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.