– Rep. Valerie Gaydos (R-Allegheny) has introduced legislation that would enable health care providers to find and share lower-cost or clinically appropriate prescription alternatives and payment options with enrollees right in the doctor’s office.
House Bill 882
would create transparency in benefits, eligibility and costs for prescription drugs by requiring health plans and pharmacy benefit managers (PBM) to share certain information with enrollees and health care providers upon request.
“Prescription drug abandonment is a growing concern in the medical community and is a leading cause of drug nonadherence,” said Gaydos. “According to the National Institutes of Health, medication nonadherence for patients with chronic diseases is extremely common, affecting as many as 40% to 50% of patients who are prescribed medications for management of chronic conditions such as diabetes or hypertension. This nonadherence to prescribed treatment is thought to cause at least 100,000 preventable deaths and $100 billion in preventable medical costs per year.”
Sharing this information directly during a visit to the doctor will help ensure that patients can make informed decisions about their medication purchases. The information available must be current and include cost-sharing information such as what the plan enrollee will pay, utilization management requirements such as prior authorization, and information on appropriate alternatives. Health plans and PBMs are prohibited from restricting health care providers from sharing lower-cost or clinically appropriate alternatives as well as additional payment options with enrollees.
While many factors may contribute to a patient not picking up a prescribed medication, a primary reason for prescription abandonment and nonadherence is believed to be the out-of-pocket cost of medications and not knowing the cost before arriving at the pharmacy to pick it up and pay for it.
“A recent survey of 1,000 patients revealed that 75% received a prescription that cost more than expected and half did not pick-up a prescription because the expense was too high when they arrived at the pharmacy,” said Gaydos. “Statistics revealed this problem could be solved if the provider had access to prescription costs as they were prescribing the medication and the patient could know the cost and availability of the prescription prior to leaving the office.”
House Bill 882 has been referred to the House Insurance Committee for consideration.