Private Health Insurance & Medication Switching
See: Medication Switching | The Issue | Data & Studies| What You Can Do | Private Health Insurance & Medication Switching | Additional Resources | News
The Epilepsy Foundation strongly believes that patient and physician consent should be obtained before an individual with epilepsy experiences a substitution in their epilepsy medication. The Foundation also supports insurers providing equitable access to epilepsy medications where a patient and/or their physician recommend against medication substitution. We support cost sharing and prescription drug copayments that do not penalize an individual who needs to maintain consistency with their epilepsy treatments. The Foundation has taken on a leadership role on this issue and contacted major insurance companies to share research on switching and request that, given the elevated risk, companies not require patients on brand AED to switch. We have also urged insurers to eliminate any cost differential between brand and generic AED's for people with epilepsy.
If you have private insurance coverage that offers a prescription drug benefit, there are a variety of ways to stay on your exact medication and it is important to understand what your plan requires. In addition, coverage does not necessarily mean that there will be no increase in cost; if you are able to avoid a medication substitution you should ask your insurer what you cost is (your total copayment to stay on the brand name drug).
- You may be able to stay on your medication with no cost or action if you elect at the pharmacy counter.
- Your physician may have to write "Dispense As Written" on your prescription to ensure that your medication is not substituted (your plan may charge you more for the brand name drug, contact your insurer with any questions).
- Your physician may have to contact your plan and/or complete paperwork to provide you with a prior authorization or medical exception to the plan policy to avoid a medication substitution.
- You may need to file an appeal with your insurer to prevent a medication switch.
- If you are newly diagnosed, you may be required to start on a generic medication.
The Epilepsy Foundation provides the following information on our outreach to health insurance companies on medication switching and their policies, this information is limited and we encourage you to contact your insurer (even if they are listed below) to fully understand their coverage and costs for your medications.
The following insurance carriers have stated that they do not require medication substitutions and do not have a cost difference between brand and generic AED:
|Blue Cross BlueShield of Alabama
Blue Cross BlueShield of Iowa/Wellmark
Blue Cross Blue Shield of Utah/Regence
Health Net (if already stabilized on a therapy)
WellPoint (for most AEDs)
Wellmark (for Topamax, Kepra, Lamictal, Dilantin, and Depakote)
The following insurance carriers have stated that they do not require medication substitutions but there could be a cost difference between brand and generic AED (contact your insurer to find out your costs):
Blue Cross BlueShield of Arizona
Blue Cross of Idaho
HMSA Blue Cross Blue Shield of Hawaii
UnitedHealthCare (commercial plans and some affiliated commercial business plans; does not apply to PacifiCare, Prescription Solutions, Secure Horizons, Medicare, Medicare Advantage, or Americhoice Medicaid plans)
The following insurance carriers have stated that they do require physicians to take some action to prevent a medication switch, there could be a cost difference between brand and generic AED (contact your insurer to find out your costs):
Tricare (they mandate substitution and require individuals to file an appeal based on medical necessity)
If your health insurance company is not listed we recommend that you contact your insurer if you have any questions about coverage or substitution. If you are faced with a medication substitution that either you or your physician are against find out what you need to do to gain coverage from your insurer and what your costs will be for that coverage. Here are some key questions to ask:
- Does my policy allow for coverage of a brand name medication if I do not want to switch?
- Do I need to get anything from my physician to gain coverage of a brand name medication and avoid a generic switch?
- What does my physician have to do?
- Can the physician note "Dispense As Written" on my prescription to ensure coverage of the brand name drug or do I need to file an appeal or a medical exception to the policy?
- If an appeal or prior authorization is required, how do I file this?
- If I am able to stay on a brand name drug for my epilepsy treatment what is my cost?