“We have heard many stories of PBMs requiring pre-approval, denying claims, or asking patients to try multiple forms of contraceptives before approving them for the product recommended by their health care provider. contrary to the goals of the ACA … ensuring access to free prescription contraceptives at the point of sale,” the senators wrote.
The Affordable Care Act (ACA) requires companies to fully cover birth control for patients at no cost or extra steps, but despite these protections, the best companies continue to force patients to jump through harmful and unnecessary hoops or to pay. out of pocket to get the contraceptive they need to stay healthy. In their letters to CVS Caremark,
“Patients shouldn’t have to rush through heavy hoops or pay extra just to get the birth control they need to stay healthy and plan a family on their own terms. So we’re asking you to ensure that your policies comply with the law and to provide requested information so that we can better understand the scope, evolution and impact of your policies.”
Recent reports have made it clear that despite the ACA’s clear requirement for contraception coverage, some insurers and the PBMs they hire to administer pharmacy benefits on their behalf are forcing patients to pay extra for birth control. births or jumping through unnecessary and harmful hoops to get the birth control they have chosen. covered method. In some cases, patients were asked to demonstrate that they had failed with up to five different contraceptive options before they could have their contraception covered.
The Senators’ letters to PBMs follow the efforts of Senators Murray and Wyden (https://www.help.senate.gov/chair/newsroom/press/amid-reports-that-insurers-are-flouting-aca-contraception-coverage-protections-senators-murray-wyden-urge-biden-administration- to-protect-access-to-birth-control-) and
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Dear Dr. Lotvin:
We continue to hear from patients who experience delays and denials of insurance coverage for contraceptive products that they and their health care providers deem most appropriate for them. The Affordable Care Act (ACA) requires all group health plans and issuers of group or individual health insurance coverage to cover preventive services for women, including the full range of approved contraceptives, authorized and granted by the FDA, without cost sharing. Thanks to this requirement, more than 64 million women benefit from insurance coverage including contraception at no cost. However, over the past nine years, thousands of women have reported difficulty obtaining covered contraceptive products as guaranteed by the ACA. As one of the nation’s largest Pharmacy Benefit Managers (PBMs), CVS Caremark’s claims policies for birth control products directly affect patients’ ability to get the birth control they need. . Patients shouldn’t have to jump through heavy hoops or pay extra just to get the birth control they need to stay healthy and plan a family on their own terms. We therefore ask that you ensure that your policies comply with the law and provide the requested information so that we can better understand the scope, evolution and impact of your policies.
Following reports that insurers were illegally denying access to birth control, the
Federal law clearly requires group health plans and health insurance coverage to cover the full range of contraceptives approved, authorized, or granted by the FDA. Since PBMs typically administer drug benefits for group health plans and health insurance coverage, the policies and practices put in place by PBMs on behalf of those plans or coverages drive coverage decisions for patients. We’ve heard many stories of PBMs requiring pre-approval, denying claims, or asking patients to try multiple forms of birth control before approving them for the product recommended by their healthcare provider. These opaque and cumbersome practices run counter to the goals of the ACA – to ensure access to free prescription contraception at the point of sale.
We are writing to request more information about CVS Caremark’s practices regarding contraceptive coverage and to ensure that you are following the law.
Please respond to the following questions and requests for information no later than
1. How have CVS Caremark medical coverage and management policies regarding contraceptive products changed since the release of departmental guidelines on
a. Please provide copies of current contraceptive coverage and medical management policies.
b. Please provide previous iterations of these policies dating back to
2. What percentage of complaints for contraceptive products were subject to prior authorization requirements?
3. What percentage of contraceptive product claims are approved without cost sharing?
4. What percentage of contraceptive product claims are approved with cost sharing?
5. What percentage of requests for contraceptive products are refused?
6. How many requests for coverage of a contraceptive product on the basis of medical necessity has CVS Caremark received in the last five annual claim periods? How many of them have been approved?
7. Please provide any documentation explaining the circumstances under which providers are required to use an exception process to request coverage for a contraceptive product on the basis of medical necessity. Please also provide an explanation of the materials suppliers must provide in order to demonstrate that a contraceptive product is medically necessary.
8. Does CVS Caremark use medical management techniques as part of a specified method of contraception? If applicable:
a. Please describe the techniques used and provide the exception forms and standard instructions that are used.
b. What review does CVS Caremark perform to determine if the exception process is burdensome for patients and their providers?
have contacts regarding this request. Thanks in advance for your quick response.