For some people, getting a much-needed prescription filled isn’t always as simple as getting it from their doctor and taking it to a pharmacy. For many, it can become a painful and arduous battle to gain prior authorization, Rep. Rod Hamilton (R-Mountain Lake) told the House Health and Human Services Finance Committee during an informational hearing Wednesday.
Prior authorization is used to limit the cost of prescription medications by making sure that patients really need those medications before they’re dispensed. Health plans often contract with pharmacy benefits managers, or PBMs, to do this.
But patients can be hurt by the system, Hamilton said.
PBMs can change which medications are available in the middle of an enrollment year and repeated authorization requests can throw off a course of treatment, both of which are especially dangerous for patients with chronic conditions, testified Dr. Julie Anderson, a family physician representing the Minnesota Medical Association and Minnesota Academy of Family Physicians.
She told the committee about the emergency room visit of a diabetic patient unable to get insulin after more than a week of delays. Sue Abderholden, executive director of the National Alliance on Mental Illness’s state chapter, told about a college student who had to put school on hold for an entire semester after the anti-depressants she needed were suddenly no longer available.
“Why should I have to call you to defend what it is that my doctor has prescribed for me? You do not know who I am,” said Hamilton, who has multiple sclerosis and has personally struggled with getting medication prescribed to him because of PBM determinations.
HF747, sponsored by Hamilton, aims to protect patients from sudden changes and unnecessary delays related to prior authorization.
The bill would limit changes made during an enrollment year, allow patients in need of ongoing medication therapy to maintain access to those prescriptions, and require approved prior authorizations to remain valid throughout the contract period or, in some cases, one year.
Health plans that have a list of drugs available to enrollees would also be required to make that list available along with related enrollee benefit information.
However, health plan companies would be permitted to make changes at any time to reduce enrollee costs, reduce copayments, increase the number of medications available, or to respond when a drug is deemed unsafe by the FDA or withdrawn by a manufacturer.
A companion, SF593, sponsored by Sen. Carla Nelson (R-Rochester), was heard in the Senate Health and Human Services Finance and Policy Committee in March and laid over for possible omnibus bill inclusion.
PBM decisions are primarily based on clinical reasons, not only financial considerations, and are needed to keep costs reasonable and maintain access to medication, said Andy Behm, vice president of the office of criminal evaluation and policy for Express Scripts, a PBM.
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