TIME medicine

Newer Birth Control Pills Raise the Risk of Blood Clots

A new study puts a number on the risk of developing potentially fatal blood clots after using the pill

Blood clots have been a known risk of oral contraceptives since the 1990s, but for most women, the chances seemed small enough to justify taking the Pill. Now, in a report published in The BMJ, scientists led by Yana Vinogradova, a research fellow at the University of Nottingham, found that using the Pill was linked to anywhere from a two- to more than four-fold increased risk of developing clots compared to women who didn’t take oral contraceptives.

“Our study suggests that the newer contraceptives have a higher risk of [blood clots] than the older agents,” Vinogradova tells TIME in an email. Overall, the risk for women on the Pill was nearly three times that of women not taking the medication. The risk was highest for people taking Pills that contain newer types of the progestogen hormone, such as drospirenone, desogestrel, gestodene, and cyproterone, as compared to people taking the Pill with first-generation versions of the hormone (levonorgestrel and norethisterone).

The difference essentially boils down to the progesterone part of the drug; since the original pill was introduced in 1960, drug developers have tweaked the progesterone to lower side effects such as acne, headache, weight gain and breakthrough bleeding. But the price for those modifications may be more blood clots.

Even after Vinogradova and her team adjusted for the potential contributions of things like cancer, heart disease, varicose veins, arthritis, smoking and obesity on the risk of blood clots, the link between the newer contraceptives and increased risk remained strong.

“While [blood clots] are a relatively rare problem, they are serious and potentially avoidable with the appropriate drug choice,” says Vinogradova. “Doctors need to consider all health issues when prescribing contraceptives, selecting a drug type associated with the lowest risk for patients with particular susceptibilities.”

Whether that means that doctors should start with prescribing the older formulations first—as well non-hormonal birth control like the copper IUD—isn’t clear yet, since the newer forms have certain advantages, including the fact that they disturb the cholesterol system less, which may be important for diabetic women.

The blood clot risk, however, is something that doctors should consider when prescribing the Pill. And since there are different formulations available, Vinogradova says doctors should monitor their patients for any potential symptoms of poor circulation and switch to other formulations if needed.

MONEY Health Care

Now You Can Really Get Free Birth Control Under Obamacare

assortment of birth control pills
Ted Morrison—Getty Images

The Obama administration just tightened the law that says insurance companies must cover all types of contraceptives.

Following recent reports that many women still pay for birth control methods that should be covered by insurers under the Affordable Care Act, the government just released a new document clarifying and tightening the law.

“Insurance companies have been breaking the law and today the Obama administration underscored that it will not tolerate these violations,” Gretchen Borchelt, National Women’s Law Center vice president for health and reproductive rights, said in a statement. “It is past time for insurers to adhere to the law and stop telling women that their chosen method isn’t covered or that they must pay for it.”

Whereas previous government FAQs about Obamacare were not as clear about the types of birth control covered under the law, the new guidance includes an explicit list—printed below—of all the contraceptive methods insurers must cover.

Until now many women, including one MONEY staffer, have found that insurers have been able to skirt the law by lumping together certain categories of contraceptives and charging expensive co-pays on all but a small number of methods. Since the previous language was vague, insurance companies have been able to deny coverage of brand name contraceptives—even when an equivalent generic is not available.

In particular, the new rules are especially good news for those who use IUDs, patches, and vaginal rings, since those are the birth control methods that women have had the most trouble getting covered, according to a recent study by the NWLC.

If your insurer is still making you pay out of pocket for your preferred method of birth control—and a generic substitute is not available to or appropriate for you because of, say, side effects—you should fight back by first talking to your doctor, who could advocate for you to your insurer.

This should be especially effective since the rules make it clear that doctors get the final say over whether a particular birth control method is medically necessary.

According to the new statement: “If an individual’s attending provider recommends a particular service or FDA-approved item based on … medical necessity … the plan or issuer must cover that service or item without cost sharing. The plan or issuer must defer to the determination of the attending provider. Medical necessity may include considerations such as severity of side effects, differences in permanence and reversibility of contraceptives, and ability to adhere to the appropriate use of the item or service.”

If that doesn’t work, consider resources like the National Women’s Law Center: Its website has templates for appeal letters and a free hotline (866-745-5487) you can use to get further help.

Here is the list of contraceptive methods that are now fully covered. Insurers must cover at least one type of birth control in each of these 18 categories:

(1) sterilization surgery for women
(2) surgical sterilization implant for women
(3) implantable rod
(4) IUD copper
(5) IUD with progestin
(6) shot/injection
(7) oral contraceptives (combined pill)
(8) oral contraceptives (progestin only)
(9) oral contraceptives extended/continuous use
(10) patch
(11) vaginal contraceptive ring
(12) diaphragm
(13) sponge
(14) cervical cap
(15) female condom
(16) spermicide
(17) emergency contraception (Plan B/Plan B One Step/Next Choice)
(18) emergency contraception (Ella)

The new government statement also clarifies that insurers must cover preventive services for transgender people when such services are medically appropriate, anesthesia services during preventive colonoscopies, and preventive screening for mutations in the BRCA-1 or BRCA-2 gene.

TIME Innovation

Why Read Hamlet When You Can Play It?

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

These are today's best ideas

1. Why read Hamlet when you can play an immersive time-traveling video game version instead?

By Jess Joho in Kill Screen

2. Here’s how to attract female engineers.

By Lina Nilsson in the New York Times

3. Everyone is losing in Yemen’s war.

By Adam Baron in Foreign Policy

4. Google and Facebook could save — or consume — journalism.

By Emily Bell in the Columbia Journalism Review

5. We know how to dramatically reduce teen pregnancies, but we don’t. Here’s why.

By Nora Caplan-Bricker in the National Journal

The Aspen Institute is an educational and policy studies organization based in Washington, D.C.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME health

Why I Love My IUD

Paragard IUD
Photo Courtesy of Paragard; Photo Illustration by Mia Tramz for TIME

It is completely and totally worth it

Last summer, my family and I attended the wedding of a close family friend. As the guests filed out onto the dance floor, my mother walked over to me while I was deep in conversation with some of the bride’s college-age cousins. The girls immediately turned red upon seeing an older adult approaching, and sensing their trepidation, I quickly changed the topic of conversation and excused myself and my mother.

“What were they so embarrassed about?” my mom asked as we walked away.

“Oh,” I said laughing, “We were all discussing IUDs, and I was telling them how much I love mine.”

I’m completely and totally obsessed with my IUD, and no, I frankly don’t care who knows about it. As women, we are taught from a very young age that our sexuality is something to hide, and that health matters that pertain to our reproductive systems are somehow less serious or important than those of our male counterparts. We are taught to hide our tampons, to covertly take our birth control pills, and to explain away any relevant health issues as “female issues,” lest we offend anyone by discussing how our bodies fundamentally work.

Yes, my IUD hurt when it was inserted. Yes, my cramps are moderately worse now. And yes, in my opinion, it is completely and totally worth it. Getting my copper IUD last year ended a 14-year saga of failed acne treatments and less than ideal birth control methods. I love my IUD so much I literally want to tell everyone about it.

I have always been self-conscious about my skin. For some women, the societal pressure to be thin hits them early, but I — as a gangly, over-tall preteen — was consumed by another perceived aesthetic, failing as soon as I entered middle school. I keenly remember slathering thick and sticky drugstore concealer all over my face and scouring the aisles of CVS for any new over-the-counter acne product that I thought might help eradicate the fledgling breakouts that continued to angrily appear on my face. When I finally got up the courage to ask my mother to see a dermatologist, I thought that the doctor would perform magic on all of my skin issues. But, the plethora of different topical ointments she prescribed always destroyed my sensitive skin and not my acne. I ended up on oral antibiotics for the later part of high school, as basically a last resort.

MORE The IUD Answer

Almost a year after I first started oral antibiotics to treat my acne, the medicine was finally working despite a host of negative side effects, and I — as a sexually active, but perplexingly responsible young person — got myself a birth control prescription from my family doctor. It was then that my skin truly went off the rails. My face was covered with cystic acne, I began to slowly gain weight, and my moods became increasingly unstable. And, I quickly discovered that it was extremely difficult for me (a self-confessed Type B person), to remember to take a pill at an exact time every single day. Moreover, some types of antibiotics — so far the only type of acne treatment that had worked on my skin — had been found to also possibly leave birth control less effective. Meaning, in short, what the heck was I doing to myself, and why?

When I entered college I was told for the first time ever that maybe my acne had something to do with my hormones — I broke out around my mouth and chin — and my hormonal birth control was making it worse and not better. What followed was a lot of experimentation, as I was slowly exposed to different birth control options that I had never heard of before (hello, birth control patch!), to find a method that I could both remember to take and that didn’t destroy my face.

When I explained this saga to my gynecologist post-college, she looked at me with a bit of surprise on her face.

“Well,” she said, “why haven’t you considered getting an IUD?”

I was confused at first — weren’t IUDs only for women who had already had kids? Didn’t they hurt a ton? And couldn’t they make you sterile?

Apparently, no. My doctor patiently explained to me that a lot of the myths that used to be pervasive about IUDs were completely untrue. It turns out, more and more doctors were recommending them to patients like myself — young women who had tried many other birth control methods and who had responded badly hormones in the past. According to the Mayo Clinic, the copper IUD, or ParaGard, “offers effective, long-term contraception [and] it can be used in premenopausal women of all ages, including teenagers. Among various benefits, ParaGard can remain in place for up to 10 years and can be removed at any time, followed by a quick return to fertility.”

It didn’t take any more convincing; I was sold. I opted for the copper IUD — which doesn’t have any hormones — instead of the low-hormone Mirena, because I wanted to start treating my acne again with a completely clean slate. I also wanted to avoid the weight gain and mood shifts that had doggedly occurred whenever I used hormonal birth control methods. After a quick and relatively painless insertion process (seriously, it wasn’t that bad, eyebrow threading is worse), I left the office with moderate cramps and a brand new IUD chilling in my uterus.

I won’t lie, the first few days of cramps were not fun, and for a couple of months my period decided to act like I was in middle school again (according to the Mayo Clinic, “the side effects associated with the ParaGuard [copper IUD] include bleeding between periods and cramps,” but no acne, yay!). However, after about 3 months, I felt totally normal, and I was super pumped about two things: One, I never had to take birth control again for 10 years; and two, my skin had already started to clear up… without any antibiotics.

It’s been almost two years now and I’m still thrilled with my decision. Yes, not all women have trouble with hormonal birth control, and not all acne-sufferers will find that removing hormonal birth control from their lives will help them regulate their acne. But, for me, the copper IUD was that elusive magic bullet that helped me both manage my reproductive choices and my acne. My skin is infinitely more clear and I get to have sex without worrying about having a kid any time soon (yay!). I’d call that a win-win.

This article originally appeared on MIMI.

More from MIMI:

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME public health

Not All Birth Control Covered by Insurance Companies Under Obamacare

Woman taking birth controll pill
Frank May—picture-alliance/dpa/AP

A new study from the Kaiser Family Foundation finds not all birth control is covered without costs or copays, including some IUDs and emergency contraceptives

Most health insurance companies are offering the free birth control required under the Affordable Care Act, but gaps still remain, according to a new report.

The Kaiser Family Foundation examined 20 health insurance providers in five states and found women are still paying some contraceptives, including vaginal rings, patches and implants.

The free birth control requirement is both a key and controversial piece of President Obama’s signature health law, seen as one of the many ways the law helps lower health costs for women. The report found that while many insurance carriers in California, Georgia, Michigan, New Jersey and Texas are covering contraceptives cost-free, some do not fully cover Depo-Provera shots, the OrthoEvra patch, certain types of intrauterine devices or IUDs, and emergency contraception.

Without coverage, the contraceptives can be expensive. An IUD, for example, costs up to $1,000—which means that without insurance coverage, one of the most effective forms of birth control is unavailable to some of the women who want to use it.

“We encourage the administration to provide guidance and clarity to insurance companies to ensure all women can access the birth control methods that work for them without cost barriers, as the law intended,” Cecile Richards, the president of the Planned Parenthood Federation of America, said in a statement.

The Kaiser report notes that insurance carriers are permitted to limit the forms of birth control they cover under Obamacare, but the companies should still offer leeway to consumers who have a medical need for certain devices, the report found.

The report also found that despite the widespread attention to the effect the contraceptive mandate would have on religious institutions that oppose birth control, few groups have applied for a religious exception to the law.

Read more: Why You’re Still Paying for Birth Control Even Though It’s ‘Free’ Now

TIME Sex/Relationships

Teens Aren’t Using the Most Effective Birth Control

IUD birthcontrol
Photo Illustration by Mia Tramz for TIME; Corbis

A new CDC report reveals few teens use IUDs and implants

American teenagers are getting better at practicing safe sex, but a new federal report reveals very few teens are using the most effective forms of birth control.

In the new report, the Centers for Disease Control and Prevention (CDC) looked at 2005–2013 data from the Title X National Family Planning Program on teen contraceptive use and found that teen use of long-acting reversible contraception (LARC)—such as the intrauterine device (IUD) and the implant—are up but still very low. The numbers show that U.S. teen LARC use increased from under 1% in 2005 to 7% in 2013. Implants were used more than IUDs by women of all ages. The state with the highest use of LARC among its teens in 2013 was Colorado at 26%. All other states ranged from use of less than 1% to 20%.

Currently, teens are opting for methods like condoms and birth control pills, which while still good options, are less effective and more prone to incorrect or inconsistent use.

MORE: Why The Most Effective Form of Birth Control is the One No One Uses

The benefit of contraceptives like the IUD and implant are that they are low maintenance and highly effective. For example, the typical use failure rate of the IUD is 0.2% and for the implant it’s 0.05%. By comparison, the birth control pill and vaginal ring have a failure rate of 9% and condoms have a fail rate of 18%.

In 2012, the American Congress of Obstetricians and Gynecologists (ACOG), considered an authority on reproductive health, concluded that IUDs and implants are safe and appropriate for adolescents and teens. In 2014, the American Academy of Pediatrics (AAP) agreed and said it recommends LARC for adolescents.

“Long-acting reversible contraception is safe for teens, easy to use, and very effective,” said CDC principal deputy director Ileana Arias in a statement. “We need to remove barriers and increase awareness, access, and availability of long-acting reversible contraception such as IUDs and implants.”

CDC

According to the new CDC report, there are a variety of reasons why a young person may not opt for the IUD or implant. Many teens don’t know very much about them and they often think they are too young to use them. As TIME reported in June, some physicians may remember the IUDs of past, which caused severe problems for women and were discontinued. Modern-day IUDs are safe and appropriate but there are still misperceptions about the device that persist within the medical community. Many providers are also not properly trained on insertion or removal of the IUD and implant. However, a recent report showed that among female health care providers 42% use LARC, which is much higher than both the general population of teens and adult women.

Overall, the CDC report shows that American teens are waiting to have sex, and when they are sexually active, nearly 90% report using birth control. The teen pregnancy rate in the United States appears to be steadily dropping, though in 2013 over 273,000 babies were born to girls between ages 15 and 19. The CDC says encouraging young women to consider LARC is an important strategy for further reducing teen pregnancy.

TIME republicans

Most Young Republicans Support Birth Control, Poll Says

TIME.com stock photos Birth Control Pills
Elizabeth Renstrom for TIME

But 60% don't think it's a health care need

A majority of young Republicans believe every woman should have access to affordable birth control, according to a new poll.

The survey, by The National Campaign to Prevent Teen and Unplanned Pregnancy, found that 57% of Republicans aged 18-34 said they had a positive view of birth control, and two-thirds of them agreed that “every adult woman should have access to affordable, effective birth control because it gives people a chance to build families on their own terms.”

“Young Republicans don’t leave their ideology behind when thinking about expanding contraceptive access, and they certainly favor limited government,” said Kristen Soltis Anderson, a Republican pollster who conducted the survey. “However, within that context, they want to know how to make sure that the most effective methods of birth control are available to those who want them.”

Despite largely believing birth control should be covered by insurance, a majority of those surveyed, including 55% of young Republican women, supported the Supreme Court’s decision in the Hobby Lobby case, which allowed an employer to deny contraceptive coverage to employees on religious grounds. And while a majority support birth control generally, 60% of respondents, including a majority of women, consider birth control “more of a personal convenience than a health care need for adult women.”

TIME Iran

Iran Mulls Laws That ‘Reduce Women to Baby-Making Machines,’ Says Amnesty

Tehran plans to outlaw vasectomies and reduce access to birth control

Amnesty International has slammed Iran for proposing two draft laws aimed at boosting the country’s population, saying the legislating would “reduce Iranian women to ‘baby-making’ machines.”

One proposal would ban voluntary sterilization and restrict access to contraceptives, while the other would make it harder for women without children to get jobs.

In a report released Wednesday, Amnesty says the laws, if approved by Tehran’s parliament, would “set the country back by decades” and have serious consequences for women and girls. (For the past two decades, Iran has had an effective birth control program in place that provided affordable contraception, subsidies for vasectomies, and education on family planning and sexual health, with the aim of reducing the population.)

“By abolishing family planning programs and blocking access to vital sexual and reproductive health services, the authorities would be exposing women to serious health risks, and violating their human rights,” said Hassiba Hadj Sahraoui, Amnesty’s deputy director for the Middle East and North Africa.

The second bill would instruct workplaces to prioritize employing men with children, married men with children and married women with children when hiring for certain jobs. The new legislation would also make obtaining a divorce more difficult, which Amnesty says would have “devastating consequences” for women in abusive relationships.

“The bills send a message that women are good for nothing more than being obedient housewives and creating babies and suggests they do not have the right to work or pursue a career until they have fulfilled that primary role and duty,” said Sahraohi, adding that without access to contraceptives more women would risk their lives and health by undergoing unsafe abortions.

TIME Sex/Relationships

IUDs Are Getting More Popular With American Women

149321478
Getty Images

More U.S. women are using the IUD or implant

American women are increasingly opting for longer-lasting and highly effective forms of birth control, according to new federal data released on Tuesday.

New numbers from the U.S. Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) show women are choosing long-lasting reversible contraceptives (LARC) like the intrauterine device (IUD) and the implant more than they have in the past. According to the numbers, IUD use increased 83% from 2006–2010 to 2011–2013 and implants tripled in use during the same time period. Both methods are approximately 99% effective at preventing pregnancy.

“I am delighted LARC use is rising. It’s terrific and I would like to see even more,” says Dr. Mary Jane Minkin, professor of obstetrics, gynecology and reproductive sciences at the Yale School of Medicine.

Overall, the use of LARC has increased fivefold in the past decade among women between the ages of 15 to 44, though overall usage remains low. Use spiked from 1.5% in 2002 to 7.2% in between 2011 and 2013. Women ages 25 to 34 are the most likely to choose LARC at 11% compared with 5% of women ages 15 to 24 and around 5.3% of women ages 35 to 44.

As TIME previously reported, one reason for the slow uptake among American women is that older versions of the IUDs from the 1970s and ’80s were plagued with problems. The new CDC data shows that LARC use declined between 1982 and 1988 and remained stable from 1988 to 1995. Today, IUDs are considered very safe and effective. Planned Parenthood told TIME it has experienced a 75% increase in IUD use among its patients since 2008.

“I think the current generation of women haven’t heard about the errors of the past, which is good,” says Minkin. “They are looking anew at LARC and looking at them for the value they have. People can forget their pills. These other methods take the human variable out of it, and they work very nicely.” (Minkin was not involved in the new study.)

MORE: Why the Best Form of Birth Control Is the One No One Is Using

New, separate data published Monday in the journal Contraception showed that among 500 female health care providers, 42% used LARC, which is significantly higher than the general population.

Women in other countries are significantly more likely to use LARC, especially the IUD. Separate research has shown that 23% of French women using contraception use an IUD as well as 27% of Norwegian women and 41% of women in China. In the U.S., cost may be a factor: the Guttmacher Institute, a reproductive-health nonprofit, reports that their research shows sharp increases in the numbers of women who don’t have to pay out of pocket for LARC thanks to the Affordable Care Act. Without insurance coverage, LARC can be prohibitively expensive for some — around $900 for an IUD, for instance.

“If you have contraceptive coverage that makes it much more doable,” says Minkin, “I think it increases the availability and viability for women.”

MONEY Health Care

Why You’re Still Paying for Birth Control Even Though It’s “Free” Now

150211_FF_BirthControl
Laura Johansen—Getty Images

Most women with private health insurance can get contraception for free, but a lack of information means some are still paying out of pocket—even when they shouldn't be.

A record scratch sounded in my head one weeknight this January, when a pharmacist at my local drugstore told me my birth control pills would—for the first time—cost more than $50 a month.

Strange, I thought, since I could have sworn I heard contraception was one of the preventive health services that are free under the Affordable Care Act, and that the law was rapidly expanding access for most women, with at least 67% of insured women on the pill paying $0 (up from only 15% in 2012), according to a recent study by the Guttmacher Institute. Perplexing.

After all, I don’t work for an exempted religious organization or a company such as Hobby Lobby, which in a Supreme Court case last year won the right to deny contraceptive coverage because of conflicting beliefs. And the same pills—Ortho Tri-cyclen Lo—cost me nothing under my old health plan. Sure, I had switched insurance companies in the new year (to Aetna, the third largest in the country), but I’d opted for a high-premium Gold plan. A monthly copay on par with the cost of an iPod shuffle seemed hefty and unfair.

So I left the pharmacy empty handed and went home to call Aetna.

My happiness was brief when a customer service agent informed me that—while most brand-name pills had a copay—I could simply switch to a free generic version of the same compound. The problem? Turns out there is no generic version of Ortho Tri-cyclen Lo yet. So I was trapped, much like women whose insurance companies have denied them coverage for the NuvaRing, reasoning that they can take generic pills with the same hormones—even though the Department of Health and Human Services has been clear that the ring is a distinct form of contraception (and should therefore be free).

I hesitated to simply choose a different generic for a reason that should not surprise the many other women who have tried multiple birth control methods: Switching from pill to pill in the past caused me side effects, which thankfully subsided once I finally found one that worked for me.

“People respond differently to different pills and a change can cause side effects like irregular bleeding and headaches,” says Jill Rabin, an ob-gyn and professor at Hofstra North Shore-LIJ School of Medicine. “There’s no predicting how someone will do unless they try it.”

The pressure I felt to switch seemed especially unjust given this aspect of the law: While women can be charged a copay for brand name drugs when an equivalent generic is available, this Department of Labor FAQ explains, “if, however, a generic version is not available, or would not be medically appropriate for the patient” as determined by her doctor, “then a plan or issuer must provide coverage for the brand name drug … without cost-sharing.”

When I brought my dilemma (and the fact that I was a journalist planning to write about it) to Aetna’s director of communications, Susan Millerick, she took swift action. Within a week, I had my Ortho Tri-cyclen Lo, free of copay.

“It is always Aetna’s intent to abide by the laws that govern our health benefits coverage, and to fairly interpret and apply all laws and regulatory guidance on behalf of our customers and members,” Millerick wrote in an email.

Millerick’s explanation for what had happened suggests any woman would be wise to question any insurer denial for contraceptive; she said Aetna’s “service reps erred” in not telling me about the option to appeal the copay. I should have been told that I could just ask my doctor to call and verify that I really needed my pill and that a different generic would not suffice.

The good news for many women is that simply being informed of your options—and getting your doctor on your side—may be enough to go from paying a wallet-draining copay to nothing at all, says Rabin.

“Figuring out the best contraception that minimizes cost and maximizes efficacy is a conversation that should be between doctor and patient,” Rabin says. “Most doctors don’t want that decision taken out of their hands and would be happy to help make that call for their patients.”

For those women who encounter more resistance than I did—or find, as Kaiser Health News reported, that certain insurers are even trying to wriggle out of covering generics—there are other resources to turn to, like the National Women’s Law Center. Their website has clear instructions on how to fight back if you think your insurer is unfairly denying you free birth control, with templates for appeal letters and a free hotline (866-745-5487) for additional assistance.

Even with all the progress, thousands of women have been contacting the NWLC’s hotline in recent months after running into problems getting free contraceptives, says Mara Gandal-Powers, a lawyer at the NWLC.

Generally, the biggest obstacle to free birth control access right now is ignorance, she says. Many women—and their insurance representatives, doctors, and pharmacists—aren’t on the same page about whether their particular contraception should have a copay or not. Instead of doing a double take at the cost of their contraceptives, Gandal-Powers says, some women never question the charge.

That’s a compelling reason to double check your insurer, pharmacist, and even doctor’s assumptions.

“There is definitely a lot of education that still needs to happen,” says Gandal-Powers, “not just among women themselves but also among health care providers and pharmacists.”

Beyond a lack of education, a few more obstacles to universally free birth control remain. Besides the religious exemption, there’s also a subset of insurance plans that are “grandfathered” in such a way that they don’t have to cover contraception right away—though they will in coming years. Enrollment in grandfathered plans is dropping, with only 26% of covered workers enrolled in a grandfathered health plan in 2014, down from 56% in 2011, according to the Kaiser Family Foundation. Another exception is self-funded student plans.

The takeaway? If you’re paying more than $0 for birth control, it can’t hurt to do a little digging. If you are lucky (and persistent), you could end up pushing your insurer to better comply with the law—and save hundreds of dollars a year, to boot.

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