Must health plans cover brand-name contraceptives without cost-sharing?


As part of a review of your company’s health plan, you are looking closely at its coverage of contraceptives. Given the requirements of the Patient Protection and Affordable Care Act (ACA), does your plan need to cover brand-name contraceptives without cost-sharing?


A health plan is required to cover all methods of contraception, but it is not required to cover all brands of contraception, especially if the brand-name birth control comes in a cheaper, generic form.

Coverage of all 18 methods. To be compliant with the ACA, health care plans must cover, without cost-sharing, the full range of FDA-approved methods for contraception. There are currently 18 distinct methods of contraception for women.

Plans and issuers must cover, without cost-sharing, at least one form of contraception in each of the 18 methods that the FDA has identified for women in its current Birth Control Guide. This coverage also must include the clinical services, including patient education and counseling, needed for provision of the contraceptive method.

Cost-sharing OK, with exceptions. Although all 18 FDA-approved contraceptive methods must be made available without cost-sharing, health plans are allowed to use reasonable medical management techniques and impose cost-sharing to encourage the use of specific services or FDA-approved items within the chosen contraceptive method. For example, a plan may discourage use of brand-name pharmacy items over generic pharmacy items through the imposition of cost-sharing.

If multiple services and FDA-approved items within a contraceptive method are medically appropriate for an individual, the plan may use reasonable medical management techniques to determine which specific products to cover without cost-sharing. However, the plan must defer to an individual’s attending provider and, if the provider recommends a particular item, the plan must cover the recommended item without cost-sharing.

Source: FAQs About Affordable Care Act Implementation (Part XXVI), May 11, 2015;

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