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College student Emily* was satisfied with her birth control pill. Her doctor settled on the current formulation after trying Emily on several prescriptions. The final one improved her chronic headaches rather than making them worse and helped clear up her skin. (*Her real name is not used for privacy reasons).
So Emily was surprised to find that under the Affordable Care Act (ACA), her insurance company rejected payment for her pill. She was especially mystified since the ACA mandates birth control coverage.
“It depends on the birth control,” the pharmacist explained to Emily.
When Emily raised the issue with her insurer, she was told her doctor should call and explain why the formulation she’d been taking was medically best for her. The doctor obliged.
A few days later came word that the insurance company rejected the doctor’s plea.
The next step was for Emily to file a formal appeal.
The appeal letter explained that if Emily were forced to change prescriptions, she could well have to add a separate, new prescription for her headaches and another for her skin. In the end, that would expose her to potential side effects from three medicines instead of one. Three prescriptions would also presumably cost the insurance company more than one.
It took more than three months for the insurance company to send word that it rejected Emily’s appeal.
Birth Control Coverage Loophole
If you like your birth control pill, you can’t necessarily keep your birth control pill.
It’s another in a growing list of clarifications and caveats discovered in the wake of implementation of the Affordable Care Act, also known as Obamacare. Millions of Americans have learned that, “If you like your health care plan you can keep it,” wasn’t the whole story. Neither was, “If you like your doctor you can keep your doctor.”
Emily isn’t alone, according to insurance marketplace consultant and policy analyst Robert Laszewski of Health Policy and Strategy Associates.
“This is another form of ‘narrow networks’—that is, limiting providers as a way to lower premiums,” says Laszewski. “In this case, the provider that is getting ‘narrowed’ out of the plan is a drug company. One of the common devices used to control pharmacy is to control the formulary—or list of drugs and brands that are covered.”
The problem is, many patients are getting hit with a double whammy: under the system offering “narrowed” choices, their premiums aren’t lower, they’re higher than they used to be.
We asked the Department of Health and Human Services (HHS), which oversees the Affordable Care Act, to comment on Emily’s predicament. It’s unclear whether the agency collects statistics or information on how many Americans have fallen victim to “narrowed” prescription choices. But no such information has been released. The agency sent information from its website that indicated insurers are allowed to save money by requiring patients to take generic or cost-saving medicine. However, the government information seems to indicate that in a case like Emily’s, where a doctor decides a different drug is medically necessary, it should be covered.
According to HHS, insurance plans “must accommodate any individual” for whom a cost-saving drug “would be medically inappropriate, as determined by the individual’s health care provider.” It further states that if a generic substitution or non-preferred brand version is “not medically appropriate for the patient…as determined by the attending provider, in consultation with the patient…then a plan or issuer must provide coverage for the brand name drug.”
Lawzewski says there’s widespread confusion over the issue.
”(T)here is almost no transparency here.”—Health policy analyst Robert Laszewski
Laszewski says in contrast to Obamacare, the Medicare drug program website allows seniors to enter actual brand names and dosage levels into the government web finder to learn which plans cover specific drugs at what level. “But with Obamacare, the provider lists are very inaccurate and there is little or no formulary info.”
Inaccurate provider lists were the subject of more than 1,800 complaints in California, according to a Sacramento Bee article last summer.
Despite many problems with the Affordable Care Act, including its failure to meet its own enrollment projections, it has had an overall positive impact on the uninsured. According to HHS, “numerous independent studies show a marked decreased in the uninsured.” That includes a recent Gallup release showing a 28+ percent reduction in the last year.
In the end, Emily concluded that birth control is covered under Obamacare– just not the birth control her doctor prescribed. She had a choice: switch to a birth control pill her insurance company, not her doctor, wanted her to take — or forget about help from her insurer.
She chose the latter, which means that she’s paying for a prescription drug benefit that, in this case, is useless to her.