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Health Benefits Coverage of Early Refills of Eye Drop Medicine

By on May 14, 2013

(TRENTON, NJ) – Legislation sponsored by Assembly Democrats Gary Schaer, Pamela Lampitt, Thomas P. Giblin and Gabriela Mosquera to require health insurance providers to cover early refills of prescription eye drops under certain circumstances has been signed into law.

“Anyone who has used eye drops knows how easy it is to miss or have more than one drop fall from the bottle. Punishing patients who rely on prescription drops to treat diseases like glaucoma for this inevitability is unfair and puts their well-being at risk,” said Schaer (D-Bergen/Passaic). “This law will help ensure that people do not skip taking critical prescription eye drops simply because they spilled or lost some of their eye drops and were not allowed by their insurer to get an early refill.”

The law (A-3080) requires, in certain circumstances, that health insurers that provide coverage for prescription eye drops provide coverage for expenses incurred for a refill of prescription eye drops in accordance with Guidance for Early Refill Edits on Topical Ophthalmic Products provided to Medicare Part D plan sponsors by the Centers for Medicare and Medicaid Services (CMS).

The CMS issued guidance on topical ophthalmics to prevent the unintended interruption of drug therapy in situations where patients legitimately need earlier refills of prescription eye drops. While the guidance acknowledges that health insurers monitor appropriate refill periods as part of utilization management, it also recognizes that self-administration of drops may involve some reasonable amount of waste and that earlier refills may be appropriate in some circumstances.

The requirement to provide this coverage is conditioned on two factors: (1) the prescribing health care practitioner indicates on the original prescription that additional quantities of the prescription eye drops are needed; and (2) the refill requested does not exceed the number of additional quantities indicated on the original prescription by the prescribing health care practitioner.

“The refill limits imposed by insurance providers leave no room for error which is unfair to patients who depend on this medicine to treat serious eye problems,” said Lampitt (D-Camden/Burlington). “This law won’t let patients get any more medicine then their prescription allows, it will simply allow them to get the next refill sooner when they actually need it.”

“These quantity restrictions can be difficult to meet. It’s not about being wasteful, it’s about being human,” said Giblin (D-Essex/Passaic). “Individuals who rely on prescription eye drops to treat certain diseases should have the peace of mind that their refills will be covered if their drops run out before their insurance company says they should.”

“Individuals who use prescription eye drops to treat diseases like glaucoma can’t risk missing even a couple of days of medicine,” said Mosquera (D-Camden/Gloucester). “They should not have to go without important medicine because their usage on occasion did not meet the timeline set by their insurance company.”

– Assembly Democrats