Universal Free Contraception Coverage Policy, Out-of-Pocket Payments, and Costs.

Importance: While most individuals in Canada have some form of drug coverage, many public and private plans leave a substantial role for direct payment by individuals. For contraceptives, cost-sharing (deductibles and copayments) and the exclusion of some contraceptives from formularies often leads to access gaps and inequity. How universal, first-dollar contraceptive coverage policies change patient and public costs compared with a mixed public-private system is unclear. Objective: To evaluate whether patient out-of-pocket (OOP) costs and payer type changed after the implementation of a universal coverage policy for contraceptives, compared with a mixed public-private insurance system. Design, Setting, and Participants: This controlled interrupted time-series analysis examined aggregate monthly contraceptive prescription data, with British Columbia (BC) as the intervention province and a synthetic control modeled using other provinces. The analysis included all contraceptives dispensed to reproductive-aged females (15-49 years) in 10 Canadian provinces who had contraceptives dispensed between April 1, 2021, and March 31, 2025, using a national prescription database. This period covered 2 years before and 2 years after the policy's implementation on April 1, 2023. Exposures: Policy change in BC implementing free coverage for contraception by the public payer. Main Outcomes and Measures: The main outcome was the monthly proportion of contraception dispensed and estimated costs, stratified by age, majority payer type, and contraception type. Costs are given in Canadian dollars (currency exchange rate of CAD $1 = US $0.73 as of April 30, 2026). Results: During the 48-month study period, 2 791 157 contraceptive prescriptions were dispensed in BC (1 341 289 before policy implementation and 1 449 869 after). In the prepolicy period, 38.7% (95% CI, 38.0%-39.1%) of these prescriptions were paid OOP, 49.2% (95% CI, 48.6%-49.8%) by private insurance, and 12.0% (95% CI, 11.3%-12.7%) by public insurance. When the policy was introduced, the OOP share immediately decreased by 24.9 (95% CI, -26.3 to -23.5) percentage points. The highest prepolicy OOP share (44.6%) was in individuals aged 20 to 29 years, who also had the highest prepolicy costs. Compared with controls, by 2 years postpolicy, the OOP share was 29.5 (95% CI, 38.2-26.1) percentage points lower (33.4 [95% CI, 37.1-29.6] percentage points lower for ages 20-29 years), reaching 9.6% (95% CI, 8.7% to 10.4%) of contraceptives being paid OOP. At 2 years, OOP per-capita costs decreased by $8 per capita (ages 15-19 years: -$7 per year; 20-29 years: -$11 per year; 30-39 years: -$7 per year; 40-49 years: -$6 per year), or a mean of -$43 per year per contraceptive user. Conclusions and Relevance: In this controlled interrupted time-series analysis, a public drug plan providing universal, first-dollar contraception coverage was consistent with substantially reduced OOP payments, with the largest reductions among individuals aged 20 to 29 years. Contraception may be uniquely sensitive to gaps in mixed public-private insurance systems; these findings suggest that universal, first-dollar contraceptive coverage mandates are a highly effective policy measure to improve access to contraceptives, especially for young adults who often lack comprehensive drug insurance coverage.