Private Insurance
The Affordable Care Act (ACA) requires most private health plans (group and individual) to cover, without cost sharing, the full range of FDA-approved contraceptive methods, which includes oral contraceptive pills. The ACA tasks the Health Resources and Services Administration (HRSA) with coverage requirements for a range of preventive services for women, which now includes contraception, that must be covered by insurance. Right after the ACA was passed, HRSA tasked the Institute of Medicine (IOM) to identify gaps in preventive recommendations. This committee identified contraceptive services and supplies as one of the eight gaps in preventive health services to promote women’s health. The IOM recommended that all FDA-approved contraceptives be included as preventive services, and the HRSA coverage requirement for contraception included that they be covered “as prescribed,” which was reflected in the original guidance issued by the Obama administration in 2013.
Currently, HRSA has commissioned the Women’s Preventive Services Initiative (WPSI) as the expert body it relies on to update and expand preventive services coverage recommendations, which WPSI last updated in 2021. The current coverage requirement posted by HRSA no longer includes a prescription requirement for coverage of contraception, but the U.S. Departments of Labor, Health and Human Services, and Treasury (federal tri-agency) guidance has not been revised to drop the “as prescribed” requirement.
The prescription requirement is currently only mentioned in federal FAQs clarifying ACA coverage requirements, with the most recent one issued by the Biden administration in July 2022. The FAQ references coverage of emergency contraception and states that plans must cover OTC contraceptives when the product is prescribed. It also states that plans are “encouraged to cover OTC emergency contraceptives with no cost sharing when they are purchased without a prescription.” In October 2024, the Biden administration proposed a new rule that would have broadened the ACA’s coverage requirements and, if finalized, would have required private insurers and states with ACA Medicaid expansion to cover OTC contraceptives without a prescription. However, the proposed regulation was withdrawn in January 2025, before the change in administration.
OTC medications and products do not require a prescription for purchase, but most people wishing to avoid cost-sharing for them need to obtain one. The prescription requirement re-introduces some of the same barriers that were intended to be reduced with OTC status such as eliminating the need to make and wait for a doctor appointment or find a pharmacy whose pharmacists are licensed and available to prescribe contraception (where permitted by state law).
Medicaid
Medicaid is the public health insurance program that covers approximately 20% of low-income children, adults, seniors, and people with disabilities. Medicaid is jointly financed by the federal government and the states. Federal statute sets broad minimum standards in exchange for federal matching funds and states have flexibility in determining other aspects of their Medicaid programs such as covered services and provider payment models.
Coverage for contraceptives is a key element in Medicaid coverage of family planning services. All states cover prescription drugs, even though it is technically an “optional” benefit category under federal law. Federal rules require state Medicaid programs that cover prescription drugs (including OTC drugs with a prescription) to cover all prescription drugs from manufacturers that have entered into a federal rebate agreement with the U.S. Secretary of Health and Human Services, though states may determine whether and how to employ utilization management controls. In order to obtain federal matching funds, a prescription is required for over-the-counter drugs and products.
Federal law also requires state Medicaid programs to cover family planning services and supplies without cost-sharing to enrollees. The federal Medicaid law does not define what services must be included and also does not explicitly cite OTC contraceptives as part of the coverage requirement, but most state Medicaid programs cover a range of contraceptive methods, and some cover OTC methods. The ACA requires states to cover at least one form of all 18 FDA-approved contraceptive methods for enrollees who qualify through the ACA’s Medicaid expansion. In general, these services are defined and determined by the states within broad federal guidelines.
With few exceptions (such as prenatal vitamins, fluoride preparations for pregnant people, and tobacco cessation products), federal law does not require states to cover OTC drugs and products in their Medicaid programs. However, state Medicaid programs can opt to cover them by submitting a state plan amendment (SPA) to CMS, the federal agency that administers Medicaid in partnership with state Medicaid agencies. For example, CMS approved SPAs Delaware, Montana, and Florida requesting to cover select OTC drugs generally. After obtaining approval from CMS to cover OTC products generally, states can choose which OTC products their program will cover. However, even when a drug is available to purchase without a prescription, enrollees usually need a prescription to obtain coverage under Medicaid and states cannot obtain federal matching dollars unless it is prescribed. If states wish to include coverage for OTC products without a prescription, state Medicaid programs may opt to use state-only funds.
