It’s no secret that navigating the insurance market can be tricky, especially if you are one of the millions of people who require daily medication. You not only have to shop around to find the best price and coverage for you, but you also must choose a plan that covers the medication that you and your doctor have agreed is the best course of treatment.
For people on maintenance medication – regular medication necessary to treat a number of conditions – including heart disease, diabetes, high blood pressure, epilepsy or cancer – it is critical to find insurance that adequately covers everything you need, from appointments with your doctor to picking up your prescription from the local pharmacy.
Imagine investing time to choose the best insurance plan for you and your condition, and then having the coverage for your prescription medications modified or ended during the policy year. You face a choice: do you pay out of pocket to continue with the treatment plan prescribed by your doctor, or do you and your doctor scramble to find another medication that you hope works?
The term for this health insurance practice is “non-medical switching” and it can easily become a reality for many Americans because state laws don’t usually require commercial health plans to honor annual contracts with enrollees when it comes to pharmacy benefits. In other words, you are locked into your plan for the full year, but your plan’s pharmacy coverage can change at any time.
Anyone who takes medication knows how hard it is to find a prescription medication that works with the least amount of side effects. Prescription medications are rarely one-size-fits-all. When your prescription is no longer covered, you and your doctor are forced to start the trial and error process all over again.
Midyear health plan changes can be very dangerous for people living with complex chronic conditions like epilepsy, where keeping consistent access to medication is particularly important because switching medications can result in life-threatening breakthrough seizures.
Finding a medication that controls an individual’s seizures with reasonable side-effects can be extremely challenging. When insurance companies end coverage for necessary medications, individuals are forced to take other medications that have not worked in the past or that their doctor did not prescribe. These changes can happen without notification—people living with epilepsy sometimes don’t even realize their medications have been switched due to insurance changes until their seizures return.
Fortunately, policymakers have an opportunity to put a stop to non-medical switching within Washington state. New legislation (House Bill 2310/Senate Bill 6147) would ensure that insurance companies have to honor the contract and cannot unfairly change your prescription drug coverage mid-year. The legislation, however, still allows health plans to remove coverage due to safety concerns.
Individuals living with chronic health conditions need continued access to the prescription medications that keep them stable, productive, and even alive. Sensible consumer protections like those proposed in House Bill 2310/Senate Bill 6147 would ensure that insurers cannot unilaterally change the plan’s coverage mid-year so that the health plan you sign up for remains available to you throughout the entire contract year.
Sharon Cupp is executive director of the Epilepsy Foundation Northwest, serving Washington, Oregon and Alaska.