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It Took a Team: Initiating access to SubQ Depo during the pandemic

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Dr. Linda Prine and Tiffany Smith, MPH, work at the Institute for Family Health, a Federally Qualified Health Center network with 17 sites across New York City and the Mid-Hudson Valley. 

Over the past few years, a team of clinicians and program staff has been working on a family planning grant that functions to expand training and access to reproductive health services in New York. As the pandemic accelerated rapidly in NYC, those of us working on the grant had to shift gears quickly and adapt to the new landscape. Though there would be no on-site training in LARC (long-acting reversible contraception, which includes IUDs and the birth control implant), we wanted to maintain the availability of comprehensive contraception services for our patients. In the past few years, we had started offering SubQ Depo (a form of the birth control shot) at our health centers. However, we had not previously focused on having patients access it at their local pharmacy or self-inject at home. But as the pandemic intensified and patients became warier about coming to our centers, we started to make that switch. 

Our project manager, Tiffany Smith, MPH, searched our patient base and found that there were more than 400 patients who were either overdue, due, or almost due for their next Depo shot – the Depo shot is generally given every 3 months. She started reaching out to patients via our patient portal and cold-calling. For those who were interested, she sent them an information sheet on how to inject the shot, and scheduled telehealth appointments for them with either Dr. Susan Rubin or Dr. Linda Prine. Quickly, we were spending much of our telehealth time on teaching people how to self-inject the SubQ Depo; however,  insurance denials soon started to roll in with patients already overdue for birth control having to wait for approval so that they didn’t have to pay out of pocket. The insurers’ reasoning was that the SubQ Depo was not on formulary (a list of covered prescription drugs), despite the coverage of injectable contraception in the Affordable Care Act, the New York Comprehensive Contraceptive Coverage Act, and the NY Reproductive Health Act!

We sprang into action and began collaborating with the Reproductive Rights branch of the NY Civil Liberties Union (NYCLU), the NY State Academy of Family Physicians (NYSAFP), the NY City Department of Health Medicaid Managed Care (DOHMMC), and the New York State Attorney General’s office. Meanwhile, our stellar nurse, Eve Stetson, LPN, began filling out prior authorization forms by the dozens. We called insurance companies, often waiting long hold times, only to be told, “This isn’t a decision I can override…” We spoke to supervisors, supervisors’ supervisors, working our way up the chain of authority, finally making our first breakthrough with Affinity Health Plan. They acknowledged that forcing people to come into the office for this contraception that was also available from their pharmacy and could be used at home was, in fact, a matter of safety. Ultimately, they agreed to cover SubQ Depo, but only for the duration of the pandemic. Next, we got the same approval from Healthfirst.

Though we found some success with those two insurance plans, the Institute takes more than 40 different health insurance plans and getting SubQ depo covered this way was proving to be slow and arduous. With the help of the NYCLU, we got someone in the New York State Department of Health to agree to tell all Medicaid Managed Care plans to cover the medication. The NYSAFP also put pressure on Gov. Cuomo’s office to act, and the Cuomo administration eventually announced that all Medicaid Managed Care plans would have to use one main formulary. The new formulary went live and the SubQ depo was on it! Getting the SubQ depo on the formulary proved only to be the first step, as Tiffany had to make phone calls to pharmacies, coaxing them through the extra steps to verify that SubQ was both covered and stocked, rather than turn patients away to other pharmacies. Ultimately, we estimate that we converted several hundred patients to the home use formulation of the Depo shot. Moreover, the feedback from the patients was positive, as they felt good about being able to continue using their preferred birth control method while avoiding unnecessary exposure. Though many patients are still using their refills, only a few have switched back to the in-office Depo shot. Our team advocacy efforts have shown that if the pandemic intensifies again, we can maintain access to comprehensive contraception services – this is something to be proud of.

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