Took four years for Joanne Guthrie-Gard to find the right seizure medication for her daughter, whose epilepsy, during the worst of it, caused her to have 20 seizures a week.
That medication started to have bad side effects — dizzy spells, slurred speech, unsteadiness — when Erin Gard reached high school, but she was able to switch to an extended-release form that proved a good substitute.
The family’s insurance plan covered the new drug. Until it didn’t.
About four months in, Gard was told to go back to the original drug or pay out of pocket for the extended-release version, which at the time cost about $10,000 for a three-month period.
That’s a practice known as nonmedical switching — when an insurance company changes coverage in the middle of a plan year, even though most plan participants are locked in.
“To have someone come in and say, ‘We’re not covering that drug now,’ it’s devastating,” said Guthrie-Gard, who lives in the northwest suburb Lake in the Hills.
Illinois lawmakers are considering a bill that would guard against those types of abrupt coverage changes, which are typically driven by efforts to cut costs.
The proposed bill would prohibit commercial health insurers from modifying coverage of a drug during the plan year if it has previously approved the drug for a medical condition. It would not prevent plans from requiring pharmacists to give generic substitutions or from adding new drugs for coverage. It does not apply to Medicaid or other public insurance.
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The goal is to end what advocates say has become a growing practice of making midyear coverage adjustments to encourage people to switch to lower-cost medicines. Sometimes the plan removes coverage of a drug altogether, though it might also switch it to a different coverage tier that requires higher out-of-pocket costs, or add prior authorization requirements.
Illinois’ bill, which was modeled after legislation in other states, last week passed out of the House Rules Committee and now awaits a hearing in the House Insurance: Health and Life Committee. It has more than 50 co-sponsors.
The Pharmaceutical Care Management Association, which represents pharmacy benefit managers, opposes the bill and others like it.
“This bill would undermine patient safety and force employers, unions and others that provide pharmacy benefits to cover expensive brand drugs, even when more affordable, equally effective competing brand drugs or new over-the-counter options become available,” association President and CEO Mark Merritt said in an emailed statement.
“It would prohibit health plans from upgrading prescription drug lists even when safer, more affordable alternatives come to market,” he said. “Similar legislation in other states has failed largely because it was viewed as a giveaway to drug companies that would raise costs at the expense of consumers.”
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A handful of states, including Louisiana and Texas, have laws or protections limiting midyear drug changes. Bills were introduced in at least nine states last year but have not passed.
A 2012 study found that people with rheumatoid arthritis who switched drugs for nonmedical reasons had 42 percent more emergency room visits over six months than people who didn’t switch. That study was authored by consultants to Abbott, which at the time was making the blockbuster rheumatoid arthritis drug Humira (Abbott spun off its pharmaceutical business, AbbVie, a year later).
Failure to adhere to treatment regimens — which can happen if people can’t afford their medicine — costs the health care system $100 billion a year, according to a fact sheet compiled by the U.S. Pain Foundation.