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Shaina Smith
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Tennessee Patient & Provider Groups Applaud Legislation to Protect Against Unfair & Unsafe
Prescription Coverage Reductions
The Reliable Coverage Act Helps Ensure Tennesseans Receive the Pharmacy Benefits They Are Sold
During Open Enrollment
NASHVILLE, TENN. – Feb. 9, 2017 – An unexpected denial letter in the mail, a surprise bill at the
pharmacy counter: many Tennessee consumers are discovering the prescription coverage benefits
they signed up for are not the benefits they actually receive. It’s a problem new legislation aims to fix,
according to the Tennessee Patient Stability Coalition, a coalition of 17 leading patient and provider
groups. The coalition today applauded a bill that would require commercial health plans honor the
terms of their prescription coverage plans for the duration of the contract year. The legislation,
known as the “Reliable Coverage Act” (HB 960/SB 991), would protect consumers by preventing
prescription coverage reductions outside of the open enrollment period.
“As both a physician and a consumer, I am proud to stand behind a common-sense bill that asks
insurers to follow through on the benefits they offer during open enrollment,” said Sen. Mark Green
(R-Clarksville), who, along with Rep. Bryan Terry (R-Murfreesboro), is sponsoring the legislation. “If
insurers advertise and sell a certain level of prescription coverage, Tennesseans should be able to rely
on that coverage for the remainder of the contract year.”
“Aside from consumer protection and fairness, the other big issue is that these plan changes can be
unsafe,” said Terry, who is also a physician. “If you’re living with a serious health condition and your
insurer changes your prescription benefits, then you can be switched to an entirely different drug
with different side effects and degrees of effectiveness. This has a real-life impact on patients which
can lead to exacerbating one's condition or even hospitalization.”
Insurers may reduce prescription coverage after open enrollment in a variety of ways, including
removing a medication from coverage altogether, increasing out-of-pocket costs for a medication or
placing additional restrictions around access (such as requiring prior authorization). The practice of
reducing drug coverage midyear has become known as “non-medical switching,” because it often
forces patients to switch to an insurer-preferred medication, regardless of the potentially negative
impact on their health.
“Arbitrarily forcing patients off a medication with no advanced warning and for no medical reason is
both unfair and dangerous,” said Katherine Moffat, executive director of the Tennessee Academy of
Physician Assistants, which is a member of the Tennessee Patient Stability Coalition. “Patients and
their clinicians may work together for years, trying multiple medications, before they find one that
works. These midyear coverage reductions can upend a patient’s hard-won stability, resulting in
otherwise-avoidable symptoms, side effects and even relapse. Insurers should not be able to
interfere with treatment in such a significant, potentially harmful way.”
Proponents of the bill point to studies that show non-medical switching may result in poorer health
outcomes and, as a result, may actually increase overall health care costs. For example, one study
found that patients with epilepsy who were switched off their original medication experienced more
breakthrough seizures and sought more inpatient and emergency care than those were not switched.
An analysis of patients with rheumatoid arthritis, Crohn’s, psoriasis and other autoimmune conditions
who were switched found they incurred 37 percent higher medical costs than normal.
“We are hearing stories from consumers across Tennessee who are stable on a medication for years
and then are suddenly forced off,” said Jeff Fladen, executive director of the National Alliance on
Mental Illness-Tennessee, also a coalition member. “With mental illness, treatment often looks more
like an art than a science as the treatment provider tries various medications. It can take years to find
the correct medications that enable an individual to keep symptoms at bay. People with mental
illness may have to miss work as they struggle to find a new medication that works, which means lost
productivity or even lost jobs and economic self-sufficiency. Then there’s the emotional impact of
unexpectedly losing access to the drug you relied on. Simply put, it’s wrong.”
While the bill would prohibit insurers from reducing prescription coverage during the plan year, it
would not impede insurers from adding medications to their formularies, including new generic
products, or making changes necessary for safety reasons that are outlined by the U.S. Food and Drug
Administration. It also would not affect or prohibit generic substitution.
“The Reliable Coverage Act is a straightforward piece of legislation that will protect consumers from
unnecessary, unfair reductions to their health plans,” said Shaina Smith, director of State Advocacy &
Alliance Development for the U.S. Pain Foundation, which leads the Tennessee Patient Stability
Coalition. “We thank Representative Bryan Terry and Senator Mark Green for realizing the lack of
consumer protections in the state of Tennessee and putting together a thoughtful, bipartisan
solution.”
A survey conducted by the coalition shows that unforeseen insurance coverage changes are a major
problem in Tennessee. According to the survey, 58 percent of Tennesseans living with chronic illness
said their insurance company made coverage changes during the plan year that reduced coverage of
their prescription medication, and 67 percent of these were forced to switch treatments as a result.
Of these:
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66 percent reported that, after switching, their medication was less effective;
89 percent reported that the side effects were worse on the insurer-preferred drug;
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44 percent said they never received any notice from their insurer detailing their plan’s
formulary of the changes being made to it;
99 percent support legislation that would prohibit insurance companies from financially
pressuring patients to switch their prescribed medication for non-medical reasons.
About the Tennessee Patient Stability Coalition
The Tennessee Patient Stability Coalition, made up of 17 patient and clinician groups, is dedicated to
protecting consumers from the unfair insurance practice known as "non-medical switching," which
occurs when insurers reduce coverage of medications after the consumer has already signed on to
the original plan terms. Coalition members include: AIMED Alliance, Alliance for Patient Access,
Arthritis Foundation, Coalition of State Rheumatology Organizations, Global Healthy Living
Foundation, Lupus and Allied Diseases Association, National Alliance on Mental Illness-Davidson
County, National Alliance on Mental Illness-Tennessee, Patients Rising, The Arc of Tennessee, TN AIDs
Action Network, TN Dermatology Society, TN Disability Coalition, TN Nurses Association, TN Physician
Assistants, TN Rheumatology Society and the U.S. Pain Foundation, which leads the coalition. For
more information, visit: https://www.facebook.com/pg/TNPatientStabilityCoalition/.
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