Health Reform and Access to Prescription Drugs

Andrew Sperling, Director of Legislative Advocacy
National Alliance on Mental Illness (NAMI)

Andrew Sperling, J.D.
The Patient Protection and Affordable Care Act (ACA) offers new choices for quality, reliable, low cost private health insurance and opens Medicaid to more people living with mental illness.

Under the law, all health plans are required to provide certain categories of benefits and services—so-called Essential Health Benefits (EHB). One of these is prescription drugs.

A question mark as to prescription drug coverage
While plans will be required to cover a minimum number of prescription drugs used to treat mental health conditions in a therapeutic class, each plan may choose to cover different medications; and the number of covered drugs will vary by state and by plan.  Most significant, the law does not require plans to cover all drugs in a particular therapeutic class.  As a result, medical and behavioral health plans can avoid covering specific drugs that, in your physician’s judgment, best address your needs.

This poses serious challenges for individuals who are in need of multiple drugs per class, particularly people with serious and persistent mental illness, chronic conditions and disabilities. Antipsychotic medications, for example, are not clinically interchangeable, and providers must be able to select the most appropriate, clinically indicated medication for their patients.  What’s more, physicians may need to change medications over the course of an illness as patients suffer side-effects or their illness is less responsive to a particular drug, and patients requiring multiple medications may need access to alternatives to avoid harmful interactions.

A Better, More Patient-Centered Solution Exists
Access to strong and meaningful prescription drug benefits is critical for people living with mental illness, and we have concerns the ACA does not go far enough on this front.  A better approach to prescription drug coverage is the one already in effect in the Medicare Part D program.

Under Medicare Part D, seniors and people with disabilities choose drug coverage administered by private insurers. These prescription plans are subsidized by the federal government and must adhere to certain minimum benefit requirements. This set-up allows the program to harness competitive market forces to drive down costs, even as the minimum coverage standards ensure that seniors have access to the prescription drugs they need.

Part D further requires insurers to cover “all or substantially all” medicines in six major drug classes affecting people with serious illnesses: immunosuppressants, antidepressants, antipsychotics, anticonvulsants, antiretrovirals, and antineoplastics.

Serious mental illness provides an illustrative example as to why it is important to follow the Medicare Part D model for access to treatment. People living with disorders such as major depression, bipolar disorder, or schizophrenia don’t always respond to the first or second rounds of treatment and often require multiple attempts with multiple combinations of medications before finding a treatment that works.

Restricting drug access doesn’t always make good financial sense.  When stable patients are forced to switch from one drug to another because of a formulary changes, and those changes result in higher rates of hospitalization, homelessness, incarceration, and other adverse events, WE ALL LOSE.

According to a recent study, Medicaid beneficiaries who can’t obtain their physician-recommend medications are over 20 percent more likely to experience adverse health events; they are 74 percent more likely to visit an emergency room for treatment; and when they do, they require 72 percent more acute inpatient days in the hospital.

Meanwhile, a study in the Journal of the American Medical Association found that Part D’s accessible drug coverage generates about $1,200 in annual savings per beneficiary by improving patient health and helping people avoid more costly and invasive treatments

What you can do
In order to manage the health and wellness of people living with chronic illness and serious mental illness, patients need to be guaranteed access to the advanced drugs and services that are most likely to improve their health and lead to a meaningful recovery.

If the new health exchanges fall short in providing fair and full coverage for mental health services and drugs, NAMI is committed to advocating at the state and federal level on the behalf of those in need. And you can help!

Post your comments here on these questions:

  • What challenges are you having in relation to prescription drug coverage? How have you dealt with them?
  • How are your healthcare providers dealing with denials or changes in prescription drug access?
  • If you are required to obtain pre-approval for certain services or treatments, what has the process been like?

Facebook Comments


I have insurance via The Texas Health Risk Pool. I am blessed to have coverage. However, in two cases, in which I had experienced serious adverse effects to two generic medications and needed brand name drugs dispenses, even when my psychiaitrist specified that it was medically necessary, the insurance company first denied me coverage for the brand name drug by sending a letter stating the denial was based on the fact I had secondary coverage, which was not true and I was able to prove that and it was resolved. I could not help wonder if it was just an action taken to discourage me by the insurance company to get coverage for the branded product that my doctor had specifically requested. In the second case, I had been able to take a generic drug  for some time, then I noticed a freakish difference with another generic company's product. Generics are not the same as a Brand,  it is lie to say they are, similar maybe. But what also is dangerous is that not even the generic medications are the same, and work differently as well. And guess who my insurance company told me reviewed the appeals, not a doctor, not a psychiatrist, but a pharmacist. REALLY? I wonder if those with mental illnesses, are more subject to denials and/or appeals.     



I have medicare and then separate insurance that covers my meds.  When I turn 65, this insurance coverage will cost almost three times as much and I won't be able to afford it.  Then I'll have to depend on medicare, God help me


The antipsychotic I'm on has been out for several years, and it's not on my hospital's formulary.  I have to bring my own meds lol which isn't going to do me much good if there's an emergency.  You can't carry this med around as it is sublingual and melts easily.  Nothing works the way this med does.  


I have trouble getting my antipsychotic at the hospital I use; it's not on their formulary and I have to bring it in myself.  So, what happens if I'm in that hospital for another reason?  I better have my easily dissolvable meds on hand I guess?   It makes no sense and is scary.


I have been prescribed some brand-name drugs and had to pay the highest tier of co-pays, but at least I could get them. It bugs me when the insurance company won't cover a particular medication and the pharmacy won't sell it to you - even with a prescription - at the price they'd charge if you were using insurance. They'll fill the prescription but make you pay some ridiculous retail price. Not fair!

careforyourmind moderator

We welcome comments about readers' experience with gaining access to prescription medications. For example, has your medical provider said that she or he would prefer to prescribe you a particular medication but was prescribing something different? Why so? It might have had to do with insurance coverage, or with the local availability of the particular medication, or some other factor. Please keep comments to your experience (for yourself or for another person) and issues related to having access to medicine, rather than experience with the medication itself. Also, please note that we are not publishing the names of medications. Thank you for joining the conversation!