Lack of coverage of essential medications causes undue stress for employees and students
On Jan. 1, pharmaceutical coverage for UC employees and retirees on Anthem Blue Cross PPO insurance plans switched. Previously covered by Anthem IngenioRx, the plans’ pharmaceutical and medical benefits were decoupled and pharmaceutical benefits were taken over by Navitus Health Solutions. This switch — which was not effectively communicated to impacted employees until March — has left some with essential medications or care no longer covered.
While it is not uncommon for employer health insurance to change medical and pharmaceutical benefit providers, this specific mishandling of such a change points to larger problems people face dealing with the health insurance industry. Jonathan Eisen, a UC Davis professor affected by the switch, explained that because his preferred insulin brand was no longer covered through Navitus, he might have been forced to pay between $8,000 and $10,000 a year for essential medication if he did not go through the laborious process of requesting, and obtaining, an exemption.
Navitus does cover some insulin brands, but the change left Eisen with two options: change brands, which would require learning an entirely new insulin delivery method and dealing with possible side effects of adapting to new medication, or jump through hoops spending hours on the phone and filling out tons of paperwork to apply for, and maybe get, an exemption that would grant him coverage of his current medication.
This points to a larger issue many patients face when their healthcare changes. After dealing with discomfort or physical illness, going through the process of identifying a diagnosis, finding a treatment plan that helps manage that diagnosis and health insurance that pays for some of it, patients may then find themselves scrambling just to maintain that regimen when their employer changes health insurance providers or their health insurance provider changes its coverage.
Putting this burden on UC employees without proper notification and transparency is not okay. Eisen, like many affected employees, did not receive notice of the pharmaceutical benefit manager change’s impact on the coverage of his medication, which took effect on Jan. 1, until March.
As the pharmaceutical benefit company, Navitus is responsible for communicating with its new members about their coverage, but it is still the UC’s responsibility to look out for its employees by holding Navitus accountable and ensuring that all necessary information is sent to impacted individuals in a timely manner. Given that many have speculated that the switch was done to save the university system money, the UC has a responsibility to be communicative and transparent to ensure a smooth transition for changes that affect its employees.
Navitus states on its website that it offers cost-effective alternatives and generic brands in order to keep costs low, but some UC employees say that this is at the expense of their ease and quality of care.
Unlike employees, UC Davis students who have healthcare through the university are not given multiple plan options. All students are eligible for one insurance plan: an Anthem Blue Cross Blue Shield preferred provider organization (PPO) plan called UC SHIP. Some students have reported that through this coverage, they are unable to acquire their preferred insulin, or have struggled to have a high enough percentage of their medications or care covered to afford it.
Though UC SHIP was not affected by the switch to Navitus, many students responded to a Twitter thread Eisen had posted of his experience, bringing to light that both students and employees face problems with their respective insurance plans through the UC.
Obviously, these patients’ struggles are not the fault of the UC alone. Some medications, like insulin, are egregiously expensive because both manufacturers and pharmaceutical benefit managers know that individuals need to purchase them regardless of the cost. A vial of insulin can be roughly $300 — 30,000% more than the original $1 patent price. If the insulin patients’ need is not covered by their insurance, some may not be able to afford critical medication.
It also goes without saying that the health insurance system itself is confusing to navigate. The process of finding out your benefits, understanding deductibles and copays, managing co-insurance, getting referred for out of network coverage and then filing for refunds for that coverage can be a lot. For patients like Eisen, who do need to get an exemption for their medication to be covered by their insurance, scheduling an appointment to see a doctor to write to the insurance company detailing the necessity of this exemption and then waiting for that exemption to be approved or denied can take months due to long wait times. In these months, costs can add up and the stress of potentially not getting an exemption and being responsible for those costs can be devastating.
But while the structural issues within the healthcare system are not easy to address, and neither individuals nor the UC can be expected to do so unilaterally, the university system can and should do more to provide the best support they can for employees and students. Students should have multiple plan options to choose from to address their differing health care needs and the university system must clearly and transparently communicate with their employees and students about their health insurance options and prioritize providing them with stable, quality care.
Written by: The Editorial Board
