As the nation grapples with the onslaught of COVID-19 cases, basic needs for contraceptive services and supplies have not diminished. Most family planning clinics and health centers remain open because they are considered essential health providers, but some have had to scale back staff or hours. Many clinics are looking to telemedicine services to find ways to ensure patients continue to have access to contraception and STI services. There has been a proliferation of online services in recent years that seek to offer individuals that cannot make it to a clinic or do not have an established source of care access to some contraceptive methods and STI testing through a telemedicine platform, usually a website or a smartphone application. This data note provides an overview of options available for the online management of sexual and reproductive health services during the current global pandemic and discusses the opportunities and limitations of these platforms in terms of availability and cost.
Family Planning Clinics
Providers and clinicians are still the front lines for provision of family planning services for most individuals. The majority of clinics remain open as essential health care providers and are still serving patients for family planning and STI services. Many clinics are now using telehealth services or are quickly working to implement telehealth as a way to continue providing contraceptive care without the need for an office visit. Individuals who are able can still contact their usual provider for contraceptive refills and receive their prescriptions through their provider or a local pharmacy, which may have home delivery or drive-through pick up options. When possible, clinics are providing a 12-month supply of contraceptive methods, prescribing Depo-SubQ Provera 104 for self-injection of Depo shots which can be administered at home, and using quick start protocols for all methods to begin contraception on the day of the visit rather than wait until the next period to initiate a new method, removing the need for subsequent visits. These services are still available without cost sharing for those covered by Medicaid or private insurance, and on a sliding fee scale for low-income and uninsured people seeking care at Title X-supported family planning clinics, Planned Parenthood clinics, and Federally Qualified Health Centers.
Because of staffing shortages or concerns about infection, however, some clinics and providers have been forced to reduce hours and limit in-person visits to patients with urgent needs. Some sites may also limit services that require specific staff (with specialized training) or personal protective equipment, such as long-acting reversible contraceptive (LARC) insertions and removals.
Online Platforms for Contraception
For individuals who cannot leave their home or get their method through their usual provider or pharmacy, an increasing number of online telemedicine platforms are available for obtaining hormonal contraceptives (the pill, patch, ring, and emergency contraception) outside of traditional health care settings. Most online platforms determine a client’s eligibility and prescribe contraception in a similar manner to a clinic. Using an online questionnaire or video consultation, the provider determines a patient’s medical eligibility for contraception by obtaining their health history, including a recent blood pressure reading, and evaluating potential risk factors including history of stroke, liver or gallbladder problems, a recent pregnancy, current breastfeeding and smoking status. After assessing the patient’s medical history and contraceptive preferences, the patient is either mailed their contraceptives or their prescription is sent to a nearby pharmacy for pick-up. Most platforms will send one to three packs of pills at a time, with a few offering six to twelve packs per delivery. In addition to the cost of the contraception, many online platforms charge a consultation fee or yearly membership that ranges from $15 to $99 and typically covers the medical evaluation and customer support for the duration of the prescription. This fee is not usually billed to or covered by insurance and is instead paid out-of-pocket by the patient.
Some companies can only prescribe to individuals in certain states, though they may be able to mail contraceptives to people who already have a prescription. For instance, Pandia Health will deliver to all 50 states, but can only currently prescribe in California, Florida, and Texas; while The Pill Club can prescribe in 37 states and DC, and delivers to all 50 states. Many of these platforms require individuals to be at least 18 years old, but some provide services to younger people with parental consent.
There is considerable variation in contraceptive costs, method availability, and Medicaid and private insurance acceptance by vendor (Table 1). The price of contraception offered by these platforms varies by method and by brand. While some online platforms accept private insurance, the majority do not accept Medicaid, which may limit low-income women’s access to these services. While most offer low-cost generic contraceptives, the cost of contraceptives on platforms that do not accept insurance can range from $10 to $225 a month, which can be unaffordable for many individuals.
It is important to note that these services and methods are covered at no cost for people covered by Medicaid or most private insurance or on a sliding fee scale at a Title X clinic, Planned Parenthood, or Federally Qualified Health Center for uninsured people. Emergency contraception is available over the counter, but is also available through many of these platforms for a similar price ($20-$45). AfterPill is an online platform that specializes in emergency contraception and charges $25/pill or $65 for three pills. For faster shipping, AfterPill can be purchased through Amazon Prime.
Online Platforms for STI Testing
In addition to contraception, some of these platforms provide at-home sexually transmitted infection (STI) testing. Some platforms require a virtual consultation and charge a fee, but most allow the individual to purchase an STI test or testing kit with multiple STI tests without a consultation. STI testing kits have options for genital, oral, and rectal chlamydia and gonorrhea testing, as well as syphilis, HIV, and trichomoniasis testing. Depending on the type of kit, individuals collect either urine samples, finger prick blood samples, or vaginal, rectal, or oral swabs, and mail them back for testing. Rather than providing at-home test kits, some entities, like Lemonaid and STDcheck.com, will order lab tests and individuals can get tested at a local clinic or lab.
If the test results are positive, a medical provider will either contact the individual or the individual can schedule a telemedicine physician consultation to discuss treatment options. Many will prescribe treatment for chlamydia, gonorrhea, trichomoniasis, and herpes simplex virus 2 that can be picked up at a local pharmacy. The physician consultation is usually provided at no additional cost, but the cost of the treatment depends on an individual’s insurance. STDcheck.com charges $95 for a physician consultation and written prescription for treatment. They will also provide a prescription for an individual’s partner for an additional $95. Lemonaid also charges a separate visit fee to assess the individual for treatment that is not included in the price of the test. Most online platforms offering STI testing do not state whether they offer expedited partner therapy (EPT). EPT is when a provider prescribes treatment for the sex partner(s) of the diagnosed patient, without first examining the partner(s). EPT is typically used in cases of chlamydia or gonorrhea, and sometimes trichomoniasis, in order to prevent reinfection by the same sex partner(s). EPT helps ensure a patient’s partner receives treatment and is a best practice in clinical settings, but many of these online platforms require an individual’s partner to set up their own account and purchase their own testing kit, which is not EPT.
These at-home tests and test kits can range in cost from $39 to $522 (Table 1). Many platforms do not accept private insurance or Medicaid, which can make this service cost prohibitive for many people. Nurx is the only platform offering at-home STI testing that accepts Medicaid, but only in California, Illinois, and Texas. The cost of their STI testing kits ranges from $75 for individuals with insurance coverage to $150 to $220 for individuals who are uninsured. Alpha Medical, PlushCare, and Virtuwell also accept private insurance, but not Medicaid. Alpha Medical, PlushCare, and Virtuwell all require a consultation fee and provide online primary care, offering more than just at-home STI testing. Usually, the most affordable way to get STI testing and treatment is to use private insurance or Medicaid at a clinic and under the ACA some STI screenings are covered without cost-sharing. Low-income and uninsured individuals can also go to a Title X clinic, a Federally Qualified Health Center, or a public health department for no-cost or low-cost testing based on a sliding fee scale, but this may be challenging when services are scaled back and travel options limited.
Opportunities and Limitations for Online Platforms
While these online platforms may offer convenience and the ability to stay home, there are tradeoffs to consider. One significant limitation is affordability. The majority of online platforms do not accept insurance or Medicaid and do not offer sliding fee scale options for uninsured individuals. In 2018, 59% of women of reproductive age (15-49) had employer-sponsored insurance coverage, 19% had Medicaid coverage, and 12% were uninsured. Most women with insurance coverage can access contraceptives at low to no cost. The Affordable Care Act requires most private health insurance plans to cover at least one form of each of the 18 FDA-approved contraceptive methods for women as prescribed without cost-sharing, and Medicaid programs are also required to cover family planning services with no cost sharing. The relatively high cost of some contraceptives available on online platforms can put them out of reach for many low-income women. In 2018, 21% of low-income women were uninsured, 42% had Medicaid coverage, and 28% had employer-sponsored coverage.
While most hormonal contraceptive methods are available through these online platforms, some of the longer-acting, most effective methods such as IUDs and contraceptive implants still require a visit to a clinic for insertion. The same is true for most DMPA contraceptive injections. Only Nurx offers the Depo-SubQ Provera 104 injection, which is developed for self-administration, at $285/shot. Other limitations include limited availability of certain brands, age restrictions for teens, and the need for a credit or debit card for payment.
While these platforms may be an attractive option for some to secure prescription contraceptive methods and STI services during the COVID-19 outbreak without leaving home, family planning providers are ramping up their telemedicine practices to make these methods available and affordable to their teen and adult clients. Unless individuals find a platform that accepts their insurance or Medicaid, they can expect to spend considerably more for contraceptive services and STI treatment than they would have if they sought care from a provider that accepts private insurance or Medicaid or participates in a family planning clinic or health center that receives federal funding to provide care. While these online platforms offer great potential to expand access to prescription contraceptive methods and STI testing, cost will continue to be a barrier for consumers until the services broaden their participation in Medicaid and private insurance so that women can receive no-cost coverage just like they do when they obtain services and supplies in clinical settings.