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Why is Hormonal Birth Control Expensive?

October 22, 2020

high drug prices

Whether hormonal or non-hormonal, birth control is one of the most common prescriptions written for women of childbearing age. Anecdotally, it may seem as though most women have taken some sort of oral or topical contraceptive (like a patch) or had a long-acting reversible contraceptive (LARC) device at one point in their reproductive lives.

Statistically speaking, we know that from 2015 through 2017, about 65% of American women between the ages of 15 and 49 (72.2 million women) were using some method of contraception. We also know that some of the most common forms of contraception are birth control pills and uterine implants, or intrauterine devices.

With so many women on some form of hormonal birth control, one might expect it to be pretty cheap. The basic laws of economics would say that if the supply is sustainable and the demand is reasonable, the price should be reasonable as well. Right?

Yes and no. The price of birth control varies widely — from literally free to thousands of dollars. Here's the difference between the two ends of the spectrum and the major factors that contribute to them.

How the ACA Affected Birth Control Access

The Affordable Care Act (ACA), also known as Obamacare, greatly expanded Americans' access to healthcare. Issues with premium prices aside (because there were, and still are, plenty of problems in that department), the ACA carried two provisions that were essential in allowing more Americans to have access to insurance — sometimes for the first time in their lives.

The first was that it took pre-existing conditions off the table, meaning that any medical condition that existed prior to the start of your insurance coverage couldn't disqualify you from eligibility. Prior to the ACA, an insurance company could deny you health coverage for hundreds of reasons, such as anemia, asthma, pregnancy, heart disease, cancer, AIDS, high cholesterol, high blood pressure, etc. The list goes on and on (and on). The ACA meant that people were no longer being denied health insurance because of underlying medical conditions.

The second was expanding the age at which children would need to come off their parents' plans. Before the ACA was signed, people could remain on their parents' health insurance plans until they were 22 or graduated from college (assuming they were enrolled as a full-time student that whole time). The ACA extended this cutoff to age 26, regardless of college status.

Amidst all of this, the ACA also required insurance plans to cover at least some birth control at little to no cost for enrollees. Oftentimes, this option became generic versions of the birth control pill because it's one of the cheapest ways to do so. For the most part, that worked out well for women of childbearing age who weren't ready to start a family, those who felt their families were complete and weren't interested in having additional children, those who simply couldn't afford to have them, or those who didn't want to be parents at all.

Between 2012 (when the provision began) and 2017, 55 million women received free (or very inexpensive) birth control through their health insurer. There have been many attempts — some successful — to dismantle this provision in the ACA so that employers can choose to restrict the law's reach (but more on that later). If it weren't for the rollbacks of this important provision, it's entirely possible that even more women could have benefited from it.

How Birth Control Prices Vary

It's true that many types of birth control have been on the market for many years, and are therefore available in generic form instead of a brand name. This refers to the American patent system, which allows exclusive rights to a drug formulation for a number of years, which is often variable in and of itself. The average timespan for a patent in this industry is about 20 years, but it can be extended by changing the formula, the device itself, or nearly anything else about the dosage or the way medication is administered.

The Birth Control Pill

When using a health insurance policy, the birth control pill — often shortened to "the pill" — can start at $0 and go up from there, usually capping around $50, but this depends on the source of your health insurance (privately purchased versus employer-sponsored, and what kind of prescription plan your employer has worked out with the insurance company). ACA-compliant health insurance plans offer at least some birth control pills at zero (or low) cost to enrollees. Oftentimes, this comes in the form of generic forms of medication, such as Junel, Norgestimate/Ethinyl Estradiol, and Desogestrel/Ethinyl Estradiol.

The main issues with the birth control pill becoming expensive is similar to when every other drug is expensive: there's no generic for it. In most cases, the birth control pill is one of the more affordable options available to women seeking contraception because there are so many generics available.

The Birth Control Patch

The birth control patch is more expensive than most birth control pills. Instead of taking it every day, you put a new patch on your skin each week, and then go patchless during your menstrual cycle. It's not one of the more common methods of birth control, but some women prefer it to an oral pill because you only have to change it once per week, as opposed to remembering to take it every single day.

There is now a generic for the patch marketed under the name Xulane, but it's still rather expensive. One month's supply of patches (so, three of them) is about $200 in the United States. Theoretically, this cost could be minimal (or nothing) if used with ACA-compliant health insurance.

Intrauterine Devices (IUDs)

IUDs are a form of long-acting reversible contraceptive (LARC). They are small devices that are implanted into the uterus, and can be left in place anywhere from three to twelve years, depending on the device. They can be both hormonal and non-hormonal — it just depends on the device.

While IUDs were more popular in America during the 1980's, they fell out of favor for a while and are now seeing a resurgence. They are considered to be the most effective form of birth control, with only sterilization being the more effective.

There are a couple issues with IUDs in terms of access. First of all, it requires an office visit with a gynecologist, so if you don't have access to a specialist, you'd need to rely on an organization like Planned Parenthood. Second, they're more expensive than most forms of birth control — usually about $1,000. And third, you can't simply buy one at your favorite international online pharmacy at a lower rate. A doctor will need to place the order because they need to implant it.

Again, many insurance plans will cover at least a portion of the IUD itself, as well as the insertion. While the IUD seems expensive up front, when taken into consideration over a period of five years, it works out to be about $16 per month.

Contraceptive Ring

Another less common birth control possibility is another expensive one. The contraceptive ring is a device that is self-inserted into the vagina and lasts for three weeks. At the start of week four of the cycle (day 21), it's removed for seven days to allow for menstruation.

Until recently, there was only one contraceptive ring available on the market — the Nuvaring. Each Nuvaring typically runs in the $200 range, but because it's a brand name drug, it's often placed in higher tiers in formularies. Insurance companies really have no "incentive" to prioritize Nuvaring when there are so many other less expensive options for them to cover. Even IUDs are less expensive when broken down into monthly cost. With a copay, the cost might be closer to $50.

Some companies — in an attempt to keep their prescription claims to a minimum — favor generics to such an extent that they place brand name drugs that do not have an alternative in the topmost tier, which means they're not covered unless they cost more than a certain amount per month.

The Birth Control Battle

From the very beginning, there was pushback against the birth control provision of the ACA. (More accurately, there was pushback against the ACA from the very beginning, but some took particular issue with the birth control aspect.)

Religiously affiliated companies immediately sought exemptions from the ACA, claiming that birth control went against their religious beliefs. Churches and non-profit businesses with religious affiliations, such as Catholic hospitals and colleges, were always able to apply for an exemption — that was never a question. In those cases, the employer would have to inform the insurance company that they wouldn't cover contraceptives, and the insurance company would have to figure out another way to pay for those prescriptions without using premium dollars.

Most organizations found ways to work around this provision, but a few companies weren't willing to compromise on a couple very specific fronts. In an infamous lawsuit that eventually made it all the way up to the Supreme Court of the United States, the provision of the ACA that provided copay-free access to a significant number of oral and implanted birth control methods was heavily challenged.

Burwell v. Hobby Lobby

Two separate suits were combined — one by Hobby Lobby, an arts and crafts store owned by an Evangelical family, and the other by Conestoga Wood Specialties, a furniture company owned by a Mennonite family. They claimed that covering these specific birth control methods violated their religious views.

In a 5-4 split, the Supreme Court of the United States decided that "closely held" companies could be exempt from this provision of the ACA. The Internal Revenue Service (IRS) defines a "closely held" company as one in which five or fewer people own more than 50% of the business. While there are other stipulations that can apply, those are the general guidelines.

There's some interesting data surrounding the number of women that this decision actually affects. On one hand, it could be argued that a significant number have suffered restricted access to birth control. At least 90% of American businesses are considered "closely held" and half of American workers are employed by these businesses.

On the other hand, it could be argued that many "closely held" businesses have fewer than 50 full-time equivalent employees, which would exempt them from the ACA altogether, as they would not be mandated to provide health insurance to their employees.

Room for Latitude

While the Hobby Lobby case did not bring up other forms of contraception, such as the ever-popular birth control pill, the decision on the case opens the door for "closely held" companies to deny their employees access to contraceptives via their health insurance plan. If the company is eligible and decides that contraception is against their religious beliefs, they can simply instruct their insurance company to not cover birth control.

What this often means for employees is that they have to pay entirely out of pocket for whatever method of prescription contraceptives they and their doctors decide is best for them — and this is where birth control gets expensive.

Finding More Affordable Hormonal Birth Control

If your hormonal or non-hormonal birth control has been affected by the rollbacks to the ACA, Burwell v. Hobby Lobby, or even just an increasing financial burden being shifted from the insurance company to you, there are places you can turn to for help. International online pharmacies like NorthWestPharmacy.com can deliver your exact prescription straight to your door at a fraction of the cost of what you'd otherwise pay.

If you have questions about our inventory, how to place an order, or if you're already set to place an order, we'd love to hear from you. Feel free to contact us via our toll-free phone number: 1-866-539-5330. You can also email us at CustomerService@NorthWestPharmacy.com. We look forward to helping you save money on your prescriptions.

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