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Non-medical switching: Looming Rx care obstacle?

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As anyone reading the headlines these days can see, the outlook for health care coverage is … well, a big question mark. Soon-to-be-president Donald Trump and Republican congressional leaders have made no bones about ushering the Affordable Care Act out the door. What they plan to replace it with remains up in the air.

Yet one issue that’s likely to keep coming up for patients and pharmacists in the days ahead is “non-medical switching.”

That happens when patients are forced to switch their prescription medications — often to a “preferred” or less expensive drug — because of insurance coverage changes or reductions. Coverage reductions may include the elimination of a drug from the formulary, increased out-of-pocket costs or other restrictions.

Non-medical switching was spotlighted this week by the Global Healthy Living Foundation (GHLF), a nonprofit group, and the Floridians for Reliable Health Coverage, a coalition of 36 organizations representing hundreds of thousands of Floridians with chronic illness and their health care providers.

Releasing the results of a survey on Tuesday, the coalition said 68% of Floridians with chronic conditions polled have had their insurer reduce coverage of their prescribed medication by changing their health plan’s formulary. And 74% of respondents said they couldn’t afford the higher out-of-pocket prices and had to switch to an entirely different medication.

Of those surveyed, 61% had to try multiple drugs before finding another that worked for them, and 58% said the medication they switched to wasn’t as effective.

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GHLF claims patients experiencing non-medical switching aren’t getting the prescription drug benefits marketed to them in the open enrollment period. The foundation noted that while insurers change their drug formulary when they want to — and often do it in the middle of the plan year — patients are stuck because they can’t renegotiate their contracts until the end of the plan year.

“Annually, when a Florida resident signs up for insurance their contract is very specific. But what may not be apparent is that their insurer is allowed to alter the contract by reducing their drug coverage at any time during the plan year,” explained Seth Ginsberg, president and co-founder of GHLF, a member of the Floridians for Reliable Health Coverage.

“Not only is the contract unfair to consumers,” he noted, “but it puts patients’ health at risk when access to their medication becomes uncertain.”

Other survey findings included the following:

• 77% of respondents experienced side effects after switching to a new medication.
• 84% reported a general “negative physical impact” after being non-medically switched, and many missed work or needed hospitalization.
• 88% reported decreased control of their disease, as evidenced by worsening symptoms when formulary changes delayed access to their medication.
• 48% never received notifications from their insurer (letters, emails or phone calls) about midyear drug formulary changes or coverage modifications.

“People with HIV, epilepsy and other chronic disease will spend weeks, months or even years seeking an effective treatment regimen. An insurance company completely disregards the severity of destabilizing a patient with a chronic disease when they make it more difficult or impossible for that patient to access or afford the medications they prefer and that are recommended by their health care provider,” stated Jason Goldman, governor of the Florida Chapter of the American College of Physicians, a member of the Floridians for Reliable Health Coverage. “These insurers may lower their drug costs but will not reduce their overall health care costs. Data shows that switching medications often increases provider visits, emergency room trips and even hospitalization.”

GHLF said non-medical switching is escalating into a key issue for patient and provider groups nationwide, including in Florida, where state legislation (HB 95/SB 182) has been filed to curtail this activity by commercial health insurers. The foundation said legislation focusing on this practice was proposed in eight states in 2016.

“We are pleased to hear that legislation is being introduced in Florida,” Ginsberg added. “It’s time for legislators to protect patients from non-medical switching.”

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