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 filed by State Rep. Dr. Bryan Terry aims to fix...

The Tennessee Patient Stability Coalition, a coalition of 17 leading patient and provider groups, applauded the bill. The "Reliable Coverage Act" (SB 991/HB 960), would protect consumers by preventing prescription coverage reductions outside of the open enrollment period.

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"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 Illnesss-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:

• 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;
• 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.