OBJECTIVES: Mandatory employer-based insurance coverage of contraception in the U.S. has been a controversial component of the Affordable Care Act (ACA). Prior research has examined the cost-effectiveness of contraception in general; however, no studies have developed a formal decision-model in the context of the new ACA provisions. As such, this study aims to estimate the relative cost-effectiveness of contraception from the employer and societal perspectives, taking into consideration newer regulations allowing for religious exemptions. METHODS: A decision-tree was developed from the employer and societal perspectives to simulate costs and outcomes associated with all contraceptive methods covered by the ACA. Method-specific estimates of contraception access, utilization, adherence, failure rates, outcomes, and costs were derived from the literature. Employer coverage rates and covariates (age, income, marital status, and access) were varied through sensitivity analysis. RESULTS: Compared to full coverage of contraception, providing no coverage resulted in 4.9 more pregnancies per 100 women of childbearing age. This subsequently increased the number of live births (3.6 per 100) and terminations (1.3 per 100). Providing no coverage for contraception also resulted in greater societal healthcare costs owing to this increase in pregnancies. Coverage via a health savings account (HSA) resulted in a lower number of pregnancies and reduced costs due to the greater access to prescribing pharmacies. CONCLUSIONS: Although lack of coverage reduced drug costs, it ultimately resulted in a greater number of unintended pregnancies. Whether the objection for coverage is due to costs or increasing terminations, denying full coverage of contraceptives appears to have the opposite consequence of increasing total costs as well as the total number of terminations. Coverage of contraceptives via an HSA may provide a compromise.