Legislation Would Keep Insurers from Increasing Out-of-Pocket Costs, Removing Coverage or Restricting Access to Medicines During the Health Plan Year
By Shaina Smith
Did you know that there are currently no regulations in Connecticut that prohibit health plans from changing contracted pharmacy benefits in the middle of the year, when individuals are locked into their plans? Unfortunately, that is the case in several states across the nation. Luckily, Rep. Michelle L. Cook (D- Torrington) and Rep. Linda A. Orange (D- Colchester) of Connecticut are working to close the loopholes for chronic pain patients.
House Bill 6622 was recently filed and would guarantee that individuals receive the prescription drug coverage they signed up for by limiting when insurer policies can change prescription drug formularies during the plan year. Without such a law in place, insurers are able to take advantage of the existing loopholes to save on costs, and, at any time, may increase out-of-pocket costs, enact more restrictions on coverage, or remove coverage of a prescription medication altogether. These reductions to coverage are often done to try to force a patient off of his or her current medication and onto an insurer-preferred drug.
This particular practice is known as “non-medical switching” because patients are forced to switch for financial reasons, as opposed to medical ones. HB 6622 would mitigate this practice by prohibiting insurers from making reductions to their prescription benefit plans for duration of the policy term. U.S. Pain Foundation has and will continue raising awareness in various states this session and in the future to make lawmakers aware of this negative practice. Currently, the organization is in the process of creating a grassroots coalition that would support HB 6622 and possibly other legislation that aims to benefit the chronic pain community. So far, the National Infusion Center Association, Global Healthy Living Foundation, Lupus and Allied Diseases Association and Aimed Alliance have committed to the Connecticut cause.
“Changing a patient’s prescription without prior warning and while they are still locked into their health plan is a dangerous practice. It not only interrupts the treatment recommended by a patient’s physician, but can also lead to higher medical costs in the long run,” Rep. Cook (D-Torrington) said. “This legislation would give patients the peace of mind that they will have access to the medication they need for the duration of their plan.”
The practice of non-medical switching is becoming an increasing problem across the nation for individuals from already vulnerable populations, including people with chronic pain and mental illness. As a resident of Connecticut and person living with an incurable connective tissue disorder, this legislation just makes sense. If consumers, which includes chronic pain patients, cannot change their health plans in the middle of a plan year, insurers should not be able to alter their prescription drug benefits either. Every year during open enrollment, families across the state carefully choose health plans that accommodate their needs and cover the treatments they take to stay stable, healthy and productive. Unforeseen changes to a family’s pharmacy benefits are not only devastating their budgets, but also to their health.
This sentiment is not only shared by U.S. Pain Foundation, but other partner organizations, as well as nationally recognized entities. For example, the consumer advisory group of the National Association of Insurance Commissioners reported mid-year formulary changes can have “significant consequences for consumers”. At the federal level, Medicare placed various limitations on mid-year formulary changes for medications covered under Part D. In fact, Part D sponsors must seek the approval of the Centers for Medicare and Medicaid Services for any negative formulary changes in addition to providing 60 days of advance, written notice of an approved negative change to the affected enrollees.
Typically, clinicians aren’t made aware of the switch until after it happens and are limited in their ability to appeal the change. Meanwhile, patients may experience increased symptoms, side effects and even relapse as they struggle to adjust to the new medication that may not be as effective as the original or might cause an adverse reaction.
In fact, numerous studies show non-medical switching may result in poorer health outcomes, especially for those with chronic conditions, and, as a result, may actually increase overall health care costs. For example, one report published by the Epilepsy Foundation found that patients with epilepsy who were switched off their original medication experienced more breakthrough seizures and sought more inpatient and emergency care than those were not switched. In addition, the journal, Value in Health, published an analysis of patients with rheumatoid arthritis, Crohn’s, psoriasis and other autoimmune conditions who were switched and found they incurred 37 percent higher medical costs than average. Another study, published in Psychiatric Services, found that patients with mental illnesses who were switched off their medication due to coverage changes were three times as likely to be homeless.
“House Bill 6622 fills a dangerous void in consumer protection by recognizing that insurers should provide the health plan benefits their enrollees sign up for,” said Emily Lemiska, associate director of State Advocacy for U.S. Pain Foundation and also a resident of Connecticut. “Without this legislation, Connecticut families will continue to face unexpected costs and restrictions and be unable to get the medications they need.”
While the bill would prohibit insurers from reducing prescription coverage during the plan year, it would not impede insurers from adding medications to their formularies, including new generic products, or making changes necessary for safety reasons outlined by the U.S. Food and Drug Administration. It also would not affect or prohibit generic substitution.
Outside of Connecticut, U.S. Pain Foundation belongs to several coalitions proposing similar legislation in states including Florida (Floridians for Reliable Health Coverage), Colorado, New Jersey and Washington state. We’re also raising awareness on the issue in Tennessee, where we’ve formed the TN Patient Stability Coalition and in Illinois, where we’re co-leading the Fair Care Coalition.
If patient or provider groups are interested in joining the grassroots coalition effort in CT, please feel free to reach out to me directly: firstname.lastname@example.org