Insurance Reform Moves to the States

In addition to the new health insurance reform law, states are looking into some of the most important issues that affect patients’ access to care. For example, Nebraska has introduced two bills:

LB 1017: An Act to Reform Insurance Prescription Fee Practices

As medical costs escalate in Nebraska and throughout the nation, insurance companies have created a new cost-sharing mechanism known as prescription drug specialty tiers. Most plans have a threetier structure of fixed-cost benefits to subscribers based upon whether a drug is generic (Tier 1); brand-name preferred (Tier 2); or brand-name nonpreferred (Tier 3). But, some insurers also have added fourth and fifth tiers for specialized drugs for serious disorders. This is causing patients who depend on lifesaving, infusible therapies such as biologics, plasma-derived therapies and their recombinants, and interferon, for example, to face even more hurdles. With the new fee structures, these therapies moved from health plans’ major medical benefits to specialty tiers with out-of-pocket costs that can range from 10 percent to 50 percent of the cost of the therapy. On average, the plans charge 35 percent of costs under Tier 4, and they charge far more for Tier 5 plans. The cost to the patient, in some cases, can be thousands of dollars per day — a price few can afford.

LB 1017 ensures that every insured Nebraskan has access to reasonable prescription drug benefits by requiring that all health plans delivered or renewed on or after Jan. 1, 2011, meet the following criteria:

• The plans cannot create specialty tiers that require payment of a percentage of prescription costs.
• The plans cannot charge prescription drug copays that exceed the cost of the prescription to the healthcare plan, nor can they charge a copay that exceeds by 500 percent the lowest prescription drug copay in the plan.
• If a health plan includes a limit for out-of-pocket expenses for benefits other than prescription drugs, the plan must include a provision that would result in the lowest out-of-pocket prescription drug cost to the subscriber.
• Either out-of-pocket expenses for prescription drugs would be included under the plan’s total limit for out-ofpocket expenses or prescription drugs could not exceed $1,000 per individual or $2,000 per family for the contract year

LB 1088: Physician and Patient Prescription Protection Act

In Nebraska and throughout the nation, it has become increasingly difficult for patients to obtain the medications their physicians prescribe. Many insurers have taken steps to encourage physicians and patients to switch prescriptions based solely on cost considerations. Increasingly, patients are being forced to switch to drugs that are similar to, but not the therapeutic equivalent of, the prescriptions that their doctors ordered. In many cases, patients and physicians are not told that the substitution has taken place, thereby placing patients’ lives in jeopardy. Known as therapeutic substitution, this practice takes patients off of medicines that work well for them and switches them to different medications with different active ingredients that are less expensive, but not necessarily as effective or safe.

LB 1088 would ensure that insurers and pharmacy benefits managers (PBMs) send notifications of request for medication changes to patients and their physicians or other prescribing health professionals whenever the insurer or PBM recommends the change. Among other things, this notification will acknowledge that no medication change will be allowed without the authorization of the original prescribing healthcare professional; clearly identify the originally prescribed medication and the medication to which the patient would be changed; describe any financial incentives that may be provided or offered to the prescribing healthcare professional by the insurer or the PBM; describe any financial incentives that a health insurer or PBM may receive to encourage a medicine exchange; explain any cost-sharing changes for which the patient would be responsible should the medication change take place; and state that the insured has the right to discuss the proposed medication change before it occurs. This bill is important because it will return the dialogue about prescription drug benefits and risks to the patient examining room, where it belongs. Physicians, rather than insurers, best know which treatments will or will not work for their patients. Factoring in the patient’s medical history and current condition, physicians can help patients make informed decisions about prescription drug costs, quality and health benefits.