Access to contraception is a key element in shaping health and well-being for many women in their reproductive years. The Affordable Care act (ACA) created a minimum set of benefits for most health plans regulated by the federal government and states, requiring most private plans to cover, without any cost sharing, the full range of FDA-approved contraceptives and services as a preventive service. In the years since its implementation in 2012, there has been a sharp decrease in the share of privately insured women who pay out of pocket costs for their prescribed contraceptives.Despite its impact reducing costs for women, the contraceptive coverage requirement has been one of the most contentious elements of the ACA leading to heated policy debates and multiple lawsuits, including three cases that reached the Supreme Court. Since the passage of the ACA, Presidential administrations have taken divergent approaches to the regulations that effect how this provision is implemented. Such as, during the first Trump governance, the Department of Health and Human Services (HHS) and other related agencies promulgated a regulation that provided a broad exception to the contraception requirement to employers or plan with religious or moral objections to contraception. The Biden administration issued a proposed regulation, that was ultimately withdrawn, that would have expanded contraceptive coverage to include over-the-counter methods.
It is not known what, if any, actions the current Trump administration will make regarding contraceptive coverage. With major plans for reorganization of agencies within HHS including HRSA, the agency that has issued the contraceptive coverage requirement under the ACA rules, as well as actions to dismantle and restructure federal advisory committees, the future of contraceptive coverage is not clear. Concern about the future of this provision has spurred multiple efforts by Congressional democrats and some state legislatures to enshrine the right to contraceptionespecially since Roe v Wade was overturned by the Supreme Court. This issue brief explains the rules for private insurance coverage of contraceptives at the federal and state level, the exemptions and accommodations available for certain employers, gaps in coverage for contraceptives obtained outside of the customary clinical setting, and how changes in the agencies responsible for making contraceptive recommendations may affect coverage for contraceptives.
Use of Contraception
Contraceptive care is an crucial component of overall health care for many people in their reproductive years, and most women use contraception at some point in their lifetime. The majority (82%) of women of reproductive age (18 to 49) say they used some form of contraception in the past 12 months (Figure 1) and three quarters say that preventing a pregnancy is very or somewhat important to them. While most women who use contraception use it to prevent pregnancy (65%), one in five (20%) use it to both prevent pregnancy and for some other reason (such as managing a medical condition or preventing a sexually transmitted infection) and 14% use it solely for reasons outside of preventing pregnancy (such as to regulate their periods or manage acne). Among women who use contraception, nearly half (48%) report using more than one kind of contraceptive method in the past 12 months. Three i
Understanding Contraceptive Coverage Under the ACA
The Affordable care Act (ACA) requires most health insurance plans to cover contraceptive services and supplies without cost-sharing, meaning no copays, coinsurance, or deductibles. This includes a wide range of methods, but implementation and coverage details have evolved over time with guidance from federal agencies.
What Must Be Covered?
Generally, plans are required to cover without cost-sharing at least one product within each FDA-approved contraceptive method category. However, federal FAQs clarify that plans must also cover contraceptives deemed “medically necessary” by a healthcare provider. This includes:
* Brand-name drugs when a generic isn’t available.
* Clinician-recommended brand-name products.
* New contraceptive products approved by the FDA not specifically identified by HRSA.
Exceptions and Choice Coverage
Plans must have a clear and accessible exceptions process for individuals whose healthcare provider determines a different contraceptive within a category – including a brand name or different generic – is “medically appropriate.”
Alternatively, plans can choose to cover all products within a contraceptive category that have no therapeutic equivalents (meaning the same active ingredients, dosage form, route of administration, and strength). Such as, covering all types of hormonal IUDs currently available.
Medical Management and Restrictions
While plans can use reasonable medical management to control costs, certain restrictions are prohibited. Plans:
* Cannot require individuals to “fail first” on one method before covering another (e.g., oral pills before IUDs).
* Cannot require failing first on products within a category (e.g.,pill A before pill B).
* Cannot impose age limits on contraceptive services for women with reproductive capacity.
Impact and Current Landscape
The ACA’s contraceptive coverage provision has led to a meaningful increase in the number of women with employer-sponsored coverage who pay $0 for various contraceptive methods. However, a considerable portion – roughly one in four – still report out-of-pocket costs due to incomplete coverage by their plans.
Despite its far-reaching impact, the ACA’s requirement for contraceptive coverage has been challenged in the courts on multiple occasions, with three cases reaching the supreme court. The earlier cases, Burwell v. Hobby Lobby (2014) and Zubik v. Burwell (2016),challenged the Obama Administration’s regulations implementing the contraceptive coverage requirement,contending that the requirement violated some employers’ religious rights. The most recent cases, Little Sisters of the Poor v. Pennsylvania (2020) and Trump v. Pennsylvania (2020), involved regulations issued by the first Trump Administration in 2018. These regulations allowed any nonprofit or for-profit employers, including private institutions of higher education, with religious objections to contraception coverage and all but publicly-traded employers with moral objections to qualify for an exemption and exclude contraceptive coverage from their plans.
In August 2025, a U.S. District Court issued a ruling in commonwealth of Pennsylvania v. Trump in favor of Pennsylvania vacating the 2018 Trump regulations. The court found the regulations are arbitrary and capricious and were promulgated in excess of defendants’ statutory authority and in violation of the Administrative Procedure Act’s (“APA”). the Trump administration has appealed this ruling to the Third Circuit Court of Appeals. While the Obama regulations allowing only houses of worship to be exempt are now in effect, it
Earlier, plans typically require a prescription to trigger coverage, even for contraceptive methods available over the counter (OTC) without a prescription-such as emergency contraception.Currently,eight states (CA,CO,DE,MD,NJ,NM,NY,and WA) have laws or regulations requiring state-regulated private health insurance plans to cover,without cost sharing,some or all OTC contraception without a prescription.requiring all plans to cover non-prescribed contraceptives would require federal legislation or administrative changes to the ACA’s preventive services policy. Federal FAQs from July 2022 encourage but do not require, plans to cover without cost sharing OTC emergency contraceptive products purchased without a prescription. In October 2024, the Biden Administration proposed a new rule that would have required most private plans to cover OTC methods purchased without a prescription from an in-network pharmacy and would have required plans to disclose to enrollees that OTC products were included in their coverage. In January 2025,days before the end of their presidential term,the Biden administration withdrew the proposed regulation.
Pharmacist Prescribing: Thirty-five states and D.C. have passed laws to allow pharmacists to prescribe certain self-administered contraceptives to women, such as oral contraceptives, emergency contraception, the patch, and the vaginal ring. In these states, pharmacist prescribing helps reduce barriers to accessing contraception by removing the need to visit a clinician to obtain a prescription, and for people without insurance, it can be less expensive than getting a prescription from a clinician. However, challenges remain for women seeking a prescription for contraception from a pharmacist. For example,pharmacies typically charge consultation fees,which some reports suggest can be as high as $50 in certain areas. While insurers are generally required to cover contraceptives without cost sharing, they are not obligated to cover this fee. This lack of payment can lead to pharmacies charging patients a consultation fee.
The Future of Contraceptive Coverage
Changes in the Department of HHS and the agencies responsible for making women’s preventive health services recommendations may affect access and coverage to contraceptives. HHS under the Trump Administration announced a proposal that would make major changes through a “conversion to Make American healthy Again.” Should this proposal be implemented, it could result in the elimination of many positions and significant restructuring and consolidation of the divisions within HHS. HRSA, along with the Office of the Assistant Secretary for Health (OASH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Agency for Toxic Substances and Disease Registry (ATSDR), and the National Institute for Occupational Safety and Health (NIOSH) would be combined to form a new division, the Administration for a health America (AHA). The statutory language in