Paul Sanchez
Access to affordable anti-seizure medication is a challenge for many people with epilepsy. While the Affordable Care Act has introduced an overall out-of-pocket cap for most forms of insurance, people with epilepsy may still struggle to afford their medications. This is where prescription drug manufacturers' copay assistance programs can help. However, some insurance companies and pharmacy benefit managers have started discouraging the use of copay assistance. In this context, it is important to understand when an insurer can refuse coverage of prescribed anti-epileptic medications, and what options are available to patients when this happens.
| Characteristics | Values |
|---|---|
| Can insurers refuse coverage of prescribed anti-epileptic medications? | Yes, insurers can refuse coverage of prescribed anti-epileptic medications. |
| What to do if your insurer refuses coverage | Ask why the drug isn't covered, request an exception from your insurer, make your case to your insurer, talk to your doctor about alternatives, apply for patient assistance programs and discounts, re-evaluate your coverage during the next enrollment period, try virtual options, appeal the decision, file for an independent review through your state's insurance regulator, or use your own funds to cover the cost of the medications. |
| How to prevent refusal of coverage | Educate yourself about your policy, know what it covers and what it doesn't, and keep up with any changes that may occur. |
| Options for the uninsured | National, state, and disease-specific drug assistance programs, mail order or bulk discounts, retailer savings programs, and prescription discount cards. |
| Options for people with epilepsy | The Affordable Care Act, pre-existing condition insurance plans (PCIPs), Medicare, and Medicaid. |
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What You'll Learn
- Anti-epileptic medications may be deemed non-preferred by insurers
- Patients can appeal insurer decisions and request exceptions
- Prior authorization is required by some insurers
- Generic medications are more likely to be covered by insurance
- Pre-existing condition insurance plans can expand access to insurance for people with epilepsy
Anti-epileptic medications may be deemed non-preferred by insurers
Anti-epileptic medications may be deemed "non-preferred" by insurers, which can result in higher out-of-pocket costs or even a denial of coverage. This designation is often based on factors such as efficacy, safety, and cost-effectiveness. In such cases, individuals may have several options to gain access to the prescribed medication:
Firstly, it is important to understand the insurance plan's coverage and limitations. Each insurance company publishes a "formulary" or a list of preferred medications that are covered under the plan. By reviewing this list, individuals can determine if their prescribed anti-epileptic medication is included. If the medication is not listed, it is considered non-preferred, and the insurance company may deny coverage.
However, individuals have the right to appeal the insurer's decision and request an exception. This typically requires a supporting statement or a letter of medical necessity from the healthcare provider, explaining why the specific medication is medically necessary and why alternative treatments would have adverse effects. Some plans may require individuals to undergo "step therapy" or "fail first," where they must try and fail with the medications preferred by the insurer before receiving approval for the originally prescribed medication.
Additionally, individuals can explore alternative medications within the same drug class that may be covered by their insurance plan. Generic medications, for example, contain the same active ingredients as their brand-name counterparts, meet FDA safety standards, and are often more affordable and likely to be covered. Patient assistance programs and manufacturer copay programs are also available to help reduce out-of-pocket costs, especially for costly brand-name medications.
It is worth noting that individuals can also seek assistance from their state's insurance regulator or human resources department if they are employed by a large company that self-funds its insurance. These options can provide support and guidance in navigating insurance coverage for prescribed anti-epileptic medications.
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Patients can appeal insurer decisions and request exceptions
If your health insurer refuses to pay a claim for prescribed anti-epileptic medications, you have the right to appeal their decision. Patients can request that the insurance company reconsider its decision, and the insurer is obliged to explain why they have denied the claim and how the decision can be disputed. There are two ways to appeal a health plan decision:
Internal Appeal
If your claim is denied or your health insurance coverage is cancelled, you can ask your insurance company to conduct a full and fair internal review of its decision. If the case is urgent, the insurance company must expedite this process.
External Review
You have the right to take your appeal to an independent third party for review. This is called an external review. In this case, the insurance company loses its power to make the final decision over whether to pay a claim.
Exceptions
You can also ask for an exception to be made to your coverage plan. You, your doctor, your prescriber, or someone acting on your behalf can request an exception (also known as a coverage decision or coverage determination). For example, you can request an exception if:
- You ask for a drug that is not on your plan's list of covered drugs (a "formulary exception").
- You ask for an exception to your plan's utilisation management tools, such as dosage limits, quantity limits, prior authorisation requirements, or step therapy requirements.
- You ask for a non-preferred drug at the preferred cost-sharing level ("tiering exception").
To ask for an exception, you must fill out and submit a Coverage Determination Request form, which can be found on the Customer Forms page of your insurance company's website. You will then need to mail or fax the form to the relevant department of your insurance company. The insurance company must respond within 72 hours of receiving your request or your doctor's statement supporting your request. If your health depends on it, they will respond sooner. If they do not meet this deadline, they must forward your request to be reviewed by an independent organisation.
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Prior authorization is required by some insurers
Prior authorization is an insurance process that requires pre-approval from the insurance company before individuals can fill a prescribed medication or undergo a recommended treatment or test. This process can delay access to care and treatment, which can be problematic for people with epilepsy since their treatment is highly individualized, and delays can have severe consequences.
Some insurance companies require prior authorization for certain medications, and this can be a hurdle for people with epilepsy. The Epilepsy Foundation opposes prior authorization and similar policies, urging that these protocols be streamlined and exceptions created. For instance, if an individual has been stable on their medication for a certain period.
If your insurance requires prior authorization, your healthcare provider can fill out a form explaining why you need that specific medication. With the proper paperwork, your prescription may be approved for coverage. If your insurance denies medication coverage, you can request an exception to the formulary, and your healthcare provider will likely need to provide a supporting statement explaining the medical necessity of the medication and why alternatives will have an adverse effect.
Some plans require you to try an alternative, preferred medication before granting a request for an exception. This is known as step therapy or "fail first", where individuals must try and fail one or more medications preferred by the insurer before receiving the originally prescribed drug. Thirty states have passed step therapy reform protocols to streamline this process and allow individuals timely access to appropriate medications.
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Generic medications are more likely to be covered by insurance
While insurance coverage can provide substantial value by shielding consumers from the financial impact of high-cost events, it can also lead to wasteful spending on low-cost generic drugs. In fact, studies have shown that insurance coverage makes common generic drugs more expensive. For instance, the Medicare Part D program paid more than half of what it would have cost at the cash prices from Mark Cuban Cost Plus Drug Company or Costco. Similarly, for a nasal allergy spray, Medicare Part D paid $5.22 per spray, while its over-the-counter price was only $0.18.
Generic drugs are widely used, constituting 90% of filled prescriptions in the United States, but they represent only 18% of prescription drug spending. This discrepancy suggests that insurance coverage for generic drugs may not always be necessary or cost-effective. In some cases, insurance companies may even require policyholders to switch to generic or biosimilar drugs when they become available, as they are often cheaper than their brand-name counterparts.
However, it is important to note that insurance coverage for generic drugs can still be beneficial in certain situations. For example, some individuals may not be able to afford the out-of-pocket costs of generic drugs, even though they are generally less expensive than brand-name drugs. In these cases, insurance coverage can provide financial assistance and peace of mind. Additionally, insurance companies typically publish formularies, which are lists of drugs, both generic and brand-name, that are covered by specific plans. This information can help consumers make informed decisions about their medication choices.
Furthermore, individuals with epilepsy may face challenges in affording their prescribed anti-seizure medications, and insurance coverage can play a crucial role in ensuring access to treatment. The Affordable Care Act implemented an overall out-of-pocket cap for most forms of insurance, and similar initiatives are being advocated for Medicare Part D. While insurance coverage may not always be guaranteed for specific medications, individuals have the right to appeal their insurer's decision and request exceptions to the formulary.
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Pre-existing condition insurance plans can expand access to insurance for people with epilepsy
People with epilepsy often rely on anti-seizure medications to control or reduce seizures. However, these medications can be expensive, and gaining access to them can be challenging. In the US, the Affordable Care Act (ACA) has made significant changes to health insurance coverage, especially for those with pre-existing conditions. Before the ACA, people with epilepsy may have struggled to find insurance that covered their needs or faced higher premiums due to their condition.
The ACA ensures that individuals with pre-existing conditions, such as epilepsy, cannot be denied coverage or charged higher insurance premiums. This has improved the market for people with epilepsy, and new options called PCIPs (Pre-existing Condition Insurance Plans) have expanded access to insurance for this group. The ACA has also ended lifetime and annual dollar limits on coverage and given states the option to expand their Medicaid programs.
Medicaid and Medicare are public health insurance programs that offer coverage for epilepsy. Medicaid is a joint state-federal health insurance program that provides health services to over 70 million low-income Americans, including one-third of people living with epilepsy. Each state administers its own program within certain parameters set by the Centers for Medicare and Medicaid Services (CMS). Medicare is a federal health insurance program primarily for those aged 65 and older, but individuals with certain medical conditions, including epilepsy, may also qualify.
In addition to public health insurance programs, private health insurance products also cover epilepsy. However, it is important to carefully review and understand the different policies on offer, as some may have limitations or exclusions. For example, some companies will approve policies but exclude coverage for epilepsy and related expenses, or they may require the policyholder to pay a higher deductible. It is also worth noting that some insurance companies require prior authorization for certain medications, which can delay access to treatment.
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Frequently asked questions
If your insurance company refuses to cover your anti-epileptic medication, you can request a formulary exception from your insurer. Your healthcare provider will need to provide a supporting statement explaining why the medication is medically necessary and that alternatives will have an adverse effect. If your insurer denies your request, you can file an appeal. If they deny coverage after an internal appeal, you can request an external review.
Some strategies to save money on prescription medication when uninsured include:
- National, state, and disease-specific drug assistance programs
- Mail order or bulk discounts
- Retailer savings programs
- Prescription discount cards
Insurance companies typically publish a "formulary" that lists the drugs, both generic and brand name, that your plan will cover. Drugs not listed in the formulary are referred to as “non-preferred” drugs, and insurance companies may refuse to cover them. Other reasons for refusal include the availability of a less expensive generic option or a more affordable alternative treatment.
