Bill aims to stop 'non-medical switching' of prescription drugs

Lawmakers in the Ohio House of Representatives are considering legislation that would prohibit health-care insurance providers from removing drugs from prescription benefit lists during a given benefit plan year.

Known as "non-medical switching," the practice is common and can have significant effects on an individual's health, according to one of the bill's sponsors — Democrat Rep. Beth Liston of Dublin.

Liston, a medical doctor who treats patients at two area hospitals, told Insurance Committee members during a hearing that previously controlled chronic conditions often destabilize when a patient is forced to change treatment for no medical reason.

"There are numerous diseases for which it is very difficult to find the medication regimen that works for an individual," she said. "Diagnoses like Crohn's disease or autoimmune diseases — even most mental-health disorders — require very individualized care."

Liston noted that patients are unique and for most chronic conditions, no particular medication works for everyone.

House Bill 291 would also prohibit a health-plan issuer from taking any of the following actions during the health benefit plan year:

* Increasing a covered person's cost-sharing burden for the drug;

* Limiting or reducing drug coverage, including subjecting the drug to prior authorization requirements; and

* Moving the drug to a more restrictive tier of the plan's drug formulary.

"I am sure everyone on this committee has had this happen to them, or someone they know; when you walk into a pharmacy to pick up a depression medication, blood pressure medication or a diabetes medication only to be informed that your regular prescription is no longer covered, and the pharmacist will need to call the doctor's office to find a substitute," Liston said. "That is non-medical switching. For some, it is only a mild inconvenience, and one medication works as well as another. For many it makes a huge difference in their ability to manage a chronic disease."

According to the text of the bill, should a health-plan provider take any of the prohibited actions, it would be deemed an unfair and deceptive insurance practice which may result in penalties.

HB 291 explicitly states that it does not prevent health-plan providers from adding drugs to a formulary or removing a drug from the list because it is no longer sold in the United States. It also would allow medically appropriate changes to a prescription and a pharmacist's substitution of an epinephrine autoinjector for the prescribed one.

Joint sponsor of the bill, Rep. Sara Carruthers, R-Hamilton, said HB 291 will result in plan providers giving patients a clear path to request continued coverage of a specific medication at the end of a given plan year "and grant them comparable access if there is no medical reason to take them off that drug."

Liston said she expected to hear criticism of the proposal from health insurance companies that have defended non-medical switching as a "cost-saving tool."

"They will give industry-written projections about what might happen that are short sighted and don't look at real-life data about what is happening now," she said. "These scare tactics are wrong. Non-medical switching does not save health-care costs when health-care utilization is considered. … The impact of non-medical switching is overwhelmingly negative. It is much more expensive to pay for a hospitalization than a medication on which the patient has been stable. It is even more costly to deal with the long-term complications on health which inevitably will follow with poorly controlled chronic disease."

The lawmaker attributed the country's rising health-care costs mostly to administrative costs, which account for about a third of all expenditures, she said.

"Health insurers focus on the short-term costs to their bottom line — costs incurred during the potentially limited period of coverage that is tied to a specific employment," Liston said. "However, it is our job as state representatives to look at the bigger picture of health-care costs and outcomes across the lifetime of all Ohioans. This means minimizing the administrative burdens that do not add value and making sure people can securely access their needed medication, without fear that the coverage they signed up for was just the bait, and a harmful switch could be coming."

Ten House members co-sponsor the bill, which awaits further consideration by the committee.