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Health insurers in Pennsylvania not holding up their end of the bargain: Lorraine Ramirez

Posted 10/4/17

As the mother of a child with epilepsy, I am well aware of the importance of having good health insurance. Without it, my family may not be able to access the medications that my daughter needs to …

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Health insurers in Pennsylvania not holding up their end of the bargain: Lorraine Ramirez

Posted

As the mother of a child with epilepsy, I am well aware of the importance of having good health insurance. Without it, my family may not be able to access the medications that my daughter needs to live a happy, healthy life. 

However, many Pennsylvanians are not getting the health care they deserve — and need — despite entering into contracts with health plans that are supposed to afford them what they were originally promised. 

Throughout Pennsylvania, health insurers and pharmacy benefit managers are changing the perimeters of their coverage at any time during the policy year, when families can’t change plans. They do so by raising out-of-pocket costs associated with certain treatments, making patients jump through additional hoops to get the treatment that stabilizes them, or by revoking drugs from coverage altogether. Oftentimes, these changes effectively force individuals off of the medicines that they depend on.

Unfair health plan changes are bad news for those with chronic medical conditions who rely on unfettered access to treatments to keep their condition stable. I know because it happened to my family.

My 17-year-old daughter, Kiley, has lived with epilepsy since she was 2 years old. For a while, her seizures were stable — thanks to her prescribed medication. But one day, she began to have involuntary tics. I checked her medication and realized that her pills had been switched. The switch had been ordered by our health insurer, yet neither I nor her doctor had been notified.

Eventually, through a long appeals process, I was able to convince the insurance company that Kiley needed her initial medication to stay stable, yet the health plan requires our family to pay four times more per month for the treatment.

Stories like ours are not unusual. Epilepsy patients experience breakthrough seizures after switching from one medication to another, even for drugs thought to be equivalent. The smallest of changes in the formula or the dose of an anti-epileptic medication can derail the condition of someone who was previously stable.

A breakdown in seizure control can have devastating effects both on health and on everyday life. Not only do seizures increase the chances of bodily injury, or even death, but they also carry substantial personal, social, legal and developmental consequences. Individuals with epilepsy, for example, can lose their driver’s license, or even their job, if their seizures return with regularity. 

Insurers and pharmacy benefit managers should not make significant treatment decisions instead of physicians — and that means they shouldn’t be making unfair plan changes that force treatment switches, especially when a family is locked into the plan for the year. Not all medications work the same on every patient, especially in treating chronic conditions.

Pennsylvanians with chronic medical conditions need protections from dangerous health coverage changes. Nobody should worry about losing their health or independence because the health plan they’ve signed up for abruptly changes.

Lorraine Ramirez of Hamburg is a mother of a child with epilepsy and an advocate for the Epilepsy Foundation of Western and Central Pennsylvania. 


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