Template Language: Your State’s Benchmark Plan Doesn’t Include Good Coverage of
Medications for MH and/or SUD
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Medications are an essential tool to assist in the treatment of all chronic illnesses.
Consumers in STATE X should have good access to medications that are effective in the treatment of all illnesses, including mental illness and substance use disorders.
 The drug formulary for State X’s EHB-benchmark plan should include comprehensive coverage of each class of medications that are approved to assist in the treatment of mental illness and SUD. Not all patients respond to medicines in the same way. Physicians may need to change medications over the course of an illness as patients suffer side-effects or their illness is less responsive to a particular drug, and patients requiring multiple medications may need access to alternatives to avoid harmful interactions.
 To ensure that individuals with MH and SUD have good access to effective medication,
STATE X’s EHB-benchmark should offer coverage for all or substantially all FDA-approved prescription medications in each class, including the following classes of drugs to assist in the treatment of mental illness and SUD: o Antipsychotic medications o Antidepressant medications o Bipolar agents/Mood stabilizers o Anticonvulsant medications o Anti-anxiety medications o ADHD medications o Anti-Addiction/Substance Abuse Treatment Agents / Opioid medications
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If STATE X’s base-benchmark plan fails to include comprehensive coverage of medications approved to assist in the treatment of mental illness and SUD, this would constitute a violation of the parity requirements of the ACA. The base-benchmark plan covers a number of medications to help in the treatment of other chronic illnesses including hypertension, cancer and heart disease. If coverage of MH/SUD medications is significantly more limited than medications utilized in the treatment of other chronic illnesses, this would violate parity. In addition, under the parity requirements of the
ACA, a plan’s MH/SUD coverage must meet standards of clinical practice. Medications are a critical piece of the continuum of care for all chronic illnesses. Failing to provide comprehensive coverage of medications approved by the FDA to assist in the treatment of SUD or mental illness would be contrary to established national standards of care and accordingly violate parity. o If the base-benchmark in your state is a small group plan : As a small group plan,
STATE X’s base-benchmark has not had to comply with the federal parity law and will very likely need to be supplemented to meet the parity requirements of the EHB. A review of the base-benchmark plan’s medical necessity criteria used to determine the exclusion of certain medications utilized in the treatment of mental illness/SUD is necessary to complete a full parity analysis. Stakeholders in STATE X need to have full access to the plan’s medical necessity criteria to determine if the base-benchmark coverage of MH/SUD medications complies

with the consumer-protective requirements of the law. Under the parity requirements of the ACA, if the criteria used to determine which medications to assist in the treatment of SUD or mental illness should be covered is different from and/or applied more stringently than the criteria used to determine coverage for medications used to assist in the treatment of other illnesses, that would also represent a violation of the law. o If the base-benchmark in your state is a large group plan: A review of the basebenchmark plan’s medical necessity criteria used to determine which medications are covered is necessary to complete a full parity analysis. Stakeholders in
STATE X need to have full access to the plan’s medical necessity criteria that was used to determine that certain medications utilized in the treatment of mental illness and SUD could be legally excluded. Under the parity requirements of the
ACA, if the criteria used to determine which medications to assist in the treatment of SUD or mental illness should be covered is different from and/or applied more stringently than the criteria used to determine coverage for medications used to assist in the treatment of other illnesses, that would also represent a violation of the law.
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Failing to provide good coverage of medications approved to assist in the treatment of mental illness or SUD would be inconsistent with the non-discrimination requirements of the ACA. Allowing EHB plans to exclude MH/SUD medications from coverage is contradictory to the ACA’s requirement that the EHB addresses the healthcare needs of diverse segments of the population. If STATE X’s EHB plan doesn’t include comprehensive coverage of MH/SUD medications, individuals with MH/SUD will have
 their choice of treatment severely restricted. There are many highly effective medications to assist in the treatment of mental illness and SUD that are consistent with recognized standards of clinical care and are beneficial to diverse groups of people whose health needs have traditionally not been well met.
Failing to provide comprehensive coverage of MH/SUD medications is also contrary to ensuring meaningful consumer choice in care, a central principle of the ACA. Excluding coverage of a significant number of medications approved to treat MH/SUD through the
ACA would severely and unfairly restrict access to and consumer choice for an effective medication. The full range of medications approved for the treatment of MH and SUD should be covered in STATE X’s EHB-benchmark plan.