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