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 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

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 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. The Nevada Regulation

Non-Medical Switching Activity in States 2016  Introduced legislation 2016  California (CoC)  Connecticut  Florida  Massachusetts  Washington  Considering legislation 2017 / Forming coalitions  California  Colorado  Connecticut  Florida  Illinois  Michigan  New Jersey  New York  Pennsylvania  Tennessee  Texas  Washington

Model Act No 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! | | National Patient Advocate Foundation