Patient access to prescribed treatment act

Liberty
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Patient Access to Prescribed Treatments Act

To ensure that health insurance companies cannot restrict patients to a “preferred medication list” when a healthcare provider has determined that an alternative medication is in the patient’s best interest.

Millions of Americans, including those with chronic conditions like Type 1 and Type 2 diabetes, as well as other complex health needs, face barriers to receiving medically appropriate treatments due to restrictive insurance formularies. These limitations can result in patients not receiving the most effective medication for their condition, undermining healthcare providers’ expertise and putting patients at risk.

This bill prohibits health insurance providers from denying coverage for a prescribed medication if a licensed healthcare provider determines it is necessary and medically appropriate, regardless of whether it appears on the insurance company’s “preferred” list.

  1. No Forced Substitution of Medications:

    • Health insurance companies shall not deny coverage of a prescribed medication, including brand-name drugs, when a healthcare provider certifies that it is medically necessary.

  2. Provider Discretion:

    • A licensed healthcare provider’s recommendation takes priority in treatment decisions, especially for chronic conditions such as diabetes, thyroid disorders, mental health, and other illnesses where specific medications are critical to patient stability and health outcomes.

  3. Annual Review and Exception Process:

    • Insurance providers must establish a clear, timely exception process for cases where a prescribed medication is not on the preferred list.
    • Appeals must be reviewed within 5 business days to avoid delays in essential treatments.

  4. Transparency Requirement:

    • Insurance companies must disclose the rationale for excluding specific medications from coverage and make these disclosures public to ensure transparency around cost-based vs. health-based decision-making.

  5. Protections for Patients with Chronic Conditions:

    • Special provisions will apply to medications that manage chronic diseases, where switching drugs due to insurance formulary requirements can lead to adverse health consequences.

Expected Benefits:

  • Restores decision-making power to healthcare providers and patients.
  • Ensures that patients have consistent access to medications that best suit their medical needs.
  • Reduces health complications arising from forced medication changes due to insurance restrictions.
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I’ll also add In the United States, the FDA requires that generic drugs must contain the same active ingredients, strength, dosage form, and route of administration as the brand-name drug. For a generic to be approved as a substitute, it must meet the following criteria:

  • Bioequivalence: The generic must deliver the same amount of active ingredients into the bloodstream in the same time frame as the brand-name drug. Specifically, it must fall within a range of 80% to 125% of the bioavailability of the brand-name drug. This range is considered small enough that it should not significantly impact the drug’s effectiveness or safety for most patients.

  • Purity, Quality, and Strength: Generics must also meet rigorous FDA standards for purity, stability, and quality to ensure consistency across different batches.

However, even within this range, some patients may respond differently to generics due to slight variations in non-active ingredients (excipients) that can affect absorption, especially with medications for chronic conditions like thyroid or diabetes treatments. This is one reason some doctors may insist on brand-name medications for certain patients.