Drug Formulary Protection

Drug Formulary Protection

Sections 7 & 8 of Senate Bill 811 (Formerly Senate Bill 24) will help consumers access medicines by (1) preventing benefit designs from discriminating against patients through imposed higher cost sharing based on their disease and 2) requiring the Insurance Commissioner to evaluate whether health insurance plans being offered are in compliance with the Affordable Care Act and prevent discrimination based on health status.

Protecting consumers from inconsistent and discriminatory drug formularies

While drug formulary issues may sound technical, if we break the issue apart it becomes clear how deeply these decisions impact consumers and why these issues are so important to improving health insurance coverage in Connecticut.

Senate Bill No. 24 – Drug Formulary Issue #1

Preventing benefit designs that impose non-preferred cost sharing based on a patient’s disease or condition

“Non-preferred cost sharing” is when an insurance plan places all medicines to treat a disease or condition on higher drug formulary tiers. This means that these drugs are among the most expensive and difficult to access on a consumer’s insurance plan. Classes of medicines used to treat HIV, multiple sclerosis and some cancers are among those most likely to be placed only on these higher tiers.

What does this mean for consumers?

Some of the health insurance plans available may cover medicines, but all of the medicines for a particular disease could be at the highest cost-sharing tier and unaffordable for the patient. Additionally, when a consumer enrolls in a plan, it is often unclear to them that all of the medicines they need to take are placed on the highest cost tier of their prescription drug formulary or what cost-sharing corresponds with their treatments.

That means that every single medicine that their doctor could prescribe them for their unique health condition would be priced at the highest possible cost tier. This increases costs for the consumer, reduces choice and can lead to lower prescription drug adherence.

Ultimately, this restrictive coverage discriminates against people with certain diseases, is a barrier to access for consumers, and can potentially lead to poor, and otherwise preventable, health outcomes down the road.

How does Senate Bill No. 24 address this issue?

Senate Bill No. 24 ensures that consumers will have access to the medicines they need at preferred pricing, making lower cost treatment options available by requiring the Insurance Commissioner to evaluate whether health insurance plans being offered are in compliance with the Affordable Care Act and prevent discrimination based on health status.

What is our take?

YourHealthCT supports consumers having access to equitable benefit designs and ensuring plan compliance with the Affordable Care Act to prevent discrimination against consumers with certain diseases, keep costs down and protect doctor and consumer choice.

Senate Bill No. 24 - Drug Formulary Issue #2

Protecting consumers with easily accessible plan formulary information

Most consumers choose health plans that specifically cover the medicines that they are prescribed and include their current doctors in-network. Consumers do not have the ability to switch plans during a plan year, so it is unfair that the information they need most to choose the correct plan can be so difficult to find. 

How does Senate Bill No. 24 address this issue?

Senate Bill No. 24 would create an easier process for consumers to find and readily understand what their benefits are and how they may compare to other plans offered. 

Specifically, Senate Bill No. 24, would require plans to make information available on details including: coverage exclusions, restrictions on use or quantity of a covered benefit, deductibles, copayments, coinsurance, preauthorization and which providers and hospitals are included in-network. 

What is our take?

It is important that consumers know exactly what they are purchasing. Incomplete prescription drug formulary and in-network information can lead to a number of issues for consumers including unknown costs at the pharmacy counter, inability to see their regular doctor, and unexpected lack of prescription drug coverage.  All of these issues can result in higher out-of-pocket expenses for consumers through disruptions in their treatment, trips to the emergency room, doctor’s visits or hospitalization. 

What can be done to ensure consumers are protected?

Together with policy makers, we can work to put consumer protections in place to allow consumers to plan ahead and access the medicines that are vital to their health and well-being.

If Section 1 is important to you...