Non-Medical Switching of Specialty Medications

Non-Medical Switching Specialty Medications

Non-Medical Switching of Specialty Medications

Amy Rios May 1, 2019

In anticipation of the imminent hearing on Texas House Bill 2099, here is why most Americans are at risk of being switched off their medications for non-medical reasons.

For many health care providers in the infusion industry, non-medical switching is, unfortunately, a common occurrence when managing their patients’ care. Non-medical switching refers to a common tactic in which a patient’s medication is changed, typically at the behest of a third-party such as a health insurer, for reasons other than the patient’s health.

Many patients who are managing a chronic autoimmune disease are treated with a specialty medication, such as a biologic that is classified as a high-cost, high-complexity medication usually administered as an injection or infusion. Health insurers frequently review their formularies and adjust their coverage tiers and policies regarding specialty medications throughout the year. In most of the United States, health insurers can change their coverage at any point during the year, sometimes meaning the plan and coverage the patient enrolled in is either not covered or have increased out-of-pocket costs. This tactic is often referred to as “bait and switch.”

Why Most Americans Are at Risk

There are currently 6 states (CA, IL, LA, ME, NV, and TX) that have passed legislation that protects their patients from mid-year coverage changes made by a commercial health insurer. In the rest of the country, patients are susceptible to being switched from the medication that is effectively managing their condition to a less expensive, alternative medication that might not be as effective.

For patients whose health depends on the timely administration of their prescribed specialty medication, a switch can result in a variety of adverse side effects that can drive up the economic burden of disease such as increased visits to the hospital, or re-emerging symptoms and new side effects.

Fighting the Change

In 2018, NICA was active on non-medical switching bills in Connecticut, Florida, Illinois, Indiana, Iowa, and Pennsylvania. Additionally, NICA joined the steering committee of the Coalition for Stable Patients in Texas to improve statutory protections for patients against non-medical switching. This year, NICA has been active in every state that is planning to introduce a bill proposing patient protections from non-medical switching and “bait and switch” tactics. These states include Connecticut, Iowa, Massachusetts, New Jersey, and Texas.

Earlier this year, Senate Bill 580 (SB580) and House Bill 2099 (HB 2099) were filed in Texas. These identical bills aim to protect patients who remain on the same health plan from being switched off the medications that are effectively managing their conditions. This is an additional protection beyond mid-year coverage changes.

On April 11, HB 2099 was unanimously voted out of the House Committee on Insurance and now it awaits a hearing in the Texas Senate. SB 580 still awaits a hearing in the Texas Senate Committee on Business and Commerce. HB 2099 has been authored by 4 members of the insurance committee, one of whom is a physician.

Changing consistent treatments based solely on cost is not a choice that patients and insurers should make—or impose—lightly. NICA believes that restricting non-medical switching for patients on specialty medications will not only protect their health but also the provider’s role in managing their care.

You can view and track current non-medical switching legislation on NICA’s interactive advocacy map here.

Texas residents: To let your legislator know that protecting patients from inappropriate non-medical switching practices is important to you, send them a message below. 

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On HB 2099

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