Advancing Contraception Access in States Through One-Year Dispensing and Extended Supply Policies

With the overturning of Roe v. Wade and many policymakers’ growing hostility toward reproductive health care, there is an urgent need and opportunity to protect and expand access to contraceptive care.¹ While many existing and emerging threats to reproductive health care are focused on restricting access to abortion,² contraceptive services are also at stake despite strong public support.³ Indeed, experts have noted that while many birth control options have a “seemingly minuscule failure rate,”⁴ the stakes are even higher now given the country’s patchwork of extreme abortion bans⁵ and the pressure of navigating pregnancy prevention and planning.

While data that characterize pregnancy desires and intentions are limited, most estimates show that unintended pregnancies⁶ account for almost half of all pregnancies in the United States.⁷ These trends demonstrate a pronounced gap in the provision of reproductive health care services. While 65 percent of women—46.9 million overall⁸—from ages 15 to 49 currently use at least one contraceptive method, many others have been systemically excluded from accessing comprehensive family planning services and contraceptive care. More than 19 million women in the United States live in contraceptive deserts⁹—areas with insufficient access to the full range of contraceptive methods—and this burden disproportionately affects women of color,¹⁰ who also tend to report more negative health care experiences overall.¹¹

However, there are several promising legislative and regulatory policy reforms that states can pursue to mitigate burdens related to contraceptive access.¹² Some states have already begun putting into effect policies to address the main barriers to access. To start, one promising policy reform is to extend quantity limits on supplies of contraceptives covered by health care plans and insurance programs such as Medicaid and private insurers.

Conventionally, most insurance plans only cover one to three months of contraceptive supplies, which are typically oral contraceptives, hormonal patches, or vaginal rings.¹³ However, that standard is slowly changing, with evidence suggesting that there are numerous advantages to ensuring coverage of a one-year supply of some contraceptives for patients. As a result, approximately half of states have begun implementing such a change. However, many have encountered barriers that have kept the promise of the policy from being fully realized; a recent scan of states with 12-month mandates found relatively low 12-month prescription utilization rates, suggesting there is room to improve. ¹⁴ (see section on “Charting a path forward”) In particular, policymakers should consider approaches that increase awareness and modernize training for providers; inform patients and apprise consumers of policy changes; optimize technology and medical management tools to correspond with policy updates; update mechanisms to promote transparency and accountability; and, finally, promote a broader understanding of the benefits and evidence pool for one-year contraceptive dispensing to counter common objections to the policy. More specific recommendations are provided at the end of this report.

Burdens alleviated by one-year dispensing

Quantity limits necessitate multiple unnecessary trips a year to a physician for new prescriptions, making health care particularly onerous and burdensome for people seeking contraceptive care. People seeking contraceptives must take into account travel time and costs, child care, and work schedules—among many other considerations—just to coordinate a contraceptive visit. Emerging research also finds that women experience emotional and mental burden, as they often regularly assume the primary responsibility of using contraception and preventing pregnancy; this anxiety is often reproduced through clinic visits and encounters with physicians.¹⁵ As a result, small quantity limits increase the likelihood of contraceptive discontinuation and diminish women’s ability to plan their pregnancies. These burdens are particularly acute for women living in contraceptive deserts and rural areas who must travel long distances to obtain a prescription from a health care provider and fill it at a pharmacy.¹⁶ Furthermore, extending the quantity limits on contraceptives could help improve access for low-income people who are uninsured or underinsured.¹⁷ About 30 percent of low-income and uninsured women rely on health centers and public family planning clinics to receive contraception as well as other preventive services.¹⁸ Moreover, low-income women are less likely to receive recommended preventive care and more likely to skip doctor’s visits because of cost.¹⁹

Overall, providing coverage for an extended supply of contraceptives can minimize disruptions in care and promote consistent use.²⁰

Benefits in minimizing disruption in access to contraception

The importance of consistent use of contraceptives is clear. Many women rely on hormonal contraceptive methods for noncontraceptive purposes. For example, some birth control may be used to address menstrual-related concerns or for other medical purposes, such as managing menstrual pain, treating acne, and managing endometriosis, as affirmed by the American College of Obstetricians and Gynecologists.²¹ Ensuring those individuals have consistent access to contraceptives will ensure continuity of care for those conditions as well.

But the top reason women choose to use contraceptives is to time their pregnancies to their choosing. And it is clear that consistent use of contraception helps people choose when to become or if they want to become pregnant.²² For instance, one study found that women who received a one-year supply of oral contraceptives through California’s family planning program had a 30 percent reduction in unplanned pregnancies compared with women who received a one- or three-month supply.²³ Not only does easier access to contraception mitigate these risks, but it also has been shown to have numerous advantages, particularly when it comes to economic outcomes, educational attainment, and overall well-being for women.²⁴ For example, studies have found that early access to birth control, which is defined as access by age 20, reduces the likelihood that a woman is living in poverty,²⁵ increases wages and earnings over a lifetime by as much as “5% more per hour and 11% more per year,”²⁶ and may increase high school graduation²⁷ and college enrollment rates.²⁸

Extended supply policies tend to fall under the scope of administrative or regulatory law, particularly for Medicaid health plans or Medicaid-managed care plans (MCOs). Sometimes Children’s Health Insurance Program (CHIP) plans and student health benefits also cover contraceptives, which makes it easier for states to enact these policies independently and often without modifying state budgets. The ability to change regulation of contraceptives and family planning without modifying states budgets is imperative, because states typically encounter more barriers with budget modifications, which are subject to legislature review and approval.³¹ States that are hostile toward reproductive health care may be less inclined to approve budget modifications even when the state’s executive branch supports such changes.

However, state administrative agencies—such as those that regulate state pharmacy standards, ensure the provision of appropriate health and social care services, regulate financial institutions, and more—can all take action to revise existing regulations outlining contraceptive quantity limits and also issue updated regulations for insurers and health care providers and prescribers to follow.³²

It should be noted that the implementation of extended supply policies is relatively new, as most states have only introduced these policies within the past five to six years. As of the publication of this report, 22 states and the District of Columbia require certain insurers to cover an extended supply of contraceptives.³³ In 2015, the District of Columbia was the first to sign into law 12-month legislation, and was quickly followed in 2016 by California, Hawaii, Illinois, Oregon, and Vermont.³⁴ Since then, other states have followed suit, although to varying degrees and with limitations or restrictions on a state-by-state basis. Common restrictions to 12-month contraceptive supply extensions include limiting these extensions to certain types of methods and devices, predominantly oral contraceptives, as they are the most common and most available method of birth control, but increasingly, the patch and ring are being included in quantity-limit extensions. Other restrictions include limiting the number of refills that can be made within an insurance plan year and requiring shorter periods for initial dispensing. It is also important to note that while these policies mandate insurers to cover a 12-month supply at one time, not all policies require a physician to prescribe contraceptives for 12 months at one time, meaning that a health care provider may sometimes use their discretion.

Below are examples of how some states have begun to revise policies, develop processes, and promote one-year dispensing for contraceptives. These case studies are not designed to be comprehensive, and some additional statistics from states are briefly described in the recommendations section of this report to further explain the need for certain changes. The following examples demonstrate the growing momentum for administrative and legislative change in a diverse set of states.

New York

A 2014 study conducted by the New York Civil Liberties Union (NYCLU) found that “most insurance companies were not complying with federal and state law, including inappropriately charging cost-sharing and omitting coverage for various methods of contraception,”³⁵ urging lawmakers to pass a bill known as the Comprehensive Contraception Coverage Act, which, among other provisions, allows for access to a one-year supply of contraception. Additionally, a New York State Department of Financial Services (DFS) investigation of 15 health plans revealed that the plans often provided incorrect and incomplete information to consumers regarding contraceptive coverage. Consequently, the DFS outlined three corrective actions to address these errors:

1. Require a corrective action plan and related relief from all health plans that failed to provide accurate or complete information.
2. Demand information and documentation from health plans regarding their coverage and reimbursement of contraceptive drugs and devices under health insurance policies. Specifically, the DFS will obtain information about contraceptive claims submitted and assess whether the claims were appropriately paid, with no cost-sharing imposed. The DFS will also investigate complaints and appeals involving contraceptive coverage.
3. Take further regulatory action as necessary to ensure that all health plans cover the full range of Food and Drug Administration (FDA)-approved contraceptive delivery methods at no cost-sharing.³⁶

In 2017, New York established minimum standards for the sale of health insurance through the DFS,³⁷ allowing an insurer to cover the dispensing of an initial three-month supply of a contraceptive. For subsequent dispensing of the same contraceptive covered under the same policy or renewal thereof, an insurer must cover up to 12 months at the same time. Later in 2019, New York signed into law S.B. S659A,³⁸ enacting the Comprehensive Contraception Coverage Act, which went into effect in January 2020 and now requires insurers to cover a 12-month supply of a contraceptive for eligible people of childbearing age, including people under the age of 21.

In December 2019, the DFS issued a press release³⁹ and circular letter⁴⁰ to remind insurers of their responsibilities to cover all FDA-approved contraceptives, including 12-month supplies, with no cost-sharing and over-the-counter emergency contraceptives. In response to further noncompliance by three insurers—Aetna, MetroPlus Health, and Oscar Health—New York Attorney General Letitia James issued a press release demanding that they immediately comply and provide coverage for 12-month contraceptive supplies.⁴¹ In addition, each company received a letter outlining the importance of extended supply of contraceptives. James also urged anyone who has been wrongfully denied coverage to reach out to the office’s helpline and file a complaint.⁴² The investigation is ongoing.

Washington

In Washington state, the Health Care Authority (HCA) “changed the policy for oral contraceptive pills (OCPs) supply in 2014 by requiring the dispensing of one-year packages for Medicaid recipients (under Section 213, Chapter 4, Laws of 2013, 2nd Special Session.”⁴³ The policy change required that the Medicaid program cover a one-year supply upon prescription. One study found that while the 2014 policy was not implemented to the scope intended,⁴⁴ it still saved $1.5 million—an average of $226 per client—on maternity and infant care services due to averted births compared with those who received an initial one-month supply in 2014.⁴⁵

In 2017, Washington State Legislature passed H.B. 1234, requiring “a health benefit plan issued or renewed on or after January 1, 2018, that includes coverage for contraceptive drugs must provide reimbursement for a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply.”⁴⁶

South Carolina

As part of its routine evaluation of the services provided through its Healthy Connections Medicaid program, South Carolina made several benefit and reimbursement changes. In July 2020, the South Carolina Department of Health and Human Services amended the South Carolina Title XIX state plan to require the Medicaid program to cover a 12-month supply of systemic contraceptives, which are defined as oral birth control pills, transdermal contraceptive patches, and vaginal contraceptive rings.⁴⁷ This requirement only applies to Healthy Connections Medicaid members. Notably, South Carolina reported that it does not anticipate a budget change as a result of this policy.

Michigan

In 2022, Michigan, having reviewed other states’ policies on extending contraceptive supplies and following the Centers for Disease Control and Prevention (CDC) recommendations, implemented its extended 12-month per fill supply policy. That policy includes the provision of oral contraceptives, vaginal rings, and the contraceptive hormonal patches to Medicaid beneficiaries.⁴⁸ The Michigan Health and Aging Services Administration (HASA) issued a policy bulletin update in June 2022 outlining the revised policy changes.⁴⁹ An April 2022 bulletin also included clarifying language for pharmacy coverage, saying, “Contraceptive prescription drug claims should be billed at point-of-sale directly to the Michigan Department of Health and Human Services,” while also stating that “medications will be subject to other existing Fee-for-Service (FFS) pharmacy policies and coverage limitations, including refill thresholds and prior authorization (PA) requirements.”⁵⁰

HASA cited three key reasons for the uptake of the new 12-month policy: 1) reducing gaps in contraception continuation and unintended pregnancies; 2) improving pregnancy timing and spacing; and 3) improving contraceptive equity and health outcomes while lowering direct costs of pregnancy management.⁵¹

With nearly half of all states having implemented some type of extended supply contraceptive policy, the remaining states can utilize the existing evidence base to inform their decisions for when and how to develop and implement new policies that meet their intended purpose and achieve measurable goals. Similarly, states with insufficient implementation may consider how to modify their policies and practices to be more effective. As previously mentioned, most states with one-year mandates have relatively low utilization rates, suggesting there is room to improve.⁵²

Statewide policy implementation is a multifaceted and complex issue that requires coordination across many different agencies and organizations. The siloed adoption of a policy in one sphere limits large-scale adoption of a policy and behavioral change. Likewise, policy without a direct implementation plan will be inadequate. Therefore, states must make a concerted effort to create actionable implementation plans, measurable objectives, and transparency and accountability structures.

Challenge: Provider awareness

A common barrier to widely implementing 12-month dispensing policies is a lack of awareness, education, and training initiatives needed to educate providers and pharmacists on new policies and changes that take place. Currently, the communication channels are not robust, and many providers report minimal to no training on new laws and subsequently how to put these changes into practice. It is imperative that providers and patients are aware of and educated on new regulations to ensure the provision of quality, comprehensive care.

For example, when Maryland passed the Contraceptive Equity Act of 2018, the majority of clinicians surveyed were unaware of the new 12-month prescribing provision.⁵³ Furthermore, of the 38 percent of clinicians who did report being aware, only 13 percent said their prescribing practices changed because of it.⁵⁴

Additionally, Massachusetts—which passed a 12-month dispensing law in 2017—has provided a critical window into understanding the implementation issues that can arise. For example, a CommonWealth investigation pointed out that the rollout of the new law may have been hampered because the state did not have a centralized way of providing updates on regulations to pharmacists and clinicians.⁵⁵ Many providers were unaware of the 12-month dispensing policy change. For example, it appears providers may receive updates from both relevant state boards, specifically the Board of Registration in Medicine and the Board of Pharmacy, as well as insurers, and that these updates are sent using either email or fax.⁵⁶ Because most pharmacies in Massachusetts had not heard of the new law, physicians often had to follow up with insurers directly to ensure patients were covered for their 12-month supply.⁵⁷

To address this implementation barrier, policymakers may want to consider the following actions:

• Create a robust alert and notification system to increase awareness of new policies and laws. As noted above, a qualitative study conducted after Massachusetts passed its Act Advancing Contraceptive Coverage and Economic Security in Our State (ACCESS) law in 2017 reported that some pharmacists recommended email alerts and notifications that contain a printable, informational flier and copy of the new policy.⁵⁸
• Provide training opportunities. The same study also found that the majority of pharmacists recommend funding training and education opportunities that also offer continuing professional education (CPE) credit. This can be an important part of professional development and ensuring providers are on par with the most recent guidance.

Similarly, states may wish to build or assign oversight to a working group or task force to develop and oversee training program opportunities and compliance. For example, part of New Mexico’s strategy to increase access to long-acting reversible contraception (LARC) was to convene a LARC work group. The work group was facilitated by the reproductive justice organization Bold Futures and included key stakeholders such as public health leaders, policymakers, clinical providers, and community members.⁵⁹ In December 2016, the New Mexico Legislature appropriated funds to the University of New Mexico LARC Mentoring Program. This program offered statewide training, including publicly funded clinics, on contraceptive counseling and provision to clinicians and clinic staff and webinars on shared decision-making and reimbursement processes. With Medicaid administrative matching funds, the LARC Mentoring Program provided procedural training to 148 Medicaid clinicians on implants, 174 clinicians on intrauterine devices, and 18 clinicians on immediate postpartum LARC. In the same year, the Family Planning Program, which is run by the New Mexico Department of Health, and the University of New Mexico launched the virtual reproductive health clinic using the Extension for Community Healthcare Outcomes model.⁶⁰

New Mexico successfully integrated separate projects focused on immediate postpartum and interval LARC to deliver clinical and administrative training and support to three geographic regions, three hospitals, two federally qualified health center networks, and more than 50 clinicians and administrative staff.⁶¹

Challenge: Patient awareness

Another barrier is patient education and awareness. Similar to the above recommendations, states must also tailor their educational campaigns to keep patients who may use contraceptives informed of changes, while also affirming patients’ right to advocate for themselves:

• Fund and adequately staff hotlines with staff who are knowledgeable of contraceptive care services.⁶² Many state Medicaid-managed care programs and private health plans operate toll-free hotlines for enrollees. In one survey study in Washington state, hotline representatives frequently struggled to answer or could not correctly answer specific inquiries about contraceptive services and benefits.⁶³Additionally, when Massachusetts passed the Contraceptive ACCESS law in 2017, research showed that only 300 women obtained a 12-month supply of birth control over the course of 2020 through the state’s largest insurers, even though more than 1 million patients were eligible.⁶⁴

• Use a multifaceted approach to notify insured patients of changes. This includes posting updates about any policy changes through both electronic and print notifications, including email, regular mail, and alert notification systems. This also includes posting information about policy changes on insurers’ websites and including links to resources for more information about who to contact with questions or concerns.

Challenge: Technology adaptation and medical management

A third barrier is that while new technologies have made patient record management more efficient, they can also be slow to uptake and reflect new administrative policies. For example, Massachusetts physicians reported encountering problems in prescribing a 12-month supply of birth control due in part to electronic medical record (EMR) systems often defaulting to the standard one- or three- month supply.⁶⁵ To address this, states and the medical field should work together:

• Facilitate smooth changes to EMR software that coincide with policy changes. Additionally, one study assessed the impact of a default order change in EMR software in multiple outpatient facilities in California. It found that changing the default order to 12-month dispensing, rather than one-month prescriptions with refills, changed prescribing practices.⁶⁶ Overall, prescribers ordered 260 12-month prescriptions, or 11 percent of total prescriptions written, before the EMR change and 669 12-month prescriptions, or 27 percent of total prescriptions written during the specified time period, after the change.

Challenge: Transparency and accountability

Another barrier to one-year contraceptive dispensing is a dearth of accountability and research on the effectiveness of some dispensing policies. New policies will only be effective with coordinated dissemination of information and measurable, actionable changes, such as the following:

• Procure research and create data teams and contracts with third-party professionals to conduct independent assessments and implementation evaluations. These groups will be key to learning if and how effective a policy is. Public outreach strategy and the dissemination plan should be determined well in advance.

In terms of accountability, one study of California’s implementation of year-long contraception found that the majority of pharmacists stated that the biggest perceived obstacle for dispensing a year-long supply of birth control at one time was whether insurance companies would provide appropriate reimbursement, which was supported by the evidence as only 55 percent, or 297 out of 532 prescriptions, were appropriately reimbursed.⁶⁷ Because of this distrust of insurance companies, many pharmacists were not willing to dispense the full year’s supply, despite California state law mandating that they do so. This further shows the dire role that insurers play in improving or hindering access to contraceptive care. As such, health plans should develop written policies that provide meaningful direction to employees and providers to ensure compliance. These policies should include organizational processes for dealing with compliance issues.

• Issue all plan letters (APLs) and guidance on best practices to provide clarification regarding contraceptive quantity limits and supplies. As mentioned by the National Health Law Program, “the APL is an important tool because it brings new law to the attention of plans, sets expectations for compliance, and provides a point of contact within the state regulator’s office.”⁶⁸ APLs are also issued at the federal level to direct insurance compliance. For example, the Biden administration sent out letters earlier this year as a reminder to comply with the Affordable Care Act contraception coverage rule that requires insurers to cover at least one FDA-approved contraception method under each device category.⁶⁹ Many health plans and insurers have not been in compliance with this requirement.⁷⁰ In fact, a big portion of health insurers and pharmacy benefit managers impose cost-sharing requirements and coverage exclusions that are against federal guidelines.⁷¹

Challenge: Fears of contraceptive waste

Finally, one remaining barrier to implementation is the concern that dispensing a one-year supply of contraceptives at one time can lead to product waste. This concern can hinder state willingness to adopt and implement this policy, especially when the concern is shared by insurance companies and policymakers.

In California, for example, insurance companies initially opposed the 12-month supply policy because they believed that people may not use a full 12-month stock of their contraceptives or may switch methods partway through the year, and therefore, medications that the insurance company had paid for would be thrown out. However, one way that the state addressed this concern was by sharing the research supporting the benefits of a 12-month supply. A professor at the University of California, San Francisco studied these benefits and found that a one-year supply resulted in lower costs and fewer unintended pregnancies.⁷² The health costs associated with an unintended pregnancy far outweigh those of potential product waste.

One-year dispensing is a crucial policy option that can significantly increase contraceptive access. One-year supply policies can help mitigate some of the burdens associated with monthly contraceptive prescribing and dispensing and bolster access for the millions of women who use monthly birth control options. When implemented effectively and to scale, one-year supply policy has the ability to help ensure that women can decide when or when not to have children and promote bodily and reproductive autonomy. Policymakers can look to some of the aforementioned states as models on how to get started in designing a one-year program that is tailored properly to their respective state.

The author would like to thank Osub Ahmed, Bela Salas-Betsch, Amina Khalique, Elyssa Spitzer, Maggie Jo Buchanan, and Tracy Weitz for their contributions to and reviews of this series.