Contact: Shaina Smith
MIDDLETOWN, CONN. – Feb. 17, 2017 –The Illinois Fair Care Coalition, made up of 14 concerned patient and provider groups, praised new legislation designed to provide safeguards for consumers enrolled in prescription coverage plans. The grassroots partnership joined with state representatives and bill sponsors Greg Harris (D-Chicago) and Patti Bellock (R-Hinsdale) to announce House Bill 2694, which would prevent Illinoisans from having their prescription coverage interrupted during the health plan year through a practice known as non-medical switching.
“There are currently no statutes in place that protect Illinois consumers from insurers abruptly changing their prescription coverage after open enrollment,” said Harris. “It is unacceptable that they have the ability during the plan year to remove a drug from formulary, increase patient out-of-pocket costs or make access more restrictive, without any regard to a patient’s medical needs.”
According to proponents of the bill, these midyear prescription coverage changes may force patients off an effective medication they have been stable on for years. 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.
“Requiring a stable patient to switch their current effective medication for non-medical reasons places the patient at risk of losing control of their disease and, in the long run, may actually increase health care costs,” said Dr. Michael Schweitz, advocacy chair for the Coalition of State Rheumatology Organizations. “For a patient on a biologic medication, for example, it can take many years to find that one therapy that works. Switching it may result in immunogenicity, which is an immune response that can lead to a severe allergic reaction and potentially cause patients to no longer respond to even the original therapy. This is why a patient’s treatment should be based only on the patient’s history, current response to treatment and medical judgment of the clinician.”
Multiple studies show that non-medical switching can be dangerous for specific patient populations with managed chronic diseases, like depression or epilepsy, and may create the need for additional clinician visits, emergency room trips and even hospitalization, which increases overall health utilization costs. For example, one report found switching treatments resulted in more breakthrough seizures for patients with epilepsy.1 Another study showed that patients with rheumatoid arthritis who were switched experienced 42 percent more emergency room visits and 12 percent more outpatient visits over six months.2
“Patients with life-threatening illnesses can’t afford to gamble on their treatment plan,” said Heather Eagleton, Illinois government relations director for the American Cancer Society Cancer Action Network. “Those care decisions should be between the patient and his or her physician – not an insurance company looking to make a profit. Illinoisans should have the freedom to focus on managing their health without worrying about a disruption in their medication coverage.”
Paul Gileno, founder and president of U.S. Pain Foundation, one of the nonprofit organizations leading the coalition’s efforts, added that the insurance tactic is simply unfair whether a consumer has a chronic condition or not. “If consumers can’t switch plans after open enrollment, insurers shouldn’t be able to switch the terms of the plans,” Gileno explained. “They are welcome to respond to market changes during the open enrollment period, when consumers have a fair opportunity to assess and compare insurance plans and choose one that fits their needs.”
While the proposed bill would prohibit insurers from reducing pharmacy benefits after open enrollment and forcing non-medical switching, it would not affect generic substitutions of prescription drugs or affect insurers’ ability to add medications to coverage or to remove medications for safety reasons as mandated by the Food and Drug Administration.
“Patients who are dependent on medications that manage or prevent life-threatening health events cannot have their treatment interrupted due to insurer cost-saving measures, which may be costlier overall,” said Ben Slack, executive director of the Epilepsy Foundation North/Central Illinois, Iowa and Nebraska. “Illinois residents, especially those with such complex medical conditions, deserve the benefits package they signed up for, without midyear formulary changes to that plan. Such interruptions to a working treatment result in unnecessary suffering.”
“Although the organization’s objective is to protect patients with chronic pain conditions, all consumers deserve to remain on the treatment their clinician think is best for them,” added Michele Guadalupe, state director of advocacy and access for the Arthritis Foundation, which is co-leading the coalition. “The proposed legislation benefits Illinois residents with commercial insurance by closing the existing loopholes. We are grateful Representatives Harris and Bellock have recognized the lack of consumer protections and have taken steps to remedy the issue with this proactive bill.”
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About the Illinois Fair Care Coalition
The Illinois Fair Care Coalition, made up of patient and clinician groups, supports legislation that protects consumers from the unfair insurance practice known as non-medical switching, an insurer cost-savings protocol that forces a medically stable patient off of the originally prescribed treatment option. The practice takes place after the consumer has already signed on to the initial health plan terms. Coalition members include: the American Cancer Society Action Network, American Liver Foundation, Arthritis Foundation, Coalition of State Rheumatology Organizations, Epilepsy Foundation of Greater Chicago, Global Healthy Living Foundation, Illinois Psychiatric Society, International Pain Foundation, Lupus and Allied Diseases Association, Mental Health America of Illinois, National Multiple Sclerosis Society, National Organization for Rare Disorders, Respiratory Health Association of Metropolitan Chicago and U.S. Pain Foundation.