A new bipartisan bill in the Ohio House would prevent insurance providers from dropping drug coverage in the middle of a patient’s annual plan. Now, that’s completely legal and causing problems for many people across the state.
Weeks after being 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 should I get?’” Hastings said.
Her new medicine is not working well.
“What is the process like when you have to stop taking a medication and start a new one?” asked WEWS/OCJ’s Morgan Trau.
“It makes me more jittery than other drugs,” Hastings said. “And uh I forgot the rest of the question. Yes, I actually forgot about the rest.”
Hastings said she left the question blank because it suggested a major problem switching medications could cause.
She had to change from the only medication that worked for her, Mydayis, to Vyvanse with an Adderall boost.
“Even though ADHD medications don’t stay in your body long-term, that doesn’t mean switching doesn’t affect how you feel on a daily basis,” she adds.
Currently, insurance companies are allowed to change the drugs they cover in a patient’s annual plan.
State Rep. Beth Liston (D-Dublin), also a physician, believes this is unfair and introduced House Bill 291 to prohibit any changes after the plan is chosen.
“Insurance companies can’t do that and lure and convert patients who thought they were going to get one coverage and now get something completely different after the contract is signed,” Liston said. .
She and state Rep. Sara Carruthers (R-Hamilton) also ensured that insurers cannot increase the insured’s drug cost-sharing burden and shift drugs to more restrictive health tiers. There are also engravings for their bills. Providers will not be allowed to remove coverage of a drug unless the FDA issues a statement questioning the drug’s safety, the drug is being permanently discontinued, or the manufacturer has remove that drug from sale in the United States.
This bill would 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 complexity of those treatment decisions,” Liston added. “A drug, although it may belong to the same class, is not the same as another drug.”
Despite her personal feelings about insurance providers changing people’s medications, Case Western Reserve University health law professor Sharona Hoffman explained why companies object this bill.
“To save money, they may decide that a certain drug is too expensive or that not many of their patients need it so it’s not worth stocking,” Hoffman says.
Manufacturers may increase drug prices, she added, so insurers may feel they have no choice but to lower prices.
“If they don’t have the power to decide whether they can pay or not, they could go bankrupt,” the professor said. “They may have to raise everyone else’s prices astronomically to pay for one person’s medicine.”
Both Hastings and insurance companies are facing difficulties while the ADHD drug shortage continues, Hoffman continued.
“If the insurance company is facing a drug shortage and they’re going to have to struggle to get a supply, they can say forget it,” she said.
Hastings countered that patients are the ones really struggling with the shortage.
ADHD medications are considered controlled substances. This means that patients in Ohio often need a new prescription for each bottle of medication, and doctors can only write a script every 3 months. However, many stimulant medications are technically “refill-free” and patients will have to call monthly for refills. Plus, ADHD medications can only be refilled every 28 days, so many users have to scramble if their pharmacy doesn’t have the medication in stock. When they find another pharmacy that has the drug in stock, they must get a completely new prescription to send to the new location.
So not only did Hastings have to face switching to another ADHD medication, she also had to switch to highly sought after and poorly manufactured medications. Plus, her two sons also have ADHD, so it was a “disaster,” she said.
“It was a mess,” she added.
Hoffman agrees that suddenly changing drug coverage could be “catastrophic and life-threatening.”
Hoffman has personal experience with insurance companies dropping the drug. She said her husband has to take medication to treat Parkinson’s disease and it is very expensive. This summer, she added, they received a letter saying their insurance company would no longer cover the particular medication he had been taking consistently for years. She is currently appealing this decision because in this case there was 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. No one can comment.
The Ohio Association of Health Plans (OAHP), a coalition of health insurance providers, has made the argument that manufacturers are the ones who need to keep their prices up.
“OAHP opposes HB 291 because health plans need to be able to update their lists of covered prescription drugs more than once per year to reduce health care costs for employers and consumers,” said Director of Government Relations Gretchen Blazer Thompson. “These changes are necessary when a new drug comes to market, when there is new guidance from the FDA about potential safety issues, and when a pharmaceutical manufacturer changes the price of a drug that They do it multiple times every year.”
The team is proposing another idea to remedy this situation.
“OAHP proposed a simple solution to this challenge by supporting an amendment that would prohibit pharmaceutical companies from changing prices while the Health Plan portfolio is frozen,” the spokesperson continued. “We hope the House will consider this proposal to improve the bill.
But for Hastings, what mattered was losing access to the medication she needed.
“It’s a relief to know that each year I only have to think about what medications my insurance will cover for me and my family,” she said.
The bipartisan bill will be heard in the coming weeks.
“If I had known my drugs wouldn’t be covered, I would have chosen another plan,” Hastings said.
This article was originally published on News5Cleveland.com and is published on the Ohio Capital Journal under a content sharing agreement. Unlike other OCJ articles, it was not made available for free reprint by other news outlets because it was owned by WEWS in Cleveland.
According toWEWSState reporter Morgan Trau onTwitterAndFacebook.
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