KFF Webinar Explores Insurance Coverage of Opill


Laurie Sobel, associate director for women’s health policy at KFF, moderated a panel discussion about the challenges associated with providing insurance coverage for the first FDA-approved oral contraceptive, Opill.

The approval of the first oral nonprescription oral contraceptive is expected to expand access to contraceptives, but cost and lack of insurance coverage could be barriers, finds a new KFF report, “Insurance Coverage of OTC Oral Contraceptives: Lessons From the Field.”

The importance of outreach and education of pharmacies, pharmacists, and consumers, as well as the need for a standardized billing process and compensation for pharmacies will be critical for ensuring that Opill meets its potential. Approved in July 2023, Opill is expected to be available in early 2024.

Federal guidance must be established so that insurance coverage decisions about Opill do not continue to vary state by state, Michelle Long, KFF’s senior policy analyst, said at a recent webinar conducted by KFF about the challenges of insurance coverage for nonprescription contraceptives.

Related: FDA Approves First Nonprescription Oral Contraceptive

Laurie Sobel, associate director for women’s health policy at KFF, moderated the panel discussion with Christine Gilroy, M.D. of Express Scripts, MPH; Victoria Nichols, MPH of Free the Pill and Don Downing, R.Ph., recently retired from the University of Washington.

Nichols, who is project director of the Free the Pill Coalition, explained that affordability will be key to ensuring that people have access to Opill once it hits shelves in 2024. Free the Pill Coalition is a national campaign backed by Ibis Reproductive Health that supports education and public engagement regarding OTC birth control pills.

Don Downing, R.Ph.

Don Downing, R.Ph.

Downing, who in June 2023 as a clinical professor at the University of Washington School of Pharmacy and endowed chair of the Institute for Innovative Pharmacy Practice, also touched on price. He explained that community pharmacies pay more for the same medications than other class trade purchasers despite being the largest medication purchaser in the United States and the site where most customers obtain medications. He noted that if the OTC billing system is not simplified, low-income people wanting Opill will be faced with costs beyond their means due to the “inherently unjust” pricing model.

“I think we need to address this before this product becomes available,” Downing said. “I personally would promote an equal price across all classes of trade and eliminating a lot of their rebate hoopla that occurs that often elevates the price of drugs.”

Other than price, Downing claimed the biggest challenge for Opill coverage was the variety of rules from different health plans in each state that create a complicated billing pathway for pharmacists; he explained that pharmacists sometimes use stopgap processes when handling OTC contraception.

“Two years ago, I had students in my pharmacy reproductive health group survey local pharmacies in Washington state trying to bill for OTC emergency contraception and found that most pharmacists had to resort to prescribing the contraception in order to get insurance coverage,” Downing said. “This means that the consumer who decided themselves to purchase the OTC product now has become a patient and the pharmacist now has become a prescriber with inherent provider liabilities. I don’t see this as a pathway for easy access to OTC medications, even though it has worked as a stopgap process in Washington state, I don’t think that’s what we should be going with in the future.”

Christine Gilroy, M.D.

Christine Gilroy, M.D.

Although OTC contraceptives are a positive step toward expanding access, Gilroy, chief medical officer at Express Scripts, a national pharmacy benefits manager, noted her concern that removing the barrier of paying for a physician visit to get a prescription will add a new hurdle for pharmacists. This is because pharmacists must enter the contraceptive into a system essentially turning it into a prescription for it to be processed against a pharmacy benefit.

She dislikes this as it “requires pulling a licensed pharmacist away from other work that they’re doing in the pharmacy, which could be administering vaccines, talking with physicians, and counseling patients about other medications, just to spend a couple of minutes entering something into the claims system in order for that to adjudicate.”

Considering these challenges, Sobel asked each panelist what they believe needs to happen overall to facilitate coverage of Opill and other OTC contraceptives. Gilroy explained that the claims system must be modernized, and pharmacists need to be reimbursed. Downing followed up by saying that a nationally accepted claim processing system needs to be created as multiple currently exist. He added that a national uniform dummy provider number should be created for pharmacists to easily indicate an OTC contraceptive when running a claim to streamline the process.

Nichols concluded by making two suggestions, her first being that other states should learn from those with already established coverage. She noted that states in the process should listen to those who have successfully done it to make it a smoother process and better support consumer education. Her second suggestion was for the federal government to have more uniform guidelines around OTC contraceptives.

“Throughout your [the KFF team’s] report, so many people reference consistency in the guidance from the federal government,” Nichols said. “It says something in the FAQs that's different from the HRSA's [Health Resources and Services Administration’s] guidance and having some consistency there would be really helpful so everyone's on the same page about what the law is and how to enforce it.”

This story originally appeared on American Journal of Managed Care.

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