Health Insurers Are Blocking Self-Administered Birth Control Injections During Pandemic, Doctors Say

In normal times, when Bronx resident Blake Ford needs to re-up her birth control, she takes the D to the A subway to visit her doctor at the Institute for Family Health on West 17th Street. Ford is one of IFH's roughly 400 patients who use Depo-Provera, a commonly used birth control shot that works for three months at a time.

But since Ford has been trying to avoid in-person medical visits and public transportation during the coronavirus pandemic, her doctor at IFH prescribed her a different version of the shot when she was due for one in May. This one she would be able to self-administer at home with physician guidance provided via video chat. She opted to have the shot delivered to her home via Capsule, a pharmacy service that does same-day delivery.

Ford had voluntarily put off her birth control refill for a couple of weeks amid the pandemic and said she was worried about withdrawal symptoms from Depo-Provera, which can be severe. The birth control shot also helps her avoid the side effects of menstruation that she faces because of her sickle cell anemia, including extreme fatigue and joint pain.

“What it does is regulate my body,” said Ford, who teaches third grade and says she has to keep her energy up. “On top of that, I’m happy with just my [14-year-old] daughter. I’m not in a rush right now to have another kid. They’re kind of expensive.”

But when Ford’s doctor sent her prescription to Capsule, she got a notification on the pharmacy’s app.

“A prior authorization is required,” it said. “We’re working on it and will contact you with updates.”

The coronavirus pandemic has created a range of possible disruptions to contraception access, including postponed doctor’s visits, the loss of employer-based health coverage, and New Yorkers, particularly college students, having to move abruptly.

On top of this, insurers have been denying or delaying approval for coverage of a version of the birth control shot that can be administered at home, New York doctors say. Health care providers don’t typically recommend patients take the shot at home, so this has created a unique situation for insurers to navigate.

But doctors say that doesn’t justify access barriers insurers have put in place, which they say violate the Comprehensive Contraception Coverage Act, or CCCA, a state law that took effect on January 1st.

Reproductive health advocates fought hard to pass the legislation. It reinforces and expands the contraception coverage mandate in the Affordable Care Act, which has faced attacks from the Trump administration. They say they aren’t allowing any non-compliance to go unchecked, even during the pandemic.

“A bunch of insurers are giving us a big runaround about filling this prescription and say we have to exhaust other methods of birth control first,” said Dr. Linda Prine, director of women’s health at IFH and medical director of the Reproductive Health Access Project, a national nonprofit that helps primary care providers integrate reproductive health into their practices.

“The only other comparable method for birth control injection is to come into the office,” Prine told Gothamist in mid-May. “We’re trying to make it so people can inject it at home to save them the travel and save them from exposure to sick people who are also coming into our offices.”

The New York Academy of Family Physicians also sent a letter to Governor Andrew Cuomo last month saying the coverage denials and delays amount to a violation of the CCCA. The law requires health plans to cover at least one type of an FDA-approved birth control method without patient cost-sharing. NYAFP says Depo-subQ Provera, the version of the shot that can be administered at home, is a “slightly different medication” than Depo-Provera, so both should be covered. The letter to Cuomo has gone unanswered.

The New York Civil Liberties Union has taken up the issue as well.

“I think it is something that is required to be covered under state law and insurers, both public and private, are getting up to speed on the law’s requirements,” said Katherine Bodde, senior policy counsel at the NYCLU. “We are hopeful and are working with the state Department of Health and Department of Financial Services to make sure compliance is consistent across the board.”

Bodde said some insurers have also violated a CCCA requirement mandating that they cover up to 12 months of birth control at a time.

“It’s certainly something that has come up in this specific environment around COVID-19 because people are trying to be responsive to getting people the contraception that’s right for them and also reduce trips to the pharmacy or health care provider,” Bodde said.

IFH has filed complaints about denials of birth control coverage with both the state Department of Health, which regulates Medicaid plans, and the state Department of Financial Services, which regulates commercial health plans. DFS directed Gothamist to the memo it sent to health plans in December reminding them of the requirements of the CCCA. The state Health Department issued guidance to Medicaid plans telling them to cover the alternative form of the birth control shot during the pandemic, although advocates say it should be covered at all times under the CCCA. The Governor's office did not respond to a request for comment.

After five days of waiting for her health insurer, Affinity Health Plan, to approve the alternative version of the shot, Ford finally decided to take the trip downtown to have the traditional shot administered in person on May 13th. Were she to pay out of pocket, it could have cost more than $200.

Affinity wavered on whether to cover the version of the shot Ford’s doctor prescribed, initially denying coverage and then finally approving it on May 16th, after Ford had caved and visited the doctor’s office.

Affinity says it is now temporarily waiving its prior authorization requirement for the at-home version of the shot during the pandemic and is not denying insurance claims.

“I talked my way up the chain of command at Affinity and Healthfirst and got them both to change their policies and incorporate this medication, for now, into their formulary,” said Prine, adding that some other insurers are still issuing denials.

Healthfirst said in a statement that “Depo-subQ Provera is a drug labeled for administration by a healthcare professional” and that the insurer’s focus is “ensuring member safety while providing access to quality and needed health care.”

“In light of the current COVID situation, Healthfirst is working to make sure the drug is available for self-administration, after a patient confirms that they have had the necessary training to self-inject,” the insurer said.

IFH has actively reached out to patients using the birth control shot to offer them this option during the pandemic.

“We’re offering it to everybody,” said Tiffany Smith, the program coordinator for family planning services at IFH. “There are patients who would prefer to go to the doctor’s office but it’s all about mitigating risk. There’s a lot of teenagers who are due [for another shot] and this is also a good option for them.”

Smith said some teens who use the birth control shot typically get it at school-based clinics that are now closed.

“Just because it’s birth control doesn’t mean it’s not important,” said Ford. “Why in the middle of a pandemic are you not making medication accessible to patients?”

This story is part of PriceCheckNYC, a collaborative project promoting transparency in health care from Gothamist, WNYC and ClearHealthCosts. We want to hear from you! Email us at [email protected] to share your stories about accessing--and paying for--health care during the pandemic. Or tell us about the personal costs of avoiding it. You can also submit your recent health care bills to our interactive health cost database below.