Patient Advocates, Lawmakers, and Doctors Call for an End to Drug Formulary Changes in the Middle of the Year

Posted May, 10 2018 by Taylor Frazier

CID-NYGuest post by Heidi Siegfried, MSW, J.D.,  Project Director of New Yorkers for Accessible Health Coverage.

Survey results were released last week showing that a majority of New Yorkers living with chronic or rare medical conditions have had the experience their insurance company changing their drug coverage in the middle of the year. They do this by eliminating a drug from the formulary or changing the co-pay – a practice that raises costs on consumers and can disrupt their medical treatment.

On behalf of 36 patient and provider groups, Global Healthy Living conducted a survey that found that nearly two–thirds (65%) of New York residents with chronic illnesses had to switch to a different medication than the one that was prescribed due to a change in coverage.

  • 54% had to try multiple medications before finding another medication that worked for them
  • 72% reported that their new medication worked somewhat or much worse than the originally prescribed medication
  • 51% experienced side effects after switching
  • 35% reported seeing their health care provider or going to the emergency room due to the complications following a switch
  • 10% reported being hospitalized after a switch

Disrupting the continuity of care and delaying effective treatment can result in detrimental life threatening consequences and can actually lead to more medical complications, expensive hospitalizations, emergency room use, and higher health care costs.  It can also discourage consumers from continuing with needed treatment due to side effects or because drug failure erodes their trust in medication. Few health plans have robust exceptions or appeals processes to protect consumers who may depend upon particular drugs for their care when formularies are changed.  However, it this happens to you and you need help to use your plan’s appeal process, you can contact Consumer Health Advocates for assistance.
Patient and Consumer Advocates like Center for Independence of the Disabled, doctors, and legislators are calling for passage of legislation, S5022-C (Serino)/A2317-C (Peoples-Stokes) to prohibit insurance companies and pharmacy benefit managers (PBMs) from switching drug coverage in the middle of the year when patients cannot change their health insurance until the next open enrollment period.  The Assembly passed the legislation earlier this year and has approved it the last four years.