent, and sufficiently expedient exceptions process that is not unduly burdensome on the individual or a provider (or other individual acting as a patient’s authorized representative).

If an individual’s attending provider recommends a particular service or FDA- approved item based on a determination of medical necessity with respect to that individual, the plan or issuer must cover that service or item without cost sharing. The plan or issuer must defer to the determination of the attending provider. Medical necessity may include considerations such as severity of side effects, differences in permanence and reversibility of contraceptives, and ability to adhere to the appropriate use of the item or service, as determined by the attending provider.

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