OPM has issued instructions to FEHB carriers stressing the range of contraceptives coverage they are expected to offer, based on requirements in the Affordable Care Act, HHS guidance and the FEHB’s own requirements.
“Carriers must have a safe and clinically effective formulary that includes a range of medications in a broad distribution of therapeutic drug classes, including contraceptive drugs, to serve the healthcare needs of the FEHB population,” OPM said in a letter that adds to recent instruction issued in the annual “call letter” that begins the process of determining coverage and premium terms for the next calendar year.
HHS guidance states that contraceptive care for adolescent and adult women should include the full range of contraceptive methods approved, granted, or cleared by FDA, to include “provision of contraceptives and related screening, education, counseling, and follow-up care . . . coverage for contraceptive care should not be subject to any cost sharing requirements. Consistent with this guidance, it is acceptable to impose cost sharing for a brand-name drug while covering the generic equivalent with no cost sharing. In such cases, branded contraceptives must also be covered with no cost sharing through an exception process.”
Further, “the provider’s determination of medical necessity should receive deference during the exception process for contraceptive coverage. Medical necessity may include considerations such as side effects, the permanence or reversibility of a contraceptive method, and the ability to adhere to the appropriate use of that form of contraception. These considerations are all determined by the individual’s provider.”
“Carriers in the FEHB program must cover at least one contraceptive from each of the FDA classes on their formulary. Coverage must be with no cost sharing for all methods for adolescent and adult women including, but not limited to, barrier methods, implanted devices, and hormonal methods. Any new classes of contraception that become approved, granted, or cleared by the FDA would be subject to this same requirement,” it said.
Carriers’ brochures “should make it clear that contraceptive coverage is available at no cost and includes at least one option in all classes of contraception (as well as the screening, education, counseling, and follow-up care). It should be clear in the brochure that no contraceptive is wholly excluded from coverage. The exceptions process described in the brochure should clearly apply to accessing any contraceptive that is not already available without cost sharing on the formulary.”
OPM added that “any conflicting guidance on contraceptive coverage from previous FEHB carrier letters is superseded by this letter.”