Senators: “We continue to hear from patients who are experiencing delays and denials for insurance coverage of birth control products .… Patients should not have to jump through burdensome hoops or pay extra just to get the birth control they need to stay healthy and plan a family on their own terms.”
Washington, D.C. – U.S. Senators Ron Wyden (D-OR), Patty Murray (D-WA), Bob Casey (D-PA) and Maggie Hassan (D-NH) this week pressed the nation’s largest pharmacy benefits managers (PBMs) to answer deeply troubling reports that they are breaking the law by illegally delaying or denying patient insurance coverage for birth control.
“We have heard numerous accounts of PBMs requiring prior authorization, denying claims, or asking patients to try multiple forms of contraceptives before approving them for the product recommended by their health care provider. These opaque and burdensome practices run counter to the goals of the ACA—ensuring access to prescription birth control that is free at the point-of-sale,” the senators wrote CVS Caremark, OptumRx, and Express Scripts, which make key coverage decisions about 80% of the prescriptions filled in the U.S.
The Affordable Care Act (ACA) requires that companies fully cover patients’ birth control with no out-of-pocket costs or extra steps, but despite these protections, top companies continue to force patients to jump through harmful, unnecessary hoops or pay out-of-pocket to get the birth control they need to stay healthy. In their letters to CVS Caremark, OptumRx, and Express Scripts, the senators called on the PBMs to fully cover patients’ birth control and clearly detail their policies related to contraception coverage.
“Patients should not have to jump through burdensome hoops or pay extra just to get the birth control they need to stay healthy and plan a family on their own terms,” they wrote. “We therefore ask you ensure your policies are compliant with the law and provide the requested information so we may better understand the scope, evolution, and impact of your policies.”
Recent reports have made clear that despite the ACA’s clear contraception coverage requirement, some insurers and the PBMs they hire to manage drug benefits on their behalf are forcing patients to pay extra for birth control or jump through unnecessary and harmful hoops to get their chosen birth control method covered. In some cases, patients have been asked to demonstrate they have failed with as many as five different birth control options before they can get their birth control covered.
The senators’ letters to the PBMs come following efforts by Senators Murray and Wyden and Senator Hassan urging the Biden administration to make clear to insurers their obligation to fully cover birth control with no out-of-pocket costs—and to take action against those failing to comply. In January, the Biden administration issued guidance clarifying that insurers must cover all FDA approved, cleared, or granted birth control that are determined by a patient’s provider to be medically appropriate.
Read the senators’ full letters to CVS Caremark, OptumRx, and Express Scripts.
A web version of this release is here.