Prescription drugs sit on a pharmacist’s counter. (Photo by John Moore/Getty Images.)
A new bipartisan bill in the Ohio House would stop insurance providers from dropping coverage of medications in the middle of a patient’s yearly plan. Right now, that’s totally legal — and causing problems for many people across the state.
Weeks after getting locked into her health insurance plan, Natalie Hastings was surprised to learn her insurance would no longer cover her ADHD medication.
“I was stuck trying to figure out ‘what do I take?'” Hastings said.
Her new medication hasn’t been working out well.
“What was the process like when you had to go off your medicine and start a new one?” WEWS/OCJ’s Morgan Trau asked.
“It makes me more jittery than the other medication,” Hastings said. “And — uhm — I forgot the rest of the question. Yeah, I literally forgot the rest.”
Hastings said to include her blanking out on the question because it shows what a big problem switching medicines can be.
She had to change from the only medicine that consistently works for her, Mydayis, to Vyvanse with a boost of Adderall.
“Even though ADHD meds are not in your system long term, that doesn’t mean that switching doesn’t affect how you feel on a daily basis,” she added.
Right now, insurance companies are allowed to change the medications they cover in the middle of a patient’s yearly plan.
State Rep. Beth Liston (D-Dublin), who is also a doctor, believes this isn’t fair and introduced House Bill 291 to prohibit any changes after a plan is chosen.
“Insurance companies cannot do that and do a bait and switch for patients that think they’re gonna get one coverage and now get something completely different after the contract was signed,” Liston said.
She and state Rep. Sara Carruthers (R-Hamilton) also made sure that insurers can’t increase a covered person’s burden of drug cost-sharing and move a drug to a more restrictive tier of health. There are also carve-outs for their bill. Providers would not be allowed to remove coverage of a drug unless the FDA released a statement questioning the safety of it, the med is being permanently discontinued or the manufacturer has removed the drug from sale in the United States.
This bill will not prevent a health plan issuer from adding a drug to its formulary, the bill states.
“I think a lot of times people don’t realize the subtleties that go into those treatment decisions,” Liston added. “One medication, even though they might be in the same group, isn’t the same as another.”
Despite her personal feelings about the insurance providers switching up people’s medications, Case Western Reserve University medical law professor Sharona Hoffman explained why companies are opposing this bill.
“In order to save money, they might decide that a certain drug is too expensive or that not a lot of their patients need it — so it’s not worth stocking it,” Hoffman said.
Manufacturers can increase the prices of the drug, so insurers may feel they have no choice but to drop, she added.
“If they have no power over whether they can pay or not, they might go out of business,” the professor said. “They might have to raise everybody else’s rates astronomically in order to cover one person’s drugs.”
Both Hastings and insurance companies probably had a difficult time during the still-ongoing ADHD drug shortage, Hoffman continued.
“If the insurance company is facing drug shortages and they would have to fight to get supply, they might just say forget it,” she said.
The patients are the ones who are actually struggling throughout the shortage, Hastings argued back.
ADHD medicines are considered controlled substances. This means that Ohio patients typically need a new prescription for each bottle and doctors can only write scripts 3-months at a time. Still, many types of stimulants are technically “no refills” and a patient will need to call each month to refill the drug. Adding to that, ADHD meds can only be refilled on the 28-day mark, so many users have needed to scramble if their pharmacy doesn’t have the medicine in stock. Once they find another pharmacy with the drug in stock — they must get a brand new prescription to send to the new location.
So not only was Hastings having to deal with switching to another ADHD medicine, she was having to switch to medicines that were highly sought-after and underproduced. Plus, her two sons also have ADHD, so it has been a “disaster,” she said.
“It’s a mess,” she added.
Changing medicine coverage suddenly can be “catastrophic and life-threatening,” Hoffman agreed.
Hoffman has a personal experience with insurers dropping meds. Her husband takes medication for Parkinson’s disease, and it is expensive, she said. This summer, they got a letter saying that their insurer will no longer cover this particular drug that he’s been stable on for many years, she added. She is currently appealing this decision because in this case — there is no equivalent or similar medication for him to take.
WEWS/OCJ reached out to eight of the most popular health insurance providers in the state: United Healthcare, Aetna, Anthem, Medical Mutual, SummaCare, Humana, Cigna and Buckeye Health Plan. None would comment.
The Ohio Association of Health Plans (OAHP), a coalition of health insurance providers, did provide the argument that manufacturers are the ones who need their prices frozen.
“OAHP opposes HB 291 because health plans need to be able to update their lists of medicines that are covered for prescription more than once a year in order to contain health care costs for employers and consumers,” Director of Government Affairs Gretchen Blazer Thompson said. “These changes are needed when a new drug comes to market, when there’s new guidance from the FDA on potential safety issues, and when a pharmaceutical manufacturer changes the price of a drug — which they do multiple times each year.”
The group is proposing another idea to remedy this situation.
“OAHP has proposed a simple solution to this challenge by advocating for an amendment that would prohibit drug companies from changing prices while a Health Plan’s formulary is frozen,” the spokesperson continued. “We hope the House will consider this suggestion in order to improve the bill.”
But for Hastings, what’s important is losing access to the medication she needs.
“It would be a relief to know that I would only once a year have to think about what medications insurance would cover for me and for my family,” she said.
The bipartisan bill will be heard in the upcoming weeks.
“If I had known my medication wouldn’t be covered, I would have chosen a different plan,” Hastings said.
This article was originally published on News5Cleveland.com and is published in the Ohio Capital Journal under a content-sharing agreement. Unlike other OCJ articles, it is not available for free republication by other news outlets as it is owned by WEWS in Cleveland.
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