Imagine you are a patient with a chronic condition — such as rheumatoid arthritis — that affects your everyday quality of life. After numerous consultations and doctors visits, you found a medication that manages your condition and has kept your health stable for months, even years.
You’ve done the research each year during open enrollment and selected a health plan that covers your medication. One day, you go to the pharmacy to pick up your refill and the pharmacist informs you that your medication is no longer covered. How could this be? You tell the pharmacist that it’s always been covered before. The pharmacist just shakes her head and says, “It looks like your formulary was changed.”
Unfortunately, this scenario is happening to Floridians on a regular basis. Without notification, without opportunity to consult their doctor, Floridians with chronic conditions are finding that their medication is no longer covered, due to cost-saving measures taken by health plans and benefits managers.
Mid-year formulary changes — modifications to the list of drugs covered by your health plan — are an attempt by health plans and benefits managers to capture savings by switching to less-expensive alternatives. In some cases, as when a generic drug is released, these changes have no impact to patients. However, the medication for many chronic conditions is specialized and expensive, and when plan providers remove these specialized treatments from their formularies it impacts patients’ health.
Responding to these changes, patients find they are short on options. Often finding out in the pharmacy line, they have to scramble to work with their doctor to determine if the alternate medication will work for them, often discovering it does not. If the alternate treatment is not effective, they are stuck with the higher cost of a drug that is no longer covered. This all adds up to more doctor visits, the patient ceasing their medication, and further complications. These complications often end up costing health plans more money in the long run, making these disruptive changes a dubious method of finding cost-savings.
Perhaps the most frustrating part about this bait-and-switch tactic, and the most compelling reason to prohibit it, is that the patient has selected their plan in good faith, choosing the coverage that they assumed would best address their medical concerns. When they have the rug pulled out from under them in the pharmacy line, their only recourse is to accept the change or pay out of pocket, because they are locked into their plan until the next open enrollment period.
That’s why Florida lawmakers, following the example of states like Louisiana, Nevada and Texas, need to pass legislation that:
1. Provides patients with notice before a formulary change occurs,
2. Allows them time to work with their doctors, and
3. Provides a mechanism to stay on their current medication for the remainder of the plan year, if it’s medically necessary.
We can allow plans and benefits managers the ability to capture savings and modify drug coverages, while still preserving the health of Florida’s most vulnerable. Because whether a formulary change is in response to changing drug prices, rising health care costs, or even the laudable goal of lowering health care costs to other patients, the outcome is the same: Florida’s patients are leaving the drug counter confused, frustrated and without the coverage they signed up for, and they deserve better.
Jared Willis, based in Tallahassee, is the Government Affairs Manager for Strategos Group, where he advocates for patient access to affordable health care, greater patient protections, and transparency in health care coverage.