Coverage of Over-the-Counter Oral Contraceptives: Military Health System

Over-the-counter (OTC) availability of a Food and Drug Administration (FDA)-approved oral contraceptive could be an important option for addressing logistical obstacles to contraceptive access and consistent
use, including among members of the Armed Forces and their dependents. However, for an OTC oral contraceptive to meet its potential, federal programs, including the Military Health System (MHS), will need to take steps to ensure that it is fully covered by its health insurance plan, TRICARE, and is readily available at health facilities such as military treatment facilities (MTFs). As part of this effort, the MHS should ensure that all OTC contraceptives are covered without cost-sharing and without a prescription, to the extent possible under the law.

Current Contraceptive Coverage Policy

Unlike most other forms of health coverage in the United States, the MHS’s TRICARE program is not bound by the Affordable Care Act’s contraceptive coverage benefit, which requires plans to cover the full range of contraceptive products and services, without patient out-of-pocket costs like copayments and deductibles. However, the MHS is committed to providing “access to comprehensive contraceptive counseling and the full range of contraceptive methods for members of the Armed Forces and all eligible beneficiaries.”

In practice, TRICARE covers contraceptive counseling and most methods of contraception (condoms and gels are excluded), but with variable cost-sharing depending on the beneficiary, the method, and the provider. For example, prescription oral contraceptives are covered and available without cost-sharing at MTFs and/or when provided to active-duty service members; cost-sharing is required for other beneficiaries who receive care from network providers (rather than MTFs). By contrast, Plan B emergency contraceptives are covered for all beneficiaries and at all locations without a prescription and without cost-sharing.

The MHS has taken steps over the past year to eliminate cost-sharing for certain contraceptive methods (including IUDs, implants, injectables, and tubal ligation). However, the Department determined that it could not eliminate cost-sharing for all beneficiaries for oral contraceptives and other methods that are part of TRICARE’s pharmaceutical benefit, asserting that the copayments are required by federal law.

Recommendations for OTC Contraceptive Coverage

The MHS should take steps to cover an FDA-approved OTC oral contraceptive under TRICARE and to provide it at MTFs, and should ensure that TRICARE covers all OTC contraceptives without cost-sharing and without a prescription to the extent possible under the MHS’s authority. Specifically, the MHS needs to:

1. Add FDA-approved OTC oral contraception to the TRICARE Basic Core Formulary. TRICARE’s pharmacy benefit generally covers prescription drugs, but there is an option to cover OTC drugs as well if they are “cost-effective and clinically effective, as compared with other drugs in the same therapeutic class.” Including an OTC oral contraceptive in the Basic Core Formulary would also ensure that it is available at all full-service MTFs.

2. Eliminate cost-sharing for all covered OTC contraceptives, including an FDA-approved OTC oral contraceptive. Federal regulations explicitly say that “the copayment may be established at $0.00 for any particular OTC drug in the retail pharmacy network.”

3. Issue a directive to make it clear that TRICARE will pay for any covered OTC contraceptive, including an OTC oral contraceptive, even when purchased without a prescription (as TRICARE currently does for OTC emergency contraceptives).

   1. TRICARE may be able to waive the prescription requirement under current federal regulations. (The regulations explicitly say the requirement may be waived for emergency care but do not specify whether it may be waived in other circumstances.)

   2. Another potential option would be to provide a standing order for an OTC oral contraceptive and other OTC contraceptives for all TRICARE beneficiaries capable of pregnancy, which would eliminate the need for beneficiaries to obtain an individual prescription.

To enhance TRICARE enrollees’ contraceptive access, the MHS should also:

4. Provide special notice to TRICARE beneficiaries, providers, and relevant staff (e.g., those who stock MTF pharmacies) about these improvements to contraceptive coverage and about how to access coverage for OTC contraceptives without a prescription.