I 

109TH CONGRESS 

1ST SESSION H. R. 4651 

To require equitable coverage of prescription contraceptive drugs and devices, 

and contraceptive services under health plans. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 22, 2005 

Mrs. LOWEY introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on 

Education and the Workforce, for a period to be subsequently determined 

by the Speaker, in each case for consideration of such provisions as fall 

within the jurisdiction of the committee concerned 

A BILL 

To require equitable coverage of prescription contraceptive 

drugs and devices, and contraceptive services under 

health plans. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Equity in Prescription 

5 Insurance and Contraceptive Coverage Act of 2005’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds that— 
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1 (1) each year, 3,000,000 pregnancies, or one 

2 half of all pregnancies, in this country are unin3 tended; 

4 (2) contraceptives and contraceptive services 

5 are part of basic health care, allowing families to 

6 both adequately space desired pregnancies and avoid 

7 unintended pregnancy, and should be provided under 

8 the same terms and conditions as other basic health 

9 care; 

10 (3) studies show that contraceptives are cost ef11 fective: it is estimated that for every $1 of public 

12 funds invested in family planning, $3 is saved in 

13 medicaid costs from pregnancy-related healthcare 

14 and medical care for newborns; 

15 (4) by reducing rates of unintended pregnancy, 

16 contraceptives help reduce the need for abortion; 

17 (5) unintended pregnancies lead to higher rates 

18 of infant mortality, low-birth weight, and maternal 

19 morbidity, and threaten the economic viability of 

20 families; 

21 (6) the National Commission to Prevent Infant 

22 Mortality determined that ‘‘infant mortality could be 

23 reduced by 10 percent if all women not desiring 

24 pregnancy used contraception’’; 
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1 (7) most women in the United States, including 

2 three-quarters of women of childbearing age, rely on 

3 some form of private insurance (through their own 

4 employer, a family member’s employer, or the indi5 vidual market) to defray their medical expenses; 

6 (8) the vast majority of private insurers cover 

7 prescription drugs, but many exclude coverage for 

8 prescription contraceptives; 

9 (9) private insurance provides extremely limited 

10 coverage of contraceptives: half of traditional indem11 nity plans and preferred provider organizations, 20 

12 percent of point-of-service networks, and 7 percent 

13 of health maintenance organizations cover no contra14 ceptive methods other than sterilization; 

15 (10) women of reproductive age spend 68 per16 cent more than men on out-of-pocket health care 

17 costs, with contraceptives and reproductive health 

18 care services accounting for much of the difference; 

19 (11) the lack of contraceptive coverage in health 

20 insurance places many effective forms of contracep21 tives beyond the financial reach of many women, 

22 leading to unintended pregnancies; 

23 (12) the Institute of Medicine Committee on 

24 Unintended Pregnancy recommended that ‘‘financial 

25 barriers to contraception be reduced by increasing 
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1 the proportion of all health insurance policies that 

2 cover contraceptive services and supplies’’; 

3 (13) in 1998, Congress agreed to provide con4 traceptive coverage to the 2,000,000 women of re5 productive age who are participating in the Federal 

6 Employees Health Benefits Program, the largest 

7 employer-sponsored health insurance plan in the 

8 world, and, in 2001, the Office of Personnel Man9 agement reported that it did not raise premiums as 

10 a result of such coverage because there was ‘‘no cost 

11 increase due to contraceptive coverage’’; 

12 (14) eight in 10 privately insured adults sup13 port contraceptive coverage; 

14 (15) contraceptive coverage saves employers 

15 money: the Washington Business Group on Health 

16 estimates that not covering contraceptives in em17 ployee health plans costs employers 15 to 17 percent 

18 more than providing such coverage; and 

19 (16) Healthy People 2010, published by the Of20 fice of the Surgeon General, has established a 10- 

21 year national public health goal to increase the per22 centage of health plans that cover contraceptives. 
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1 SEC. 3. AMENDMENTS TO THE EMPLOYEE RETIREMENT IN2 COME SECURITY ACT OF 1974. 

3 (a) IN GENERAL.—Subpart B of part 7 of subtitle 

4 B of title I of the Employee Retirement Income Security 

5 Act of 1974 (29 U.S.C. 1185 et seq.) is amended by add6 ing at the end the following new section: 

7 ‘‘SEC. 714. STANDARDS RELATING TO BENEFITS FOR CON8 TRACEPTIVES. 

9 ‘‘(a) REQUIREMENTS FOR COVERAGE.—A group 

10 health plan, and a health insurance issuer providing health 

11 insurance coverage in connection with a group health plan, 

12 may not— 

13 ‘‘(1) exclude or restrict benefits for prescription 

14 contraceptive drugs or devices approved by the Food 

15 and Drug Administration, or generic equivalents ap16 proved as substitutable by the Food and Drug Ad17 ministration, if such plan or coverage provides bene18 fits for other outpatient prescription drugs or de19 vices; or 

20 ‘‘(2) exclude or restrict benefits for outpatient 

21 contraceptive services if such plan or coverage pro22 vides benefits for other outpatient services provided 

23 by a health care professional (referred to in this sec24 tion as ‘outpatient health care services’). 
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1 ‘‘(b) PROHIBITIONS.—A group health plan, and a 

2 health insurance issuer providing health insurance cov3 erage in connection with a group health plan, may not— 

4 ‘‘(1) deny to an individual eligibility, or contin5 ued eligibility, to enroll or to renew coverage under 

6 the terms of the plan or coverage because of the in7 dividual’s or enrollee’s use or potential use of items 

8 or services that are covered in accordance with the 

9 requirements of this section; 

10 ‘‘(2) provide monetary payments or rebates to 

11 a covered individual to encourage such individual to 

12 accept less than the minimum protections available 

13 under this section; 

14 ‘‘(3) penalize or otherwise reduce or limit the 

15 reimbursement of a health care professional because 

16 such professional prescribed contraceptive drugs or 

17 devices, or provided contraceptive services, described 

18 in subsection (a), in accordance with this section; or 

19 ‘‘(4) provide incentives (monetary or otherwise) 

20 to a health care professional to induce such profes21 sional to withhold from a covered individual contra22 ceptive drugs or devices, or contraceptive services, 

23 described in subsection (a). 

24 ‘‘(c) RULES OF CONSTRUCTION.— 
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1 ‘‘(1) IN GENERAL.—Nothing in this section 

2 shall be construed— 

3 ‘‘(A) as preventing a group health plan 

4 and a health insurance issuer providing health 

5 insurance coverage in connection with a group 

6 health plan from imposing deductibles, coinsur7 ance, or other cost-sharing or limitations in re8 lation to— 

9 ‘‘(i) benefits for contraceptive drugs 

10 under the plan or coverage, except that 

11 such a deductible, coinsurance, or other 

12 cost-sharing or limitation for any such 

13 drug shall be consistent with those imposed 

14 for any outpatient prescription drug other15 wise covered under the plan or coverage; 

16 ‘‘(ii) benefits for contraceptive devices 

17 under the plan or coverage, except that 

18 such a deductible, coinsurance, or other 

19 cost-sharing or limitation for any such de20 vice shall be consistent with those imposed 

21 for any outpatient prescription device oth22 erwise covered under the plan or coverage; 

23 and 

24 ‘‘(iii) benefits for outpatient contra25 ceptive services under the plan or coverage, 
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1 except that such a deductible, coinsurance, 

2 or other cost-sharing or limitation for any 

3 such service shall be consistent with those 

4 imposed for any outpatient health care 

5 service otherwise covered under the plan or 

6 coverage; 

7 ‘‘(B) as requiring a group health plan and 

8 a health insurance issuer providing health in9 surance coverage in connection with a group 

10 health plan to cover experimental or investiga11 tional contraceptive drugs or devices, or experi12 mental or investigational contraceptive services, 

13 described in subsection (a), except to the extent 

14 that the plan or issuer provides coverage for 

15 other experimental or investigational outpatient 

16 prescription drugs or devices, or experimental 

17 or investigational outpatient health care serv18 ices; or 

19 ‘‘(C) as modifying, diminishing, or limiting 

20 the rights and protections of an individual 

21 under any other Federal law. 

22 ‘‘(2) LIMITATIONS.—As used in paragraph (1), 

23 the term ‘limitation’ includes— 

24 ‘‘(A) in the case of a contraceptive drug or 

25 device, restricting the type of health care pro-
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1 fessionals that may prescribe such drugs or de2 vices, utilization review provisions, and limits on 

3 the volume of prescription drugs or devices that 

4 may be obtained on the basis of a single con5 sultation with a professional; or 

6 ‘‘(B) in the case of an outpatient contra7 ceptive service, restricting the type of health 

8 care professionals that may provide such serv9 ices, utilization review provisions, requirements 

10 relating to second opinions prior to the coverage 

11 of such services, and requirements relating to 

12 preauthorizations prior to the coverage of such 

13 services. 

14 ‘‘(d) NOTICE UNDER GROUP HEALTH PLAN.—The 

15 imposition of the requirements of this section shall be 

16 treated as a material modification in the terms of the plan 

17 described in section 102(a)(1), for purposes of assuring 

18 notice of such requirements under the plan, except that 

19 the summary description required to be provided under the 

20 last sentence of section 104(b)(1) with respect to such 

21 modification shall be provided by not later than 60 days 

22 after the first day of the first plan year in which such 

23 requirements apply. 

24 ‘‘(e) PREEMPTION.—Nothing in this section shall be 

25 construed to preempt any provision of State law to the 
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1 extent that such State law establishes, implements, or con2 tinues in effect any standard or requirement that provides 

3 coverage or protections for participants or beneficiaries 

4 that are greater than the coverage or protections provided 

5 under this section. 

6 ‘‘(f) DEFINITION.—In this section, the term ‘out7 patient contraceptive services’ means consultations, exami8 nations, procedures, and medical services, provided on an 

9 outpatient basis and related to the use of contraceptive 

10 methods (including natural family planning) to prevent an 

11 unintended pregnancy.’’. 

12 (b) CLERICAL AMENDMENT.—The table of contents 

13 in section 1 of the Employee Retirement Income Security 

14 Act of 1974 (29 U.S.C. 1001 note) is amended by insert15 ing after the item relating to section 713 the following 

16 new item: 

‘‘714. Standards relating to benefits for contraceptives.’’. 

17 (c) EFFECTIVE DATE.—The amendments made by 

18 this section shall apply with respect to plan years begin19 ning on or after January 1, 2007. 

20 SEC. 4. AMENDMENTS TO THE PUBLIC HEALTH SERVICE 

21 ACT RELATING TO THE GROUP MARKET. 

22 (a) IN GENERAL.—Subpart 2 of part A of title 

23 XXVII of the Public Health Service Act (42 U.S.C. 

24 300gg–4 et seq.) is amended by adding at the end the 

25 following new section: 
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1 ‘‘SEC. 2707. STANDARDS RELATING TO BENEFITS FOR CON2 TRACEPTIVES. 

3 ‘‘(a) REQUIREMENTS FOR COVERAGE.—A group 

4 health plan, and a health insurance issuer providing health 

5 insurance coverage in connection with a group health plan, 

6 may not— 

7 ‘‘(1) exclude or restrict benefits for prescription 

8 contraceptive drugs or devices approved by the Food 

9 and Drug Administration, or generic equivalents ap10 proved as substitutable by the Food and Drug Ad11 ministration, if such plan or coverage provides bene12 fits for other outpatient prescription drugs or de13 vices; or 

14 ‘‘(2) exclude or restrict benefits for outpatient 

15 contraceptive services if such plan or coverage pro16 vides benefits for other outpatient services provided 

17 by a health care professional (referred to in this sec18 tion as ‘outpatient health care services’). 

19 ‘‘(b) PROHIBITIONS.—A group health plan, and a 

20 health insurance issuer providing health insurance cov21 erage in connection with a group health plan, may not— 

22 ‘‘(1) deny to an individual eligibility, or contin23 ued eligibility, to enroll or to renew coverage under 

24 the terms of the plan or coverage because of the in25 dividual’s or enrollee’s use or potential use of items 
12 

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1 or services that are covered in accordance with the 

2 requirements of this section; 

3 ‘‘(2) provide monetary payments or rebates to 

4 a covered individual to encourage such individual to 

5 accept less than the minimum protections available 

6 under this section; 

7 ‘‘(3) penalize or otherwise reduce or limit the 

8 reimbursement of a health care professional because 

9 such professional prescribed contraceptive drugs or 

10 devices, or provided contraceptive services, described 

11 in subsection (a), in accordance with this section; or 

12 ‘‘(4) provide incentives (monetary or otherwise) 

13 to a health care professional to induce such profes14 sional to withhold from covered individual contracep15 tive drugs or devices, or contraceptive services, de16 scribed in subsection (a). 

17 ‘‘(c) RULES OF CONSTRUCTION.— 

18 ‘‘(1) IN GENERAL.—Nothing in this section 

19 shall be construed— 

20 ‘‘(A) as preventing a group health plan 

21 and a health insurance issuer providing health 

22 insurance coverage in connection with a group 

23 health plan from imposing deductibles, coinsur24 ance, or other cost-sharing or limitations in re25 lation to— 
13 

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1 ‘‘(i) benefits for contraceptive drugs 

2 under the plan or coverage, except that 

3 such a deductible, coinsurance, or other 

4 cost-sharing or limitation for any such 

5 drug shall be consistent with those imposed 

6 for any outpatient prescription drug other7 wise covered under the plan or coverage; 

8 ‘‘(ii) benefits for contraceptive devices 

9 under the plan or coverage, except that 

10 such a deductible, coinsurance, or other 

11 cost-sharing or limitation for any such de12 vice shall be consistent with those imposed 

13 for any outpatient prescription device oth14 erwise covered under the plan or coverage; 

15 and 

16 ‘‘(iii) benefits for outpatient contra17 ceptive services under the plan or coverage, 

18 except that such a deductible, coinsurance, 

19 or other cost-sharing or limitation for any 

20 such service shall be consistent with those 

21 imposed for any outpatient health care 

22 service otherwise covered under the plan or 

23 coverage; 

24 ‘‘(B) as requiring a group health plan and 

25 a health insurance issuer providing health in-
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1 surance coverage in connection with a group 

2 health plan to cover experimental or investiga3 tional contraceptive drugs or devices, or experi4 mental or investigational contraceptive services, 

5 described in subsection (a), except to the extent 

6 that the plan or issuer provides coverage for 

7 other experimental or investigational outpatient 

8 prescription drugs or devices, or experimental 

9 or investigational outpatient health care serv10 ices; or 

11 ‘‘(C) as modifying, diminishing, or limiting 

12 the rights and protections of an individual 

13 under any other Federal law. 

14 ‘‘(2) LIMITATIONS.—As used in paragraph (1), 

15 the term ‘limitation’ includes— 

16 ‘‘(A) in the case of a contraceptive drug or 

17 device, restricting the type of health care pro18 fessionals that may prescribe such drugs or de19 vices, utilization review provisions, and limits on 

20 the volume of prescription drugs or devices that 

21 may be obtained on the basis of a single con22 sultation with a professional; or 

23 ‘‘(B) in the case of an outpatient contra24 ceptive service, restricting the type of health 

25 care professionals that may provide such serv-
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1 ices, utilization review provisions, requirements 

2 relating to second opinions prior to the coverage 

3 of such services, and requirements relating to 

4 preauthorizations prior to the coverage of such 

5 services. 

6 ‘‘(d) NOTICE.—A group health plan under this part 

7 shall comply with the notice requirement under section 

8 714(d) of the Employee Retirement Income Security Act 

9 of 1974 with respect to the requirements of this section 

10 as if such section applied to such plan. 

11 ‘‘(e) PREEMPTION.—Nothing in this section shall be 

12 construed to preempt any provision of State law to the 

13 extent that such State law establishes, implements, or con14 tinues in effect any standard or requirement that provides 

15 coverage or protections for enrollees that are greater than 

16 the coverage or protections provided under this section. 

17 ‘‘(f) DEFINITION.—In this section, the term ‘out18 patient contraceptive services’ means consultations, exami19 nations, procedures, and medical services, provided on an 

20 outpatient basis and related to the use of contraceptive 

21 methods (including natural family planning) to prevent an 

22 unintended pregnancy.’’. 

23 (b) EFFECTIVE DATE.—The amendments made by 

24 this section shall apply with respect to group health plans 

25 for plan years beginning on or after January 1, 2007. 
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1 SEC. 5. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT 

2 RELATING TO THE INDIVIDUAL MARKET. 

3 (a) IN GENERAL.—Part B of title XXVII of the Pub4 lic Health Service Act (42 U.S.C. 300gg–41 et seq.) is 

5 amended— 

6 (1) by redesignating the first subpart 3 (relat7 ing to other requirements) as subpart 2; and 

8 (2) by adding at the end of subpart 2 the fol9 lowing new section: 

10 ‘‘SEC. 2753. STANDARDS RELATING TO BENEFITS FOR CON11 TRACEPTIVES. 

12 ‘‘The provisions of section 2707 shall apply to health 

13 insurance coverage offered by a health insurance issuer 

14 in the individual market in the same manner as they apply 

15 to health insurance coverage offered by a health insurance 

16 issuer in connection with a group health plan in the small 

17 or large group market.’’. 

18 (b) EFFECTIVE DATE.—The amendment made by 

19 this section shall apply with respect to health insurance 

20 coverage offered, sold, issued, renewed, in effect, or oper21 ated in the individual market on or after January 1, 2007. 

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