By: Robert W. Levin | Orlando Sentinel

Mary is a 45-year-old patient in my practice with severe rheumatoid arthritis. She was incapacitated. Her illness prevented her from working, and also made it difficult to dress, cook, do housework and other everyday tasks that most of us take for granted. I treated her with three separate medications before we finally found one that worked. Just six weeks later, she was able to go off long-term disability, go back to work and begin living a more normal life again.

Several years later, her insurance plan removed the treatment from its “preferred drug list,” or PDL, meaning it would no longer cover the treatment that had given Mary her life back. She is once again disabled.

While Mary’s story might seem like just a cautionary tale, I see it all too often. Health plans in Florida are changing their PDLs to reduce existing pharmacy benefits and forcing stable patients to switch therapies with little to no warning. It’s even happening in the middle of a policy year, when patients have no ability to switch to a new plan.

The reality is that PDLs are controlled by pharmacy benefit managers — often large corporations that manage prescription benefits for health plans and negotiate with pharmaceutical companies to get rebates for medications, which in turn, drives up drug prices for everyone. When pharmacy benefit managers negotiate a better rebate on a different drug in the same therapeutic class, they change the PDL to incentivize patients to switch to the drug with the higher rebate. Insured patients who need the old medication must either pay more out of pocket, or, in cases where the drug is removed from the PDL, must shoulder the entire cost themselves.

The benefit managers and the health plans they manage institute these benefit changes in order to save money, but little to none of the savings is passed on to the patients, who are simply caught in the middle of this tug-of-war.

Fortunately, Florida lawmakers are considering legislation to protect people like Mary from having the medication they need unexpectedly denied. The Bait-and-Switch Bill, introduced by Sen. Debbie Mayfield as S.B. 360, and by Rep. Ralph Massullo as H.B. 229, would prevent commercial health insurers from reducing prescription-drug benefits outside of open enrollment, when families are locked into their health policy for the year. California, Nevada, and Texas have already implemented similar protections to ensure prescription benefit stability within each policy year.

The Florida Bait-and-Switch Bill is critical because insurers generally change PDLs every three months, even though patients are only able to change their insurance plans annually. Often individuals or employers choose an insurance plan based on the prescription-drug benefits it offers, only to find out a few months in that the medications they need are no longer accessible on their plan. As Mary can attest, this “bait-and-switch” can have severe health consequences.

Choosing medications based on what is in the financial best interest of the pharmacy benefit managers and insurance companies is a harmful practice that puts insurance companies, not physicians, in the business of making treatment decisions. Eliminating this corrupt practice should be a high priority as we move toward health-care reform in Florida and nationally.

Dr. Robert W. Levin is president of the Florida Society of Rheumatology and president of the Alliance for Transparent and Affordable Prescriptions. He is a practicing rheumatologist in Clearwater.

Article last accessed here on March 2, 2018.