QUESTION

There’s a co-pay for my brand name birth control pills, but not for the generic brand. I thought birth control bills had to be covered without any cost-sharing, is this allowed?

Post enrollment issues | Individual Health Insurance |
ANSWER

In general, under an Affordable Care Act plan, contraceptive methods that have been approved by the U.S. Food and Drug Administration (FDA) have to be provided without cost-sharing if a provider determines the product to be medically appropriate for the patient. FDA-approved contraceptive methods include items like oral contraceptives (i.e., the pill) and intrauterine devices (IUDs). While health plans must cover all methods approved for women, they are not obligated to cover each form of contraception under each method. For example, if a health plan covers both a generic and brand name birth control pill, it can impose cost-sharing on the brand name over the generic as part of its medical management. However, if your doctor determines you should take the brand name birth control because it's medically appropriate, the health plan must cover the brand name birth control without cost-sharing. 

(26 CFR § 54)

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Post enrollment issues