Transcript Larry Lanier NPAF_WIG_Denver_Non

Policy Roundtable
September 14, 2016
Denver, Colorado
Protecting Stable Patients
from Non-Medical
Switching
Larry R. Lanier
President, State Advocacy & Community Outreach
National Patient Advocate Foundation
About NPAF/PAF
 The National Patient Advocate Foundation (NPAF) serves as
the patient voice for patients with chronic, debilitating illnesses
who need access to affordable, high quality health care.
 NPAF, a 501(c)4, is the partner organization and advocacy
affiliate to Patient Advocate Foundation, a 501(c)3, which
provides direct case management services to patients who
have trouble affording or accessing treatments.
 NPAF helps translate the individual experiences of PAF patients
to federal and state legislative or regulatory policies.
Most Common Patient Issues
(from the PAF Patient Data Analysis Report, 2015)
1.
Lack of access to prescription treatments (such as):
•
Barriers through Utilization Review (such as prior
authorization, step therapy, and non-medical switching
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Out of pocket costs
2.
Medical Debt
3.
Lack of transportation to treatments
Snapshot of Patients Served in 2015
Top 5 Pharmaceutical Access Issues by
Income
Non-Medical Switching:
Myths vs. Facts
Non-Medical Switching:
Myths vs. Facts
Studies
Current Medical Research and Opinion - 1 April 2016
Value in Health Journal – May 2015
Current Protections
 Colorado – Recently released voluntary guidelines instructing
insurers not to enact coverage changes mid-year.
 Texas – Continuity of Care (CoC) law the partially protects
against mid-year non-medical switching.
 Washington – If an insurer removes medication for anything
other than safety, the patients will only be able to access their
original prescription through the insurer’s substituion process;
does not prevent the insurer from raising OOP costs in the
middle of the plan year.
 Nevada – adopted Dec 2015, a health benefit plan cannot
remove a drug its formlary, or raise OOP costs in the middle of
the plan year.
Good Policy Language
The Nevada Regulation
Except as otherwise stated, a health benefit plan which provides
coverage for prescription drugs and uses a formulary that has been
approved by the Commissioner, shall not:
(a) Remove a prescription drug from the formulary; or
(b) Move a drug to a tier with a larger deductible,
copayment, or coinsurance during the plan year for which
the formulary was approved by the Commissioner.
Non-Medical Switching Activity
in States 2016
 Introduced legislation 2016
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California (CoC)
Connecticut
Florida
Massachusetts
Washington
 Considering legislation 2017 /
Forming coalitions
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California
Colorado
Connecticut
Florida
Illinois
Michigan
New Jersey
New York
Pennsylvania
Tennessee
Texas
Washington
Model Act No. 22 - NAIC
 National Association of Insurance Commissioners have
convened a workgroup to review and consider revisions to
the Health Carrier Prescription Drug Benefit Management
Model Act (#22) to address issues related to:
 a) transparency, accuracy and disclosure regarding
prescription drug formularies and formulary changes during
a policy year;
 b) accessibility of prescription drug benefits using a variety of
pharmacy options; and
 c) tiered prescription drug formularies and discriminatory benefit
design.
As Patient Advocates…
• We ask that policy be enacted that:
• Preserves the patient-provider relationship
• Ensures that out-of-pocket costs are transparent
• Honors the contract
Bottom line:
Patients deserve the health plan they signed up for.
Thank you!
www.npaf.org | www.patientadvocate.org
@NPAF_tweets |
National Patient Advocate
Foundation