Arbitrary changes jeopardize patient health and access to care

By Hui-Lim Ang

Thursday, Oct. 30, 2014 | 2 a.m.

Nevada patients living with chronic and life-threatening conditions depend on access to affordable medications to help manage their diseases. Some Nevada insurers, however, risk disrupting that access to care and jeopardizing the health of patients by arbitrarily driving up the patient’s out-of-pocket cost for many new and innovative treatments.

Nevada insurers are allowed to make midyear drug formulary changes to remove certain drugs from a formulary altogether, or to move medications to a pricing tier with a larger deductible, copayment or coinsurance. For patients living with a range of conditions such as lupus, arthritis, MS, cancer, fibromyalgia, neuropathy and many others, a formulary change could mean hundreds or thousands of dollars in additional out-of-pocket costs per month.

When patients are unable to afford their medication, they often undertreat or stop taking their medication altogether, which can jeopardize the gains made in treatment and lead to a further deterioration in patient health.

Patients often choose their insurance based on coverage of specific medications for specific conditions for themselves or their loved ones. When insurers make midyear formulary changes or put the cost of medication beyond reach, those families have the rug pulled from under them.

It is not only the health of patients that suffers. Increases in patient out-of-pocket costs for medication threaten the financial solvency of families and could increase long-term health costs to the state in the form of unnecessary hospital visits, emergency care and loss of employee productivity.

Fortunately for Nevada patients, some help may be on the way soon. The Nevada insurance commissioner is currently considering a proposed regulation, R074-14, that would prohibit insurers from removing a prescription medication from a formulary or moving it to a tier with a larger patient cost burden after the formulary has been approved by the commissioner, except under specific circumstances.

The proposed regulation has broad support from the Nevada patient and provider communities and is a common-sense step that allows insurers to continue to manage costs while also ensuring that patients are not subjected to arbitrary and potentially dangerous midyear coverage changes.

Changes in health plan requirements should mirror the annual enrollment cycle in order to ensure a patient’s access to therapies and continued and uninterrupted access to care. The lives and livelihoods of many Nevada patients hang in the balance.

Hui-Lim Ang is the executive director of Colors of Lupus Nevada, a nonprofit organization dedicated to supporting the lives of Nevada lupus patients.