While it may be inconceivable or even unconscionable to cut off access to life-saving treatment for stable patients with diseases, such as cancer, diabetes, arthritis, and psoriasis, insurers and pharmacy benefit managers (PBMs) are doing just that. Two PBMs, CVS and Express Scripts, recently announced that, in efforts to lower costs, they will be dropping coverage of several drugs that patients are currently taking. This change is despite the fact that some patients are finally stable on these medications after months or years of trying and failing on several others.

Last week, CVS announced it would stop covering 35 currently covered medications in 2017, including groundbreaking cancer and diabetes drugs. Back in 2015, the PBM originally announced it would drop coverage of 95 medications. In 2016, the number grew to 124. With the addition of these 35 medications, the number is now up to 155. CVS’s reason for the move is simple: to replace higher cost drugs, that is, save money at the patients’ expense. Likewise, Express Scripts list is now up to a total of 85 excluded medications.

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Over the years, cancer went from a death sentence to a survivable disease thanks to new and innovative treatments, but a practice few know about—nonmedical switching—makes the disease a potential death sentence yet again.

“Nonmedical switching” occurs when an insurer or PBM essentially forces a stable patient to switch from his or her prescribed medication that is working well for him or her to an alternative medication by dropping the prescribed medication from the formulary or increasing out-of-pocket costs for the patient so that the medication becomes unaffordable. The PBM or insurer requires the patient to use a different medication regardless of what the patient’s doctor prescribed—sometimes without the doctor’s knowledge—and regardless of whether the switch will cause adverse events or a diminished quality of life. In doing so, the PBM or insurer takes on the role of doctor, despite a lack of medical expertise or an understanding the individual patient’s needs.

The practice of nonmedical switching is not to be confused with requiring a patient to switch from a brand medication to a generic. Instead, the patient is switched to a drug in same therapeutic class that has some level of “medical interchangeability.” While the new drugs’ therapeutic value is similar to the original medication, the chemical makeup is different and can, therefore, be less effective or cause adverse events in certain patients.

Consumers sign a contract with their insurers with the understanding that the benefits they signed up for will be available to them with the agreed-upon out-of-pocket costs throughout the entire plan year. Therefore, as long as an insurer drops the medication at the end of the plan year, it can drop these medications regardless of the effectiveness of the medication and necessity to the patient.  But, the question isn’t if they could…it’s whether they should.  The question at this point hasn’t been a legal one, but an ethical one.  It is now time to reshape that debate. 

Policymakers must start holding insurers and PBMs accountable so that stable patients are protected.

Luckily, some states are already ahead of the curve. This year, the Florida legislature introduced SB 1142, which would have required an insurer to maintain current coverage of a drug for a complex or chronic medical condition or a rare disease if the patient is regularly and correctly using the medication during the plan year and any renewal period. While the bill did not pass, it is a step in the right direction.

We finally have the medications needed to control these diseases, put them in remission, and prevent relapses. Many ailments have gone from being deadly to livable based on innovative treatments, but these treatments are useless if patients are unable to access them. Patients deserve more.

The practice of dropping vital medications could endanger lives. It is time for those who can protect the millions of patients throughout the U.S. to step forward and ensure there are protections in place to halt this dangerous practice before it’s too late for countless Americans.

Stacey L. Worthy, Esq., Executive Director of the Alliance for the Adoption of Innovations in Medicine (Aimed Alliance)


The views expressed by authors are their own and not the views of The Hill.