Why won't ACA cover quarterly shots?

QUESTION: My wife gets depoprovera shots every quarter. We have an ACA plan. The plan is refusing to pick up the costs of the “administration” of the shot, claiming that is separate from the actual drug, even though, by law, my wife cannot self-inject this like insulin or an Epi Pen. She has to go to the doctor's office to have it administered. Is that allowed? Also, I have read the 150 page handbook for our plan cover to cover, and there is nothing in there differentiating the cost of the doctor giving the shot, from the drug itself. Wouldn't this render the ACA's mandate to cover birth control somewhat meaningless?

by Robert Field, Ph.D., J.D., M.P.H., Professor, School of Law & Drexel School of Public Health

Published Jul. 20, 2014, 4:00 a.m. ET

QUESTION: My wife gets depoprovera shots every quarter. We have an ACA plan. The plan is refusing to pick up the costs of the "administration" of the shot, claiming that is separate from the actual drug, even though, by law, my wife cannot self-inject this like insulin or an Epi Pen. She has to go to the doctor's office to have it administered. Is that allowed? Also, I have read the 150 page handbook for our plan cover to cover, and there is nothing in there differentiating the cost of the doctor giving the shot, from the drug itself. Wouldn't this render the ACA's mandate to cover birth control somewhat meaningless?

-Josh

ANSWER: Insurance companies are required to fully cover at least one type of contraceptive in each FDA-approved category when it is delivered by a network provider. Since DepoProvera is the only FDA-approved injectable contraception method, it must be covered. However, if your doctor is billing for the office visit separately from the contraception itself, the plan may impose a cost-sharing requirement on the office visit, as they did for your wife. (See 45 C.F.R. § 147.130). The National Women's Law Center offers free help to individuals who are having trouble getting their contraceptive method covered. Their toll-free number is 1-866-PILL4US, or you can email them at pill4us@nwlc.org.

Robert I. Field, Ph.D., J.D., M.P.H.

is a professor of law at the Earle Mack School of Law and professor of health management and policy at the School of Public Health at Drexel University. He also writes for

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