Posted: January 29, 2019
A new law in Illinois ensures that commercial health plans deliver on policies they market and sell to Illinoisans. Prior to January 1st of this year, insurers in Illinois could change prescription drug coverage on a patient at any point during the year, and while patients were still locked into their plan. This practice is referred to as “non-medical switching” and can have serious negative health effects for patients. Public Act 100-1052 ensures continuity in prescription drug coverage for residents in Illinois with state regulated, non-ERISA Employer-sponsored plans.
Under Illinois law, commercial health insurance plans cannot remove a drug from its formulary unless the plan notifies the patient at least 60 days before the coverage change occurs. When a health plan notifies the prescribing provider about a midyear formulary change, they are required to include a one-page form or instructions to access an online portal where the provider can easily request that the health plan continues providing coverage because the drug is medically necessary.
A health plan is required to authorize coverage for the drug based solely on the prescribing provider's assertion that coverage is medically necessary. The plan is also prohibited from making modifications to the coverage that increase out-of-pocket costs for the covered drug.
Advanced advocacy efforts put forth by numerous organizations led to the passage of the law in Illinois. The CSRO is committed to advancing advocacy efforts in others states throughout the country in 2019. So far this year, legislation has been introduced in Indiana, Florida, and Oregon. More states are expected to file non-medical switching legislation in the coming weeks.
In sum, health plans initially marketed and sold to patients at open enrollment should be honored through the duration of the plan year. Physicians, in consultation with the patient — not health plans or brand drug manufacturers — are in the best position to make decisions about patient care. Decisions about a patient’s treatment should be based on the patient’s history, current response to treatment, and medical judgment of the provider.
For more information on the Illinois non-medical switching law, download this one-page handout on Public Act 100-1052. CSRO is also compiling patient and provider experiences with non-medical switching. Please submit occurrences to email@example.com.