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Panelists Discuss Insurance Coverage of Opill, OTC Contraceptives During KFF Webinar


Laurie Sobel, the associate director for women’s health policy at KFF, moderated a panel discussion with Christine Gilroy, MD, MPH; Victoria Nichols, MPH; and Don Downing, RPh, about insurance coverage of FDA-approved Opill and other OTC contraceptives.

Stakeholders explored the benefits and challenges of covering OTC contraceptives in a panel discussion on September 15 moderated by Laurie Sobel, the associate director for women’s health policy at KFF (formerly known as the Kaiser Family Foundation).

The topic was first introduced by Michelle Long, KFF’s senior policy analyst, who summarized the KFF team’s recent findings published in a report, “Insurance Coverage of OTC Oral Contraceptives: Lessons From the Field.” She explained that the team conducted 35 structured interviews with nearly 80 key players from the 7 states that offer such coverage (Illinois, New Jersey, New Mexico, New York, Oregon, Utah, and Washington); the interviewees included pharmacists, payers, manufacturers, and federal and state regulators. Each interviewee highlighted their experiences implementing coverage, including their successes and challenges.

dr christine gilroy

Christine Gilroy, MD, MPH

Image credit: Express Scripts

Based on information gained from the interviews, Long identified key strategies to successfully implement national insurance coverage of OTC contraceptives, like the FDA-approved Opill. She explained that the interviewees noted the importance of outreach and education of pharmacies, pharmacists, and consumers. Also, Long noted the need for a standardized billing process and compensation for pharmacies and pharmacists billing for nonprescribed Opill. She concluded by explaining that federal guidance must be established so that coverage decisions do not continue to vary state by state.

To further explore this topic, Sobel moderated a panel discussion with Christine Gilroy, MD, MPH; Victoria Nichols, MPH; and Don Downing, RPh. Gilroy is the chief medical officer at Express Scripts, a national pharmacy benefits manager, where she leads clinical efforts to improve health outcomes and increase affordability for members and clients. Nichols is the project director of the Free the Pill Coalition, a national campaign backed by Ibis Reproductive Health that supports education and public engagement regarding OTC birth control pills. Downing retired in June 2023 as a clinical professor at the University of Washington School of Pharmacy and endowed chair of the Institute for Innovative Pharmacy Practice.

To begin the discussion, Nichols explained that affordability is key to ensuring that people have access to Opill once it hits shelves in 2024. She noted that Free the Pill is switching its focus to advocating for insurance coverage and affordable pricing to guarantee that no prescription is required for any OTC birth control pills.

don downing

Don Downing, RPh

Image credit: UW School of Pharmacy

Downing also touched on price, explaining that community pharmacies pay more for the same medications than other class trade purchasers despite being the largest medication purchaser in the United States and the site where most customers obtain medications. He noted that if the OTC billing system is not simplified, low-income people wanting Opill will be faced with costs beyond their means due to the “inherently unjust” pricing model.

“I think we need to address this before this product becomes available,” Downing said. “I personally would promote an equal price across all classes of trade and eliminating a lot of their rebate hoopla that occurs that often elevates the price of drugs.”

Other than price, Downing claimed the biggest challenge for Opill coverage was the variety of rules from different health plans in each state that create a complicated billing pathway for pharmacists; he explained that pharmacists sometimes use stopgap processes when handling OTC contraception.

Victoria Nichols, MPH

Victoria Nichols, MPH

Image credit: Ibis Reproductive Health

“Two years ago, I had students in my pharmacy reproductive health group survey local pharmacies in Washington state trying to bill for OTC emergency contraception and found that most pharmacists had to resort to prescribing the contraception in order to get insurance coverage,” Downing said. “This means that the consumer who decided themselves to purchase the OTC product now has become a patient and the pharmacist now has become a prescriber with inherent provider liabilities. I don’t see this as a pathway for easy access to OTC medications, even though it has worked as a stopgap process in Washington state, I don’t think that’s what we should be going with in the future.”

Although OTC contraceptives are a positive step toward expanding access, Gilroy noted her concern that removing the barrier of paying for a physician visit to get a prescription will add a new hurdle for pharmacists. This is because pharmacists must enter the contraceptive into a system essentially turning it into a prescription for it to be processed against a pharmacy benefit.

She dislikes this as it “requires pulling a licensed pharmacist away from other work that they’re doing in the pharmacy, which could be administering vaccines, talking with physicians, and counseling patients about other medications, just to spend a couple of minutes entering something into the claims system in order for that to adjudicate.”

Considering these challenges, Sobel asked each panelist what they believe needs to happen overall to facilitate coverage of Opill and other OTC contraceptives. Gilroy explained that the claims system must be modernized, and pharmacists need to be reimbursed. Downing followed up by saying that a nationally accepted claim processing system needs to be created as multiple currently exist. He added that a national uniform dummy provider number should be created for pharmacists to easily indicate an OTC contraceptive when running a claim to streamline the process.

Pharmacist helping a customer

Pharmacist helping a customer | Image credit: Reese/peopleimages.com - stock.adobe.com

Nichols concluded by making 2 suggestions, her first being that other states should learn from those with already established coverage. She noted that states in the process should listen to those who have successfully done it to make it a smoother process and better support consumer education. Her second suggestion was for the federal government to have more uniform guidelines around OTC contraceptives.

“Throughout your [the KFF team’s] report, so many people reference consistency in the guidance from the federal government,” Nichols said. “It says something in the FAQs that's different from the HRSA's [Health Resources and Services Administration’s] guidance and having some consistency there would be really helpful so everyone's on the same page about what the law is and how to enforce it.”

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