Kilpatrick Townsend

Preventive Care Guidance Released

This afternoon the agencies issued additional ACA guidance in the form of frequently asked questions. This twelfth set of frequently asked questions addresses a number of issues under the preventive care contraceptive requirement. This requirement only applies to non-grandfathered plans.

The guidance confirms that all FDA-approved contraceptives must be provided without cost sharing under the preventive care requirement, not just oral contraceptives as some have suggested. But, more importantly, the guidance also addresses the generic and brand-name drug question with respect to contraceptives. In this regard, the guidance provides that plans may cover a generic contraceptive drug without cost-sharing and impose the regular cost-sharing for branded contraceptive drugs, but with an important caveat. In that case, a plan must accommodate any individual for whom the generic drug (or a brand name drug) would be medically inappropriate, as determined by the individual’s health care provider, by having a mechanism for waiving the otherwise applicable cost-sharing for the branded or non-preferred brand version. Further, if a generic version is not available, or would not be medically appropriate for the patient, then a plan must provide coverage for the brand name drug without cost sharing.

The full version of the guidance can be accessed here.