Legislative Agenda

Our society has employed the services of a lobbyist to work on state issues and help us coordinate efforts with the state medical society and patient advocacy groups. Our lobbyist has allowed FSR to stay current on the important legislative and administrative issues facing Florida rheumatologists and has helped shape our legislative agenda. Members of our executive committee have testified at legislative committee hearings and have visited with legislators in Tallahassee regarding these issues. We also have met with the Office of Insurance Regulation and have worked on issues with AHCA. Recently were able to reach a reasonable conclusion of a Medicaid preferred drug list change through our advocacy.

Patient Steering Through White Bagging Mandates

What is it?
White bagging is a new tactic by health insurers requiring certain medications to be purchased through specialty pharmacies, often owned by the insurance company, with no input from the physician, and then the PBM ships those drugs to the doctor instead of using the drugs doctors have on hand.

What this means for patients:
When health insurance companies require specialty drugs to be purchased only from insured owned specialty pharmacies, clinicians cannot quickly adjust treatments based on the patient’s immediate needs. This steering tactic creates an unnecessary risk for patients by sourcing drugs outside the normal supply chain and quality control processes, causing patient appointments to be canceled due to shipping problems and creates delays in medication administration, which can significantly affect patient health.

FSR Policy:
Health insurance companies in Florida should not be allowed to steer patients through payer mandated “white bagging” policies to specialty pharmacies owned by insurance companies. This process puts insurance company profits above patient safety and choice.

Step Therapy Reform

What is it?
Step therapy, or “fail first”, is a policy used by health insurers that requires patients to try and fail one or more formulary-covered medications before providing coverage for the originally prescribed non-formulary or non-preferred medication. Insurers implement this policy in an effort to try to maintain elevated health care costs.

What this means for patients:
Step therapy can lead to serious negative patient outcomes. Some patients are required to try up to 5 different medications with durations lasting up to 130 days per medication. This practice inhibits physicians from being able to provide individualized care, can sacrifice valuable treatment time, and may cause patients to suffer unnecessarily. Also, step therapy can lead to increased costs for patients if it is not carefully managed.

FSR Policy:
The Florida Society of Rheumatology knows that a physician’s medical decision-making expertise in consultation with his patients should drive treatment decisions. Basing treatment decisions on cost rather than clinical considerations ignores important variations that may exist among patients in terms of safety, efficacy and tolerability in drug classes. Physicians should have the authority to override decisions based on a patient’s personal medical history and what they deem to be in the best interest of the patients.

PBM Transparency

While PBMs were originally set up to control drug utilization and cost, they have since become incredibly effective at negotiating discounts and rebates from manufacturers that they keep for themselves as profits rather than passing those savings onto patients.

Non-Medical Switching

What is it?
Formulary-Driven Switching refers to a policy used by insurers to limit prescription drug coverage to the less expensive medications. It can be used to alter a patient’s medication to the less expensive option during the current contract without any physician or patient consultation.

What this means for patients:
Insurers maintain the argument that formulary-driven switching is utilized to benefit patients by providing them with similar alternative drugs at a fraction of the cost. However, in reality, this policy can be extremely detrimental to a patient’s health and their wallets. Without any restrictions, insurers are able to change a patient’s coverage and fundamentally alter the agreed-upon contract. This means that a patient on a prescribed and effective medication can have their treatment disrupted at any time. Because there is no guarantee that a similar alternative will produce the same effective result, patients are exposed to potentially adverse health effects caused by the switch in medication. This, in turn, leads to exponentially higher costs as well.

FSR Policy:
Switching a patient’s coverage without the consultation of their physicians and the patients themselves is fundamentally irresponsible. These switches take stable patients and force them into unnecessary health risks and economic burdens. Insurers must be required to provide complete transparency regarding coverage and whether or not a patient will be required to make a switch before enrolling in their health plan. Furthermore, patients who are already receiving stable and effective treatment should never be forced to deviate to an alternative medication unless their physician deems it necessary for medical reason.

Accumulator Adjustment Programs (AAPs)

What are they?
What are they? Accumulator Adjustment Programs (AAPs) are tools utilized by insurers and pharmacy benefit managers (PBMs) to exclude co-pay assistance as an out-of-pocket expense. This, in turn, excludes co-pay assistance from being applied to a patient’s deductible.

What this means for patients:
For patients with complex, chronic conditions, co-pay assistance is vital. Typically, it offers these patients access to their necessary medical therapies at a reasonable rate, however when it is excluded as an out-of-pocket expense, cost of care skyrockets. Patients are then left to choose between two options: endure outrageously high medical costs, or discontinue their successful treatment, leading to adverse health effects.

FSR Policy:
Nothing is more important to our organization than a patient’s health. That is why co-pay assistance should count towards the deductibles of patients with chronic conditions. We also emphasize that insurers have a responsibility to notify patients of any existing AAPs.