Washington, D.C. -Rep. Carolyn B. Maloney, the Chairwoman of the Committee on Oversight and Reform, sent letters to pharmacy benefit managers CVS Caremark, Express Scripts, OptumRx, and Prime Therapeutics, and health insurers UnitedHealth, Anthem, Aetna, Cigna, and Humana requesting information regarding no cost-sharing coverage of contraceptives and related services for individuals enrolled in private health plans, as required by the Affordable Care Act (ACA). Chairwoman Maloney issued the following statement on today’s letters:
“I am deeply troubled by reports that health plans and issuers may not be fully complying with the ACA’s requirement to cover contraceptives at no cost, potentially depriving patients of access to critically important reproductive health care. I am committed to uncovering the full extent of this problem and ensuring that every person can access the birth control that works best for them without unnecessary cost or delay."
Under the ACA, all non-grandfathered private health plans must cover the full range of contraceptives and related services without beneficiary cost-sharing obligations. Although plans and issuers are allowed to use “reasonable medical management techniques" in administering benefits, each plan or issuer must cover at least one form of contraception for each Food and Drug Administration (FDA)-approved method, without patient cost-sharing.
In 2015, the Centers for Medicare and Medicaid Services (CMS) issued guidance explaining that in order to meet these requirements, plans and issuers must have a cost-sharing exceptions process in place for situations when a health care provider determines that a patient requires a specific contraceptive that is not typically covered without cost-sharing under that patient’s plan.
Public reporting and information obtained by the Committee indicate that some plans and issuers, including their Pharmacy Benefit Managers (PBMs), have not been in compliance with the ACA’s no cost-sharing birth control coverage requirements. For example, reports indicate that plans and issuers are routinely not covering without cost-sharing contraceptive products that were recently approved by FDA, in particular contraceptive products approved by the FDA after 2011, as well as the services associated with contraception-such as office visits, counseling, or the insertion or removal of a contraceptive device.
In addition, a recent investigative report found that when patients are denied coverage for a specific contraceptive product, plans and issuers do not always have in place an exceptions process that meets the requirements of CMS’s 2015 guidance.
The Committee requested information regarding insurers’ and PBMs’ compliance with the ACA and CMS guidance by June 8, 2022.
