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You likely have an opportunity over the next few weeks to take more control over your health insurance. It’s “open enrollment” season for many Americans — the time when we can weigh our options and potentially switch health plans for the coming year.
Open enrollment offers a good opportunity to review your health insurance plan, make changes, or find a better one that works for your health — and your wallet — in 2017.
It’s critical that everyone — whether you’re healthy or not — take a moment to review your insurance options, even if your current plan has been serving you well. That’s because it may not be the same plan next year.
The nation’s two largest pharmacy benefit managers – Express Scripts and CVS/caremark, which set the coverage for many health insurers – recently announced additional drugs that they aren’t covering in 2017, bringing their total excluded products to 124 and 154, respectively.
Another reason why taking advantage of open enrollment is critical: Your health plan can even change after the new year begins.
In most states, there are no statutes requiring commercial health plans to honor their annual contracts with enrollees as it relates to pharmacy benefits. Your insurer is likely free — at any time — to move a drug to a higher tier (increasing your copay or making you jump through more hoops to get your medication) and even remove coverage of your treatment altogether.
Put another way, you’re locked into your health plan with the start of a new contract year, but your insurer isn’t required to provide the pharmacy benefits you signed up to receive.
Sometimes referred to as “non-medical switching,” these unforeseen insurance coverage changes can be devastating. I work with people living with HIV/AIDS who experience this reality, and it’s happening to many other insured Americans, especially those living with chronic health conditions.
These patients have worked with their physician to find an affordable therapy that keeps them stable, and then their insurance plan makes a coverage change that means they are switched to another drug altogether — potentially forcing them to face loss of disease control and even deal with debilitating side effects.
For people with epilepsy, for example, even the slightest medication changes can lead to breakthrough seizures, and medication switches can push a stable person living with mental illness into a health crisis.
The reality is that insurer-motivated medication switches can be a serious threat to patients’ stability, leading not only to serious health ramifications but also driving up societal and system-wide costs by requiring more inpatient and emergency health care, and causing lost productivity and possible job loss.
It stands to reason that since you can’t change your health insurance plan throughout the year, your insurer shouldn’t be able to change your pharmacy benefits. And while we certainly need to improve consumer protections to keep this insurance bait-and-switch from happening, it makes reviewing your health plan during open enrollment even more critical to protecting your health.
So take the time to take advantage of open enrollment. See what’s supposed to be covered in 2017 and get a better idea for coverage changes to look out for next year. Pay attention to details. Picking the right plan is worth the effort.
Michael Ruppal is executive director of The AIDS Institute, a national nonprofit dedicated to supporting and protecting health care access for people living with HIV/AIDS and other chronic diseases.
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