COLUMBUS, Ohio — A new bipartisan bill in the Ohio House of Representatives would prevent insurance providers from dropping drug coverage midway through a patient’s annual plan. Right now, it’s perfectly legal — and it’s causing problems for a lot of people across the state.
Weeks after enrolling in her health insurance plan, Natalie Hastings was surprised to learn that 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 was the process like when you had to stop your medication and start a new one?” asked News 5’s Morgan Trau.
“It makes me jittery more than other drugs,” Hastings said. “And…um…I forgot the rest of the question. Yeah, I literally forgot the rest.’
Hastings said her silencing of the issue should be included because it shows how big of a problem switching medications can be.
She had to switch from the only medication that consistently worked for her, Mydayis, to Vyvanse with an Adderall boost.
“Even though the ADHD meds aren’t in your system long-term, that doesn’t mean switching them doesn’t affect how you feel on a day-to-day basis,” she added.
Currently, insurance companies are allowed to change the drugs they cover midway through a patient’s annual plan.
State Rep. Beth Liston (D-Dublin), who is also a doctor, believes that’s not fair and introduced House Bill 291 to prohibit any changes after a plan is selected.
“Insurance companies can’t do this and bait patients who think they’re going to get one coverage and now get something completely different after signing the contract,” Liston said.
She and state Rep. Sarah Caruthers (R-Hamilton) also made sure that insurers could not increase the burden on the covered person to share drug costs and move the drug to a more restrictive level of health care. There are also cuts for their account. Providers will not be allowed to remove coverage for a drug unless the FDA issues a statement questioning its safety, the drug is permanently discontinued, or the manufacturer has removed the 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 subtleties that go into these treatment decisions,” Liston added. “One drug, although it may be in the same group, is not the same as another.”
Despite her personal feelings about insurance providers switching people’s medications, Case Western Reserve University medical law professor Sharona Hoffman explained why companies oppose the bill.
“To save money, they may decide that a drug is too expensive or that not many of their patients need it — so it’s not worth keeping,” Hoffman said.
Manufacturers can raise the price of the drug, so insurers may feel they have no choice but to cut it, she added.
“If they don’t have control over whether they can pay or not, they may go out of business,” the professor said. “They might have to raise everyone else’s prices astronomically to cover one person’s medication.”
Both Hastings and insurance companies likely had a hard time during the still-ongoing shortage of ADHD drugs, Hoffman continued.
“If the insurance company is facing drug shortages and has to struggle to get supplies, they can just say forget it,” she said.
Patients are the ones really struggling during the shortage, Hastings countered.
ADHD medications are considered controlled substances. That means Ohio patients typically need a new prescription for each bottle, and doctors can only write 3 months’ worth of scripts at a time. However, many types of stimulants are technically “non-refillable” and the patient will need to call each month to refill the medication. Adding to that, ADHD medications can only be refilled on the 28th day, so many consumers have had to struggle if their pharmacy doesn’t have the medication in stock. Once they find another pharmacy with the drug in stock, they must obtain a brand new prescription to send to the new location.
So not only did Hastings have to deal with switching to another ADHD drug, she had to switch to drugs that were in high demand and underproduced. Plus, her two sons also have ADHD, so it’s a “disaster,” she said.
CONNECTED: Adderall shortage affects patients in Northeast Ohio
“It’s a mess,” she added.
A sudden change in medical coverage can be “catastrophic and life-threatening,” Hoffman agreed.
Hoffman has personal experience with insurers denying drugs. Her husband takes medications for Parkinson’s disease, and they are expensive, she said. This summer, they received a letter saying their insurer would no longer cover that particular drug, which he had been taking steadily for many years, she added. She is currently appealing that decision because in this case — there is no equivalent or similar drug for him to take.
News 5 reached out to eight of the state’s most popular health insurance providers: United Healthcare, Aetna, Anthem, Medical Mutual, SummaCare, Humana, Cigna and Buckeye Health Plan. No one would comment.
The Ohio Association of Health Plans (OAHP), a coalition of health insurance providers, provided the argument that manufacturers are the ones who need to freeze their prices.
“OAHP opposes HB 291 because health plans should be able to update their lists of covered prescription drugs more than once a year to contain health care costs for employers and consumers,” said Director of Government Affairs Gretchen Blazer Thompson. “These changes are necessary when a new drug comes on the market, when there is new guidance from the FDA about potential safety issues, and when a pharmaceutical manufacturer changes the price of a drug — which it does several times each year.”
The group proposes another idea to correct this situation.
“OAHP has proposed a simple solution to this challenge by advocating for an amendment that would prohibit drug companies from changing prices while a health plan’s formulary is frozen,” the spokesperson continued. “We hope the House will consider this proposal to improve the bill.”
But for Hastings, what matters is losing access to the drugs he needs.
“It would be a relief to know that only once a year I would have to think about what drugs insurance would cover for me and my family,” she said.
The bipartisan bill will be heard in the coming weeks.
“If I had known my drugs weren’t going to be covered, I would have chosen a different plan,” Hastings said.
I follow WEWS statehouse reporter morgan traw on Twitter and Facebook.