Finding a hormonal birth control that works for your lifestyle is tricky. And then, once you figure that out, you have to get a grip on how your health insurance works, and
how much you should be paying for your prescription. It can be overwhelming, particularly right now, when there's something about reproductive rights and health insurance in the news almost every other day.
If you have health insurance and take birth control pills, you've probably gotten used to a routine of going to the pharmacy and paying a certain amount (or nothing, if you're lucky) every single month. Or perhaps you use the mail-in pharmacy option through your health insurance company, which can make things even easier (most of the time), because the pills just magically arrive at your door in a bundle — like the stork, but different.
But, what if that setup suddenly changes, and when you go to the pharmacy, you're asked to pay a not-insignificant amount of money for your pills? You have every right to be confused and possibly angry, but that doesn't mean you should go ballistic on your pharmacist (it likely doesn't have to do with them). You just might have to do some detective work to figure out why the price was hiked, and if there's anything you can do to make your birth control more affordable again.
"If a person feels the cost of the prescription is too much or incorrect, they should not pay for the medication at the pharmacy until they get more information," says
Jean Moon, PharmD, clinical pharmacist and associate professor at the University of Minnesota College of Pharmacy. Obviously, that's not always the best decision for you — birth control pills are less effective if you skip days, and since you don't know exactly how long it will take to sort out the issue, you might need to just pay up so you can get your pills in the meantime.
Before you call up your health insurance company and sit on the phone with a robot, these questions might help you sort out why the price of your birth control pills has changed.
What health insurance plan are you on?
The price you're responsible to pay (a.k.a. your co-pay) for your birth control all depends on your health insurance coverage, Moon says. "Some prescription plans cover the entire cost of birth control, some require a co-pay or deductible payment, and some do not provide any coverage," Moon says. As with other types of medications, the price can vary, because some health insurance plans decide that they'll only cover certain brands of pills or generic versions, says
Papatya Tankut, RPh, vice president of pharmacy affairs for CVS Health.
the Affordable Care Act fit into this equation? Technically, under the ACA, most health insurance plans must cover birth control pills with little to no cost to you, Tankut says. " Health insurance Marketplace plans must cover these services without charging a copayment or coinsurance when provided by an in-network provider — even if the patient hasn't met their deductible," she says. But, this doesn't always work out in your favor, because insurance companies don't cover every single type of medication. That means that, if you need to be on a specific type of pill (with a specific formulation of hormones), and your insurance company decides not to cover it (even the generic), you're out of luck. More
What kind of birth control are you on?
There are a few things you can do to try and get a cheaper pack of pills every month, like requesting that your doctor prescribe a 90-day pack of pills instead of 30, which can come with a cheaper co-pay, Tankut says. You can also ask your doctor if it's absolutely necessary to be on your specific type of birth control, or if there's another pill that's basically the same as the one you're on that might be cheaper — but you shouldn't settle for something that's not exactly what you need just because it's cheaper (as long as you can afford it), Tankut says. "It’s important that the medication prescribed is best for the individual patient and meets their specific healthcare needs," she says.
First, see if you can get a generic pill, Moon says. Generic medications are cheaper than name-brand ones, because drug manufacturers don't have to duplicate the same clinical trials for effectiveness and safety, so it's cheaper to bring the drug to the market, Tankut says. (If you're not sure if you're on the generic version of your pill, you can just ask your pharmacist.) But, if something's cheaper, does that mean you're getting sale-rack quality medications?
"It is not detrimental to use a generic brand medication," Moon says. Generic medications have the same active ingredient as brand-name drugs, but they might have different inactive ingredients. Some people have allergies to these ingredients, though, so they can't use a generic option, she says. Otherwise, they're totally fine: "It's the same in dosing, safety, strength, quality, the way it works, the way it's taken, and the way it should be used," Tankut says.
In many states, pharmacists automatically fill your prescription with a generic alternative, unless they hear otherwise from your provider, Moon says. "It never hurts to ask your pharmacist for a generic brand medication alternative," she says. "The pharmacist may also be able to offer another birth control option that is less expensive."
What drug "tier" is your birth control?
Here's where it gets complicated. Now, say the co-pay for your specific type of birth control pill all of a sudden becomes crazy-expensive (like it goes from $10 to $60). That's a different story, says
Paige Clark, RPh, director of alumni relations and professional development at the Oregon State University College of Pharmacy. The sudden change is probably because your birth control pill changed drug "tier," she says.
So what does that mean? Insurers have
a list of drugs (called a formulary) that they agree to pay for, and it's broken down into a hierarchy of tiers, including "nonpreferred" or "specialty" drugs, both of which usually have higher co-pays or are not covered, Clark says. People on some Blue Cross Blue Shield plans, for example, might be required to pay 45% of the drug cost if their birth control falls in the "nonpreferred" drug tier (these are usually brand-name drugs). The most expensive drugs fall in the "specialty" category for BCBS, and they're usually drugs that treat complex conditions (like cancer). People pay 33% of the drug cost for those. You can easily look up your health insurance plan's formulary and tier system online, Clark says.
Sometimes, particular drugs (like birth control) can switch tiers because your company changed their formulary, which can then make your co-pay more expensive, Clark says. "That's a decision made annually, and there's so much negotiation that goes on between the employer and the insurance company," Clark says. Or, if you switch health insurance companies, and the cost of your birth control goes up, that could mean that your new insurance carrier has your medication on a different tier in their formulary than your previous insurer did. You're not necessarily doomed if either of these things happens, and you may not need to stomach that $50 or $60 fee every month, Clark says.
In these cases, you would have to call your doctor and have them communicate with your insurance company and make a case for why you have to be on this birth control pill, Clark says. It's called "prior authorization" in pharmacist lingo, she says. "This process is in place for situations like this, where medically, you need to be on a certain medication, and the formulary changes," she says. "
I'm a special case, is what you're saying, and you're getting medical documentation for that to happen." Of course, this doesn't always work, since it's dealt with on a case-by-case basis, but it's worth a shot.
Dealing with the complexities of health insurance can be frustrating, especially when it's impacting your ability to have access to contraception. (And don't forget:
Birth control has many other health benefits beyond just preventing pregnancy.) Luckily, there are people that can at least try to help you. "Generally, clinical pharmacists are very good at problem-solving like this," Clark says. If something seems wrong or doesn't make sense about the cost of your birth control pills, there's a good chance it is wrong. At the end of the day, it's your body — and your right to ask questions. More Like what you see? How about some more R29 goodness, right here? 5 Things That Can Cause Multiple Pregnancies Confused About Gender Dysphoria? Here's What It Is — & Isn't Watch: The Tattoo Artist Changing Women's Lives By Inking Their Breasts