It was sometime in December that I received the notification from my insurance carrier. In the midst of holiday cards and end-of-year charitable appeals, it was tempting to toss the unremarkable envelope aside. But as someone who grapples with health issues both personally and professionally, I opened it.
In the midst of all the text was an innocuous mention there would be changes to prescription drug coverage in the new year. The letter directed me to a website to learn more. I logged on and scanned the lengthy list of prescription drug changes for the new plan year. I was surprised to see that one of my medications — one for which there is no “therapeutic equivalent” — was no longer on the approved drug formulary.
Thus began a series of phone conversations over several weeks with my physician’s office, my insurance company and the third-party pharmacy benefit manager (PBM) contracted by the insurance company to determine which drugs would be available to patients. In fact, the PBM representative expressed surprise that I had reviewed the list. Most patients discover their medication is no longer covered only when they are denied a refill.
Since I became paralyzed after a sports injury damaged my spinal cord 25 years ago, I have taken many medications to manage neurological, muscular and digestive issues, as well as chronic pain. My testosterone therapy for low energy and decreased bone density was no longer going to be covered. Previously, I had tried other treatments to elevate my testosterone and hopefully prevent osteoporosis in my legs, but my doctor and I found them to be ineffective. Since starting this less expensive weekly injectable testosterone treatment a couple of years earlier, I had been happy to see my body become stronger and more resilient.
Accessing that treatment — even when it was covered — has always required navigating some hoops: working with my doctor’s office each December to prove the treatment was still medically necessary so I could secure pre-authorization for continued coverage, plus quarterly doctor’s appointments and lab workups to prove it was working.
But this time, the treatment was not going to be covered at all, even though the PBM representative acknowledged there is no therapeutic equivalent or substitute.
It was humbling for me, a longtime patient advocate at the Texas Capitol, to be personally experiencing one of the issues I had sought legislation to correct: “non-medical switching.” Non-medical switching describes tactics used by health insurers to switch stable patients from their already-prescribed medications for non-medical reasons, including:
- Removing a currently-covered medication from the formulary
- Adding a requirement that an enrollee receive prior authorization for the currently-covered drug
- Imposing or altering a quantity limit for the medication
- Moving the drug to a higher cost-sharing tier
Health insurers argue the practice is justifiable because it is a cost saver. The reality is that non-medical switching is a cost shifter.
For patients with chronic health conditions, finding stability is a painful, time-consuming and expensive process that may take months or years, with visits to various specialists, treatments tried and failed, time away from work and family and even costly hospitalizations when things go wrong.
A study by the Institute for Patient Access showed that patients who are switched off their stabilizing prescription drugs often experience higher non-drug health care costs, due to additional doctor’s appointments, lab tests, outpatient care and hospital stays.
Even if a patient finally finds a treatment that achieves stability, maintaining that stability can be daunting. So, when health insurers switch a patient’s treatments for non-medical reasons, it can send that patient into a tailspin — medically, emotionally and financially.
Although my physician and I eventually were able to get the treatment reinstated, many other patients are not so fortunate. That is why I am working alongside patient advocates and healthcare professionals to encourage the Texas Legislature to protect patients from non-medical switching by their insurers. Senate Bill 580 by Sen. Donna Campbell, and House Bill 2099 by Rep. Stan Lambert will do just that. We urge lawmakers to build on their strong record of patient protections to ensure some of the state’s most vulnerable patients can remain stable on their treatments as long as they remain on the same health plan.
Disclosure: Chase Bearden has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.