OBJECTIVE: A patient assistance program (PAP) provided women with the option to have their levonorgestrel implants (Norplant System) removed at no cost, but the PAP only received half of patient-requested removal certificates (vouchers) for reimbursement. The primary goal of this study was to examine the reasons for apparent underutilization of the certificates and to identify treatment barriers. METHODS: The study population in this cross-sectional study was made up of women with the levonorgestrel implant who requested removal certificates from the Norplant Foundation during a seven-month period, but did not return completed certificates via their physicians. A total of 1820 women qualified for the removal program during the 6-month data collection period. Seventy-five percent of these women agreed to participate in the study. A 3 page self-report questionnaire and a return envelope were mailed to each participant, with a single follow-up sent to non-responders within two weeks of the initial mailing. The survey covered the patient's current removal status and possible reasons for non-removal. RESULTS: Thirty-nine percent of the questionnaires were successfully completed (N=538). Of respondents, 81% had already had their implant removed by the time of the survey. Furthermore, the vast majority of these women (91%) stated that they did turn in removal certificates to their physicians. Those who did not have their implant removed cite a variety of reasons, usually personal time constraints and difficulty identifying a provider. CONCLUSION: Providers appear to be retaining removal certificates in their offices, creating the perception that women are not obtaining removals. This is likely due to the known contributing factors of low reimbursement rates and the administrative burden to obtain reimbursement. This study emphasizes the importance of using follow-up studies in patient programs to ascertain reasons for program underutilization and to guide program revisions.