Medicaid Coverage of Plan B® Over-the-Counter: New York State's Experience

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Women's Health Activist Newsletter
May/June 2009

By The Education Fund of Family Planning Advocates of New York State

Advocates fought for years to make emergency contraception available over-the-counter so that women could have convenient and timely access to this contraceptive option when they needed it. But removing the prescription requirement created a new barrier for some women -- over-the-counter drugs are usually not covered by insurance, so the change increased the expense of getting EC for women who might otherwise have been able to get it at low- or no-cost. In some states, including New York, advocates figured out a solution to this problem, working with the state to pay for EC for women receiving Medicaid. The Education Fund of Family Planning Advocates of New York State (Ed Fund) studied the experience with Medicaid coverage of EC and produced a policy brief with recommendations to help ensure that low-income women’s access to EC is not impaired by unnecessary barriers. That report is excerpted below.

In August 2006, the Food and Drug Administration approved over-the-counter sale of Plan B® emergency contraception (EC) for women 18 years of age and older -- significantly expanding access to this safe and effective method of preventing unintended pregnancy.1 Despite being available over-the-counter (OTC), the retail price of Plan B® ($35--$60) remains a significant barrier for low-income women.2 Several states have addressed this barrier by paying for EC through the Medicaid program. The Ed Fund, which has been working with state agencies and other organizations to expand access to EC, recently released a study of the effect of this coverage decision.

Federal Medicaid law allows states to cover OTC products if they are treated as prescriptions and if the patient obtains a “fiscal order,” meaning that a qualified health practitioner must provide a pharmacist with a patient- and drug-specific order in writing before the OTC product can be dispensed.3 In practice, the fiscal order requirement is just as cumbersome as the need to get a prescription for EC, and similarly delays women’s use of the product. Because EC is most effective when used as soon as possible after unprotected sexual intercourse, it is critical that a woman obtain it without delay.4

In order to circumvent the federal requirement for the fiscal order, the New York State Department of Health (DOH) assumed 100% of the cost of Plan B® emergency contraception for eligible recipients. In January 2007, the DOH informed pharmacists that it would no longer require a fiscal order for Plan B®. New York is now one of 16 states that cover Plan B® with Medicaid funds, joining AR, CA, HI, IL, MD, MS, MN, NJ, NM, NC, OK, OR, UT, WA, and WY.5 At the time the policy brief was published, only four of these states, including NY, waived the fiscal order requirement.

The Ed Fund study of the cost of covering Plan B® and usage levels of the emergency contraceptive among Medicaid beneficiaries indicate that, in 2007, almost 18,000 women ages 18 years and older obtained Plan B® through the Medicaid program. The state paid $774,904 for non-prescription and prescription Plan B®, which was much less than DOH had anticipated. DOH had estimated that claims would double but, in fact, they remained essentially flat: 23,402 claims from 2005—2006, versus for 23,005 in 2007.6 Additional savings are likely to have occurred because health care providers no longer needed to write fiscal orders or prescriptions.

New York mandated Medicaid pay for no more than six courses of Plan B® per woman in any 12-month period. Among the Medicaid beneficiaries who used Plan B® in 2007, however, 89 percent obtained only one or two courses of the EC. Only one percent of women asked for the full six courses of treatment allowed in a year. This finding indicates that the six-dose cap is not needed to control costs and that removing it would have a minimal fiscal impact to the state, while ensuring women in need have access to critical pregnancy prevention methods.

Applying conservative estimates, between 300 and 500 pregnancies were prevented as a result of New York’s policy. New York’s patient-centered policy of providing Medicaid coverage for over-the-counter Plan B® without burdensome paperwork removes significant financial and logistical barriers for low-income women who fear they might be pregnant. Despite the policy’s success, however, the stable number of claims from 2006-2007 suggests the need to increase both pharmacists’ and women’s awareness of the state’s Medicaid coverage for Plan B®. (As noted, the number of claims remained level in New York after the policy change, while Plan B® sales increased 120 percent nationally after the FDA decision.7

Policy Priorities

FPA commends the New York State Department of Health, pharmacists, advocates, and health professionals for their laudable efforts to increase low-income women’s awareness of, and access to, emergency contraception and on-going reproductive health care. But more must be done by health departments, health care providers, and advocates alike to increase consumers’ awareness not only of EC in general, but also of this policy specifically. FPA recommends that:

  • New York should continue Medicaid coverage of Plan B®OTC without a fiscal order. In addition, the state should ensure that Medicaid recipients who live in the counties with disproportionately low numbers of Plan B® claims are aware of the EC policy and have access to Plan B®, if needed.
  • New York should expand access further by eliminating the annual six-course cap on Medicaid coverage of Plan B® or raise the cap to 12 courses.
  • New York should incorporate information about Plan B® into all state initiatives focused on improving birth outcomes and reducing infant mortality rates. EC can play an important role in helping women prevent unintended pregnancies and poor birth outcomes. Educational materials should be developed for consumers and women to explain Medicaid’s coverage of prescription and non-prescription Plan B®. FPA has developed fact sheets for consumers and pharmacists (available on-line in English and Spanish at: http://www.fpaofnys.org/resources/other/index.asp).

On a national level, the NWHN and other women’s health advocates recommend that:

  • The Federal regulations should be changed to allow federal Medicaid reimbursement for states that cover OTC contraception in general, and cover EC over-the-counter specifically. Unfortunately, without the ability to obtain federal funds for this coverage, it seems very unlikely many states are going to be willing to make the switch.
  • States that do not yet cover EC using their Medicaid funds should do so immediately.
  • States that provide Medicaid coverage for Plan B® but have not waived the fiscal order requirement should note of the lower-than-expected outlay and waive the fiscal order requirements that hamper women from accessing this product.

References

1. Plan B® is a registered trademark of Duramed Pharmaceuticals, Inc.
2. Not-2-Late Website. http://ec.princeton.edu/questions/eccost.html (retrieved 3/21/08)
3. According to the emergency rule published in the NYS Register, February 13, 2008, “a written order requires that a qualified medical practitioner provide a written, telephone or fax order for a specific drug for a specific patient.” Federal regulation [42 CFR 440.120(a)(3)] referenced in the rule, refers to a written prescription that is maintained in the records of the pharmacist or practitioner.
4. Plan B® Website. http://www.go2planb.com/ForConsumers/Index.aspx (retrieved 3/21/08)
5. Only four states—New York, Washington, Illinois, and Oregon—have waived the fiscal order requirement. The Medicaid program in New Mexico will soon cover Plan B® without a prescription for adult women. In the nine “pharmacy access” states, Medicaid covers Plan B® prescriptions so women of any age can easily obtain Plan B® at participating pharmacies. National Health Law Program (2007). Over the Counter or Out of Reach? A Report on Evolving State Medicaid Policies for Covering Emergency Contraception. Also, personal communication with Dale Tinker, Executive Director, New Mexico Pharmacists Association, June 15, 2008.
6. Between 12/1/05 and 11/30/06, there were 23,402 claims for 16,934 recipients totaling $716,841 (excluding one claim from OMH). (Data Source: DOH/OHIP AFPP Data Mart). The study noted that one of the possible reasons accounting for the steady number of claims was that New York’s family planning centers were providing Plan B® in increasing numbers to low income women.
7. Andrea Porzio, Duramed, presentation delivered at the STATES Meeting hosted by the Pharmacy Access Partnership in San Francisco, May 19, 2008.

To read the full report from FPA, see  http://edfundfpa.org/documents/FPA-MedcdPolBrf-8-08Final-hi.pdf http://edfundfpa.org/documents/FPA-MedcdPolBrf-8-08Final-hi.pdf. This research was made possible with the generous support of The Compton Foundation.

The Education Fund of Family Planning Advocates of NYS would like to thank Linda Simkin for conducting this study. We also wish to acknowledge Jane Wishner, Executive Director, Southwest Women’s Law Center, and Lawrence Finer, Guttmacher Institute, for their assistance.