House Bill 6622 Would Keep Insurers from Increasing Out-of-Pocket Costs, Removing Coverage or Restricting Access to Medicines During the Health Plan Year

MIDDLETOWN, CONN. – Feb. 8, 2017 –  U.S. Pain Foundation, a nonprofit organization dedicated to serving those who live with painful conditions, today applauded Rep. Michelle L. Cook (D- Torrington) and Rep. Linda A. Orange (D-Colchester) for introducing legislation to ensure stable prescription drug benefits for patients across Connecticut. H.B. 6622 would guarantee that individuals receive the prescription drug coverage that they have signed up for by limiting when insurer policies can change prescription drug formularies during the plan year.

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. As a result, insurers are increasingly taking advantage of the loophole 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. H.B 6622 would mitigate this practice by prohibiting insurers from making reductions to their prescription benefit plans for duration of the policy term.

“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,” Cook 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 conditions like chronic pain, autoimmune conditions, epilepsy, and mental illness. The state of Connecticut, according to Shaina Smith, director of State Advocacy & Alliance Development for the U.S. Pain Foundation, is no exception.

“If Connecticut 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,” said Smith. “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.”

Smith noted that the consumer advisory group of the National Association of Insurance Commissioners published a report recommending states prohibit midyear formulary changes. She also pointed out that, 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, and even if approved, affected enrollees are exempt from the change for the remainder of the year. They also must provide 60 days of advance, written notice of an approved negative change.

In contrast to the above, commercial insurers typically don’t make clinicians aware of the switch until after it happens, and clinicians and their patients 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 strive to provide the health plan that their enrollees sign up for,” said Smith. “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.

About U.S. Pain Foundation

U.S. Pain Foundation is a 501 (c) 3 nonprofit organization dedicated to serving those who live with pain conditions, their families and care providers. Founded in 2010, U.S. Pain was created by people with pain for people with pain. The mission is
to educate, connect, inform and empower those living with pain while also advocating on behalf of the entire pain community. Nationally recognized at the leading patient-focused organization for chronic pain, U.S. Pain helps individuals find resources and inspiration. To learn more about U.S. Pain Foundation, visit