Access To Medications
NAMI’s Position (taken from the NAMI Policy Platform)
NAMI strongly opposes measures that limit the availability and right of individuals with brain disorders to receive treatment with "new generation" medications.
Understanding the Issue:
NAMI members strongly support research to discover a cure for severe brain disorders. Until then, more than anyone else, NAMI consumers and families recognize the need for medications that can control the symptoms of these brain disorders.
NAMI believes that professional judgment and informed consumer choice should determine the choice of medications. Choice of treatments should be based on our knowledge of effectiveness and side effects and should be consistent with existing treatment guidelines.
Medications for mental illnesses differ from one another - either in their effectiveness in treating specific symptoms or disorders, or in their side effects. There is ample evidence that newer medications offer some advantages over conventional medications in either effectiveness or side effects. For example, most guidelines now recommend newer antipsychotic medications as the drugs of first choice because they can be more effective in treating symptoms in some individuals and because their side effects may cause fewer short-term and long-term problems - and in particular, fewer cases of tardive dyskinesia, an irreversible and potentially disabling movement disorder.
However, some health plans, both private and public sector, place restrictions on access to medications. Sometimes these policies may be appropriate, to avoid the inappropriate use of drugs or to encourage the use of generic equivalents. But often the limitations are designed primarily to discourage the use of more expensive medications. Limitations may take the form of a restricted formulary, in which only certain medications are covered by the plan, or a "fail-first" policy, requiring trials of older, less expensive medications before prescribing newer medications.
NAMI members are committed to work to identify and remove any barriers that prevent persons with severe brain disorders from receiving "the right medication, at the right dose, at the right frequency, and for the right duration." NAMI members understand that the right medication is not only right for the consumer, it is also right for the payer and the health plan - there is growing evidence that access to newer medications may reduce the total cost of the illness by reducing other medical expenses such as hospitalization, by improving compliance, and by reducing disability.
NAMI is supportive of many of the provisions contained in the separate House and Senate managed care patient Bill of Rights proposals. In particular, NAMI supports:
- Mandatory access to medications. Health plans must offer access to all effective and medically appropriate medications. If a health plan uses a formulary, exceptions from the formulary limitation must be allowed when a non-formulary alternative is medically indicated. Health plans must establish procedures whereby members may appeal a decision to prescribe a medication. Medication appeals must comply with the third-party, independent, clinical review advocated above; and until the appeals process is finalized, the enrollee shall remain on his or her previously prescribed medication. Plans must not require enrolled individuals to switch medications that have been effective for them.
- Mandatory third-party, independent, clinical review with prompt timelines for binding decisions. Such clinical review entities must be composed of specialists who understand and deliver clinical care to persons with severe mental illnesses. Such clinical review must be independent of the health plan. Such clinical review must be completed promptly. Such clinical review must be binding on the health plan. While the appeal of a denial is in progress, the patient must continue to receive necessary services. Access to immediate, necessary, and appropriate care is the highest priority of NAMI.