An OTC Contraceptive Pill Is Coming Soon, but Who Will Pay for It?

TUESDAY, Sept. 19, 2023 (HealthDay News) -- The first over-the-counter birth control pill is slated to hit drug stores in early 2024, but questions about cost and insurance coverage loom.

The U.S. Food and Drug Administration approved Opill (norgestrel) for preventing pregnancy without a prescription in July, but pill maker Perrigo has yet to announce the price of the contraceptive. So far, only six states require coverage of some OTC birth control methods: California (effective in 2024), Maryland, New Jersey, New Mexico, New York, and Washington, according to KFF.

To get ahead of any potential access issues before Opill is rolled out, KFF researchers conducted interviews with 80 stakeholders from private insurance plans, state Medicaid programs, and chain pharmacies in the states that already require such coverage. They found that people will generally need to get Opill at the pharmacy counter, as opposed to off the shelves, for their plan to cover it. In some private health plans, people may be able to pay for Opill at the cashier and then seek reimbursement from their plan.

"The current system is designed for covering prescription, not OTC, drugs, and there is a lack of uniformity in billing practices which leads to confusion among many key players," Michelle Long, a senior policy analyst for Women's Health Policy at KFF, said during a recent KFF news conference on insurance coverage of OTC birth control. There is also an awareness gap. "Few plans provide information about this covered benefit to enrollees in enrollee-facing materials," Long said.

There is also a need for greater awareness among pharmacists, said Don Downing, a clinical professor at the University of Washington School of Pharmacy in Seattle. Pharmacists need to know there is no age restriction and no parental consent needed for Opill (unless such restrictions are imposed in given states), Downing said during the news conference.

There is no nationally accepted claims processing system for pharmacists to use for OTC contraceptives, he added. Streamlining this process should include creating a universal dummy National Provider Identifier. Another option is for states to issue standing orders, which assert that a pharmacist is not prescribing but just fulfilling a preauthorized request to provide a product. With standing orders, pharmacists will not be filling out claims information and cannot be held liable, as they could be if they were prescribing the product.

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