The Massachusetts Medical Society is pleased to provide its support to S.561/H.969, An Act empowering health care consumers. The Medical Society strongly supports greater transparency of health plan formularies, and believes this is an important step in allowing shared decision-making between patients and physicians.
This bill would require that every health insurance provider post the formulary for the health plan on the carrier's web site in a manner that is accessible and searchable by enrollees, potential enrollees, and providers. It would also require insurers to update the formulary within 24 hours of making changes; and include a standard set of information, especially information with respect to cost sharing and coinsurance.
This issue is of significant priority of the Medical Society. MMS has formal policy calling for such transparency.
It should be the responsibility of the insurer to provide transparency and full disclosure of formulary medications, acceptable alternatives, covered products and services, co-pays, and restrictions in electronic format to facilitate a less costly, more patient-centered, more expedient, and more satisfying method of pre-authorization.
In discussion of this policy at the Medical Society, physicians routinely lament the time they spend determining with a patient the best prescription or course of treatment, which is often deemed moot when they subsequently receive a call from a pharmacy indicating a drug is not contained on the patient’s formulary. At present, physicians often have these initial conversations with a patient in the exam room blind to the specific formulary of the patient, especially in light of the proliferation of different formularies across carriers and plans. Since physicians’ offices often do not learn that a prescription is not on a formulary until they receive a call from a pharmacy, determinations of “next best options” often occur without the patient present.
In addition, formularies do not only indicate which drugs are covered, but which drugs are covered at which costs to patients. With trends towards more health plan design that values patient cost-sharing as a means of controlling costs, through high-deductibles, tiering, etc., out-of-pocket cost of drugs, especially for chronic disease management, must often take cost into account. Transparency of formularies for each patient would greatly benefit these important conversations.
In addition to simply indicating which drugs are on a given formulary, and what costs are associated with them, the Medical Society urges amendment to this important idea to also show which drugs on a formulary are subject to a prior authorization. This would allow physicians to anticipate when additional paperwork may be necessary before a patient can receive the prescription medication. This additional information could reduce delays in patients receiving important medications. We hear from physicians the frustration of prescribing an urgent drug towards the end of a work day, only to find when the patient arrives at the pharmacy (after the physician office is close) that a prior authorization is required. For some prescriptions, this can be an annoyance and require a 12 hour delay in medication. For other prescriptions, the delay can result in additional discomfort, or worse, be the barrier that leads a patient to abandon the treatment altogether.
For these reasons, the Medical Society urges a favorable discharge of this bill to inject important transparency into the drug formulary process.
