Birth Control Coverage FAQs
Updated August 2012
Note: This information was developed to provide consumers with general information and guidance about insurance coverages and laws. It is not intended to provide a formal, definitive description or interpretation of Department policy. For specific Department policy on any issue, regulated entities (insurance industry) and interested parties should contact the Department.
Effective January 1, 2004, Illinois law required all individual and group insurance and HMO policies that provide coverage for outpatient services and outpatient prescription drugs or devices, must also provide coverage for all outpatient contraceptive devices approved by the Food and Drug Administration (FDA). Deductibles and coinsurance under that law are the same as those imposed for any other outpatient service or outpatient prescription drug or device under the policy.
Federal Law - New
The federal Affordable Care Act (ACA), which applies to self insured employer health plans as well as fully insured health plans, requires coverage of preventive health services without cost sharing when they are delivered by a network provider. These preventive health services include with respect to women, all FDA approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a provider, for all women with reproductive capacity. These provisions apply to non-grandfathered group and individual insurance coverage without cost sharing, in plan years (or, in the individual market, policy years) beginning on or after August 1, 2012. For example, if a plan or policy renews on January 1st, the new benefit will be provided effective January 1, 2013. This provision of the ACA does not apply to "grandfathered" plans. A "grandfathered" plan is a plan that existed on March 23, 2010.
Churches, other houses of worship, and similar organizations (religious employers) are exempt under the federal law from covering contraception on the basis of their religious objections. In addition, there is a one year safe harbor for group health plans sponsored by non-profit organizations that, on February 10, 2012, did not provide some or all contraceptive coverage consistent with state law (e.g., some hospitals fall in this category). Those organizations do not have to provide the coverage until the first plan year that begins on or after August 1, 2013.
Plans will retain the flexibility to control costs and promote efficient delivery of care by, for example, continuing to charge cost-sharing for branded drugs if a generic version is available and just as effective and safe for the patient to use. However, insurers must cover brand-name drugs with no cost-sharing when there is no generic equivalent available. Additionally, if a contraceptive method is approved by the FDA (even those not a part of the plan's formulary) and prescribed by the patient's health care provider, the provider can work with the carrier to get the method covered for the patient's medical condition.
Following are frequently asked questions regarding the state law. These questions apply to fully insured Illinois policies which (1) are grand-fathered plans or (2) have not yet renewed after August 1, 2012.
- How do I find out if my plan is self-insured?
You can ask your employer or call the plan to find out if your plan is self-insured. Most large employers and most union plans are self-insured. Many self-insured plans use insurance companies to process their claims and perform other administrative duties so it can be confusing to the covered person. If you cannot determine if your plan is self-insured, call us at (877) 527-9431. We may be able to assist you over the phone or we may request that you send a written inquiry so we can contact the company on your behalf.
- My plan has a $35.00 copayment for prescription drugs. Instead of birth control pills cost $32.00 so my plan does not pay anything. Is that acceptable under the law?
Yes. The law requires the plan to pay for birth control at the same benefit level as similar services under the policy. If your prescription drug copayment is $35.00, then the copayment applies to your birth control pills.
- My major medical policy has a $250.00 deductible for office visits and procedures performed in the office. Does this deductible apply to my office visit to consult my physician about birth control? Does it apply to office procedures such as insertion of an IUD (Intrauterine Device)?
Yes. The deductible that applies to office visits and procedures also applies when those services are necessary for purposes of birth control.
- I use Depo-Provera, a hormone injection that lasts for 3 months, as my form of birth control. I have to pick up the medicine from the pharmacy and take it to my physician for injection. How should this be paid under my policy?
The Depo Provera injection is administered in the doctor's office. Many physicians do not keep a supply of the Depo Provera medication in their office because it is not used often enough for them to maintain a fresh supply. Those physicians have their patients pick up the medication at the pharmacy and bring it to the office for injection. Benefits for the prescription should be paid according to the prescription drug benefit under the policy. Benefits for the injection are paid as any other injection in a physician's office. If the plan pays for injections under the major medical portion of the policy (for example, $100.00 deductible and then 80% benefit), then that benefit applies. If a physician does keep a supply of Depo Provera in his office, then the injection and medicine are subject to the major medical portion of the policy if that is how other injections are paid under the policy.
- Are condoms covered under the law?
No. Over the counter drugs and supplies are not covered.
- Does the law require insurance carriers to pay for the morning after pill?
There are two types of pills to take if you have had unprotected sexual intercourse and do not want to become pregnant. Pills called emergency contraceptive pills (ECPs) stop ovulation, fertilization and implantation. They are basically stronger birth control pills. They are called “morning after pills”, although you can take them up to 72 hours after intercourse.
The second type of pill is called RU-486 (mifepristone) is taken after a women becomes pregnant. This pill causes the uterus to expel the egg, ending the pregnancy. This is loosely classified as a form of abortion.
Insurers are required under the law to pay for the ECP but not for the RU 486. The ECPs or morning after pills are taken to prevent a pregnancy and are covered under the law. RU 486 is taken to end a pregnancy and it is not covered under the law.
- Do contraceptive drugs only need to be covered if the insurance policy covers both outpatient services and outpatient prescription drugs?
The law only applies to insurance plans that provide coverage for both types of services in order for birth control to be covered.
- Is an insurance company allowed to have a pre-existing clause for birth control pills and devices?
No, the insurance policy/certificate must provide immediate coverage after the effective date for contraceptive drugs and contraceptive outpatient services.
- My insurance company uses a drug formulary. My birth control medication is not on the formulary and I have to pay a higher copayment. Is that acceptable?
Yes. The company may apply drug formulary provisions to birth control prescriptions.
- My pharmacist refuses to fill my prescription for the morning after pill based upon her moral beliefs. Can a pharmacist refuse to fill my birth control prescription?
No. An emergency rule requires pharmacists to fill prescriptions in an appropriate and timely manner. Consumers can call toll-free at (800) 280-4149 to file a complaint with state regulators if a pharmacy fails to do so.
For More Information
Call our Office of Consumer Health Insurance toll free at (877) 527-9431 or visit us on our website at http://insurance.illinois.gov
215 ILCS 5/356z.4can be found at Illinois Compiled Statutes 215, Article XX, Accident and Health Insurance (scroll to approximately 1/3 of the way down the page or use find and search for "356z.4"), or by clicking on 215 ILCS 5/356z.4.