Out-of-pocket expenses for OCs targeted

Findings from a new analysis indicate that women pay a higher percentage out of pocket when it comes to oral contraceptive (OC) expenditures.1 The analysis shows that women pay about 58% in total expenditures for the Pill, compared to about 30% for other maintenance medications. A red-light finding for family planners: Researchers say young and uninsured women are likely to pay more out of pocket for the Pill, which might impact their ability to continue using them.

To perform the observational cohort study, scientists at the University of California, San Francisco analyzed information from the 1996-2006 Medical Expenditures Panel Survey, which gathers material from patients, healthcare providers, and pharmacies to provide nationally representative data. The researchers looked at 8,151 women ages 13-50 who had made at least one OC purchase, examining such factors as out-of-pocket costs and numbers of packs obtained per purchase. Out-of-pocket expenditures were defined as payments made by the survey respondent or other family members.

Researchers determined the number of packs per purchase by looking at data from the pharmacy and then calculated the ratio of out-of-pocket costs versus the total expenditures paid by the woman and her health plan. They also estimated the annual out-of-pocket cost if a woman were to obtain 13 medication cycles per year with a median cost per pack, and then determined the ratio of annual out-of-pocket expenditures for pills versus annual out-of-pocket expenditures for all healthcare services.

The analysis reports that women's out-of-pocket expenses per Pill pack averaged $16, but uninsured women had the highest out-of-pocket cost at an average of $26. Privately insured women who did not have prescription drug coverage paid an average of $21 per pack, while Medicaid beneficiaries paid $16 per pack. Privately insured women with prescription drug coverage paid the least out-of-pocket costs: an average of $14. Out-of-pocket expenses varied by the number of packs a woman was able to purchase and were highest when women only obtained one pack per purchase, researchers report.

The amount women pay out-of-pocket for OCs often is determined by their insurance coverage, such as whether they have drug coverage, and if so, the type of health plan and benefit they have, such as the formulary tier, and the amount of copayment required by the health plan for oral contraceptives, explains Su-Ying Liang, PhD, senior analyst and center data manager at the Center for Translational and Policy Research in Personalized Medicine at the Department of Clinical Pharmacy at the University of California, San Francisco. "In addition to the absolute out-of-pocket amount, we were also interested in examining an additional dimension of financial burden: how this out-of-pocket amount compared to the total OC payment," says Liang, who served as lead author for the paper. "Thus we calculated the ratio of out-of-pocket to total expenditures. When evaluating this measure, the denominator, total expenditures, matters."

In the final analysis, the average out-of-pocket and total payment per OC pack were $16 and $27, By comparison, the average out-of-pocket and total payment are $30 and $101 for Lipitor, a highly prescribed maintenance drug, Liang notes.2 Robert Hatcher, MD, MPH, professor of gynecology and obstetrics at the Emory University School of Medicine in Atlanta, points out that a woman can purchase Sprintec or Tri-Sprintec, two low-dose combined pills, for about $9 a cycle from discount and grocery story chains. Even if she pays 100% of this amount, she is far better off than the copayments women make when purchasing most other pills, he notes. Clinicians should strongly consider the use of one of these two medications if concerned about the cost of OCs for their patients, he states.

When it came to total expenditures, researchers report women on average paid about 58% of total OC expenditures. Women with private insurance paid 56%; women without insurance paid 95%. Women without insurance paid less than 100% because of other federal, state, and local programs that helped pay for their pills.

What other trends did researchers note? Almost half (46%) of women paid more than $15 per physician visit to manage their contraception, and women averaged 1.6 visits per year. When it came to purchasing pill packs, about half (44%) of survey respondents got one pack per purchase, while 27% obtained 2-3 packs, and 29% obtained more than four packs. Dispensing practices also have changed; the proportion of women who obtained only one pack per purchase was significantly lower in recent years: 76% in 1996-1998 versus 35% in 1999-2006.

Researchers report women were more likely to pay at least $15 per pack if they did not have insurance, were younger, or did not have prescription drug coverage. Women enrolled in managed care plans and younger women also were more likely to obtain just one pack per visit, they note.

While the findings suggest that dispensing limitations, whether coming from clinicians or from the insurance industry, are slowly being chipped away, there is still progress to be made when it comes to contraceptive access, the researchers note. "More work needs to be done to remove any barriers that prevent women from obtaining as many pill packs as they want," they conclude.1

How to increase access?

What will it take to increase access to contraception for women? One possibility is working with a pharmaceutical company to bring an oral progestin-only pill to market for over-the counter (OTC) use in the near future. This possibility is being explored by the Oral Contraceptives Over-the-Counter Working Group, an Oakland, CA-based coalition focused on providing easier access to safe, effective, acceptable, and affordable contraception, says Dan Grossman, MD, a member of the working group steering committee.

Two recently published reports from the Border Contraceptive Access Study gives insight to potential OTC use, says Grossman.3,4 Those reports took advantage of a natural experiment along the United States-Mexico border where U.S. residents sometimes purchase OCs over the counter in Mexican pharmacies.

One study found that continuation among women who obtained pills in Mexican pharmacies without a prescription was significantly higher than among those who got pills in U.S. clinics, Grossman notes.3 The other study examined contraindications among women obtaining combined oral contraceptives over the counter in Mexican pharmacies. It found that the prevalence of World Health Organization Medical Eligibility Criteria Category 3 contraindications (a condition for which the theoretical or proven risks usually outweigh the advantages of using the method) was significantly higher among OTC users compared to women obtaining pills at public clinics.4,5

Taken together, these studies suggest that over-the-counter access to oral contraceptives does not adversely affect effectiveness and might improve it, Grossman notes. However, progestin-only pills might be a better option as the first over-the-counter oral contraceptive, given their fewer and rarer contraindications, he states.


  1. Liang SY, Grossman D, Phillips KA. Women's out-of-pocket expenditures and dispensing patterns for oral contraceptive pills between 1996 and 2006. Contraception 2011; 83:528-536.
  2. Stagnitti MN. The top five outpatient prescription drugs ranked by total expense for children, adults, and the elderly, 2004. Statistical Brief #180. Agency for Healthcare Research and Quality, Rockville, MD; 2007. Accessed at http://www.meps.ahrq.gov/mepsweb.
  3. Potter JE, McKinnon S, Hopkins K, et al. Continuation of prescribed compared with over-the-counter oral contraceptives. Obstet Gynecol 2011; 117:551-557.
  4. Grossman D, White K, Hopkins K, et al. Contraindications to combined oral contraceptives among over-the-counter compared with prescription users. Obstet Gynecol 2011; 117:558-565.
  5. World Health Organization. Medical Eligibility Criteria for Contraceptive Use. Fourth ed. Geneva; 2009.