Changes in Emergency Contraceptive Fills After Massachusetts’ Statewide Standing Order

• In Event: Evaluating Policies to Improve Access to Contraception in the US

Abstract

Introduction:
Emergency contraceptives are key to prevent unintended pregnancy after unprotected sexual intercourse orcontraceptive failure. While federal policy requires private and Medicaid plans to cover contraceptives without cost-sharing, this requirement only applies to medications when prescribed. To reduce barriers to obtaining a prescription, Massachusetts became the first state to implement a standing order for emergency contraceptives in August 2022. This policy allows pharmacists to dispense prescription-only ulipristal (Ella) and over-the-counter (OTC) levonorgestrel (Plan-B and generics) using a standing prescription ordered by the state. If effective, this policy could be adopted by other states. 
Research Objective:
The goal of this research was to evaluate the association between Massachusetts’ statewide standing order and prescribed emergency contraceptive fills overall and by individual-level characteristics (e.g., adolescent [15-17 years] vs. non-adolescents, insurance coverage, and previous use of hormonal contraceptives) 2+ years after policy adoption.
Methods:
We used a difference-in-differences study design to compare changes in emergency contraceptive fills before (July 2021-May 2022) and after (August 2022-December 2024) the policy was implemented, examining Massachusetts and a comparison group comprised of Illinois and Connecticut (states with similar abortion, contraception access, or health insurance access policies). We used IQVIA’s individual-level, longitudinal prescription (LRx) claims which capture 93% of all prescriptions dispensed at retail and mail-order pharmacies and American Community Survey data to derive the population of women of reproductive age (15-49 years) for each state. We calculated monthly fill rates for emergency contraceptives per 100,000 women overall and for ulipristal and prescribed levonorgestrel. The period after the Dobbs decision but before the policy change was a washout period (June 2022-July 2022).
Results:
This study included 159,705 emergency contraceptive fills between July 2021 and December 2024. In the adjusted analysis, after 2-years of implementation, the statewide standing order was associated with an additional 29 emergency contraceptive fills per 100,000, a 29% increase. Ulipristal fills increased by 19 fills per 100,000 (49%) whereas fills for levonorgestrel increased by 7 per 100,000 (12%). In subgroup analyses, larger increases for ulipristal were observed for older women (30 fills per 100,000) compared to adolescents (13 fills per 100,000). The increase in fills was entirely accounted for by an increase in fills with insurance. Increases were concentrated among women with a history of using hormonal contraceptives (19 fills per 100,000, compared to 6 per 100,000 for women without such a history). Event-study analyses found no differences in pre-policy trends between the treatment and comparison groups (P=0.59). 
Conclusions:
The Massachusetts statewide standing order policy was associated with an increase in emergency contraceptive fills at pharmacies, particularly prescription-only Ella. This is important because Ella is effective for pregnancy prevention for up to 5 days (vs 3 days for levonorgestrel) and is more effective in overweight and obese women.  Because this policy can be implemented at no cost to the state, other states could readily adopt it. However, the policy did not increase fills without insurance and had a limited impact among adolescents and people without prior contraception use; efforts to improve equitable access remain necessary.

Author

• Rebecca Myerson, Emory University
  Presenting Author