Ryan Haumschild, PharmD, MBA, MS, provides background on the Affordable Care Act (ACA) within the scope of women’s health, including specific mandates on contraceptives.
Ryan Haumschild, PharmD, MBA, MS: It was identified that there are disparities in care [for women in the United States], and they recognized how important women’s health is. Women’s health is a public health need across so many different areas. There was a women’s health study that came from HRSA [Health Resources & Services Administration] that had some of the founding research that said [that] not only do we need to create access, but we need to do it in a cost-effective way. Doing that without cost-sharing was a way to give everyone access regardless of socioeconomic background. That was a mandate that came forward as part of the Affordable Care Act that we need to comply with as payers, and I think that has created better access and reduced the amount of expense for women across the country looking for contraceptive care, prenatal care, or any type of care related to women’s health.
Coming down to the $0 copay was a process. Prior, there were some exceptions that you could have, meaning [that] as long as you had some preference and regional management strategies, you could go ahead and utilize those step-through management strategies. More recently, there has been information that we need to provide all types of contraceptives, regardless of brand or generic, if [it is a] medical necessity required by the provider to create those medications. We’ve pivoted strategies, and we want to become more compliant with the Affordable Care Act. We have some therapies we recommend [that] cover the 18 common contraceptive therapies for treatment, but at the same time, we now have a very transparent and straightforward process if a provider feels like there’s medical necessity around a specific treatment that might not be preferred or a generic, and we create a pathway for that to provide access to all the different medications when medical necessity requires it.
When we look at the different therapies that are required, the ACA’s FAQs [frequently asked questions] make sure that we provide medications across the spectrum. That means contraceptive medications, any type of hormonal medications, preventive medications, and prenatal medications. We want to provide those therapies. There are 18 different therapies that fall within that, and we want to make sure that we cover at least 1 of all of those [types]. It might be IUDs [intrauterine devices]. It might be oral contraceptives, [or] it might be female condoms. All of those fall within that greater strategy, so we need to make sure that we have access through our payer plan.
We’ve revamped our policies to have access without cost-sharing for all of those products. With that, we want to reinforce that if someone has a medical necessity where they need a specific product or a specific brand, we [will] create a pathway of access for those that’s clear. At the same time, we gather information that justifies the medical necessity, but we can still give all females access to those medications.
As new medications are approved that aren’t always in the federal list, you want to be looking at them with a unique lens. What is the mechanism of action? What is the improvement they’re providing in efficacy and safety, and how will they improve adherence? Those are the kinds of pillars that we look at when we’re evaluating new therapies. Also, we do look at costs because at the end of the day, we want to provide cost-effective treatment for our patients. We may still favor medications based on clinical efficacy and safety, but if there’s a specific patient population that needs that therapy, we’re going to create a way for them to get access to it without cost-sharing.
This transcript has been edited for clarity.