Coverage of Over-the-Counter Oral Contraceptives: Department of Veterans Affairs

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 veterans and their family members. However, for an OTC oral contraceptive to meet its potential, federal agencies, including the Department of Veterans Affairs (VA), will need to take steps to ensure that it is fully covered by programs, including VA Health Care and the Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA). As part of this effort, the VA 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, neither VA Health Care (which covers veterans) nor CHAMPVA (which covers family members) are 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. Both programs include contraception, but each on their own terms.

VA Health Care provides the full range of contraceptive methods and services at its facilities, including both prescription methods like oral contraceptives and IUDs and OTC methods like condoms and Plan B emergency contraception. Contraceptive supplies are offered both on-site and by mail order. Cost-sharing varies based on the service and characteristics of the veteran, including income and disability status.

CHAMPVA provides coverage for most prescription contraceptive methods and services. However, the program imposes cost-sharing (25% copayment and a deductible) for prescription contraceptives, unless obtained at VA facilities or by mail order. There is nothing in statute barring CHAMPVA from covering OTC contraceptives; however, the program has to date excluded coverage for all OTC contraceptives (and almost all OTC drugs generally). Regulations proposed by the VA in October 2022 would add CHAMPVA coverage for OTC emergency contraceptives and would eliminate cost-sharing for covered contraceptive services and supplies.

Recommendations for OTC Contraceptive Coverage

The VA should take steps to provide an FDA-approved OTC oral contraceptive in VA Health Care and to provide all OTC contraceptives without cost-sharing and without a prescription to the extent possible under the VA’s authority. Specifically, the VA needs to:

1. Add any FDA-approved OTC oral contraceptive to the VA National Formulary, so that it is among the contraceptive options that are stocked and offered by VA Health Care facilities. That process involves
   a review and decision by the VA National Formulary Committee, and procurement through the VA National Acquisition Center.

2. Make OTC oral contraceptives available at VA Health Care facilities and by mail order to the same extent as other OTC products, such as Plan B emergency contraception. The VA should take steps to ensure that all covered OTC contraceptives are readily available without an appointment at all facilities and available at facilities and by mail order without a prescription.

3. Explore all options to eliminate cost-sharing in VA Health Care for contraceptive services and supplies, including OTC contraceptives, such as determining whether some or all contraceptives may be categorized as Tier 0 ($0 copay) items.

The VA should also take steps to improve contraceptive coverage in similar ways under CHAMPVA:

4. Issue a final rule for CHAMPVA (based on the October 2022 proposed rule) that eliminates cost-sharing for all contraceptive services and supplies and that adds coverage for all FDA-approved, -granted, or -cleared OTC contraceptives (not only OTC emergency contraception). The rule should also explicitly state that OTC contraceptives must be covered even when purchased without a prescription. These changes would be in line with comments submitted by numerous organizations supportive of reproductive rights.

To enhance contraceptive access for veterans and family members, the VA should also:

5. Provide special notice to VA Health Care and CHAMPVA beneficiaries, providers, and relevant staff (e.g., those who stock VA pharmacies) about these improvements to contraceptive coverage and about how to access coverage for OTC contraceptives without a prescription. These communication efforts should be part of a broader campaign by the VA to publicize the availability of contraceptive services and supplies to veterans and their families.