In April of 2022, I was diagnosed with Attention-deficit/hyperactivity disorder, better known as ADHD. For this, I take a medication called Vyvanse, which, in short, helps me “function normally” in society. I have prescription insurance so that I can afford it.
My mother works for the school district in Millburn, N.J., specifically in its high school. We’re under the health insurance provided by this district, which includes prescription insurance. Earlier this month, the prescription insurance company was switched to Benecard who had reassured everyone that nothing would change, that this switch would be “seamless.”
Suddenly, my Vyvanse was not covered anymore. I would have to pay $478.99 for my 30-day, 40-milligram prescription. I can go without taking it, but I experience intense executive dysfunction, “a behavioral symptom that disrupts a person’s ability to manage their own thoughts, emotions and actions.” I was already behind on schoolwork before this insurance switch, but because I was unmedicated, I fell even further.
What makes my specific situation more complex is that Vyvanse is difficult to be prescribed. I was unable to get it covered unless I tried other related medications, such as Ritalin and Adderall.
My mother was never notified of the change in our coverage. We only learned of it when I went to pick up my prescription. In fact, prescription insurance companies can add and remove medications that are covered whenever they want, without notifying their enrollees.
In New Jersey, it should be a law to notify enrollees. When any prescription insurance company makes changes to their formulary (or a drug list), whether adding or removing medications, those taking said medications must be notified 30 days prior to the change.
There are states that already have such laws in place. According to a report made by the Connecticut General Assembly in 2016, insurers in New Mexico and Louisiana must notify affected enrollees at least 60 days before any change to a drug’s coverage. The only exception for New Mexico is if the FDA deems it unsafe. In Nevada, health insurers cannot make changes to their formulary during the plan year.
But in New Jersey, there is nothing.
It even says in Benecard’s primary formulary of last year that the list of drugs they can cover, depending on one’s specific benefit plan, “it subject to change at any time.” These changes, even when notified, can be extremely inconvenient and expensive.
According to a report made by NPR in 2020, “shares of middle-income and low-income adults say they have recently experienced serious problems paying prescription drug costs, they did not fill a prescription because of costs, or they cut back on dosage.” That’s what I had to do; I simply couldn’t refill mine. It was almost $500.
Luckily, there are health insurance companies that are required to notify their enrollees, specifically Medicare. In their policy, if there are any mid-year formulary changes, “they must give you 60 days notice or provide you with a 60-day transition refill.”
After an entire week, I was able to get my Vyvanse covered. My psychiatrist faxed over paperwork that proved I tried other medications previously. Instead of paying almost $500, now I have a $10 co-pay. Apparently, I was not the only one as a result of this switch to have such a drastic hiccup, as there were many families under this plan that had prescriptions that were now no longer covered.
I was fortunate enough to remain physically healthy without Vyvanse. But it begs the question: How often has this happened to someone who needs life-saving medications, like inhalers or insulin? Does our insurance prefer to see their enrollees suffer?
For an insurance company that saves me $468.99 whenever I get a prescription refill, you’d think I’d be notified 30-60 days before I suddenly have to pay almost $500 dollars out-of-pocket just so I can keep up with school deadlines.
Emma Thumann can be reached at email@example.com.
Image via https://click2pharmacy.co.uk/.