Assembly bill would allow patients to opt out of mail-order prescriptions

The Fresno BeeJune 2, 2014 

Fifty-six-year-old Mark Helm who has hemophilia, and was earlier infected with HIV and Hepatitis C, would like to get his drugs from a local pharmacy but his insurance company requires that he get the speciality medications through the mail.

JOHN WALKER — Fresno Bee Staff Photo Buy Photo

Mark Helm of Sanger gives himself an injection every other day so his blood will clot.

He has hemophilia, and the medication keeps the blood disorder in control. He also takes drugs daily for HIV, which he acquired decades ago from blood transfusions that were needed during bleeding episodes.

Helm, 56, is careful not to skip his prescription medications. But because he gets his drugs by mail, on occasion they arrive late at his home, he said. "One time, they screwed it up for 10 days and I did run out of my HIV medications."

He would prefer to fill the prescriptions locally — he co-owns a pharmacy in Fresno that specializes in drugs for hemophilia — but his insurance company makes him order from a mail-order pharmacy.

Mandatory mail-order programs have become popular in recent years. In 2013, more than 25% of large employer-sponsored plans had such prescription requirements, according to the Pharmacy Benefit Management Institute annual report.

Mail-order delivery is convenient and saves money for employers and consumers, health plans say.

But opponents say face-to-face interaction with pharmacists is helpful to patients with numerous prescriptions to fill and helps ensure that people take their medications as prescribed.

So there is support and opposition for California legislation that would require health plans to allow consumers to "opt out" of mandatory mail-order programs.

Assembly Bill 2418, introduced by Assembly Member Susan Bonilla, D-Concord, would give an "opt out" to approximately 1 million California health consumers who are in health plans with mandatory mail-order programs.

"The issue here is of patient rights," Bonilla said in an interview last month. Patients should "have flexibility to meet their own health needs the best way they see fit," she said.

Bonilla's bill passed unanimously out of the Assembly Appropriations Committee on May 23 and now goes to the Assembly floor. If signed into law, it would take effect after Jan. 1, 2016.

But the bill is not without opposition, and Bonilla said room remains for negotiations.

Health plans argue the bill would increase costs for consumers. In addition to the "opt-out" provision for mandatory mail ordering, the bill also would prohibit plans from denying refills of prescription eyedrops and would require plans to allow refills so consumers can synchronize prescription orders.

But the opt-out provision has drawn the most concern.

"Health plans are trying to keep costs down because that's what consumers want," said Patrick Johnston, president and CEO of the California Association of Health Plans.

Under Bonilla's bill, "health insurance premiums will increase because it interferes with the health plans' ability to deliver medications in an efficient and safe and cost-effective way," Johnston said. "Passing a law that is restricting the ability of plans and pharmaceutical companies and pharmacies to negotiate the best ways to deliver medication safely and cost effectively is a mistake."

According to an analysis for the Assembly Appropriations Committee, yearly premiums would increase by at least $500,000 and out-of-pocket costs for consumers would increase by at least $1.8 million.

Bonilla said people could indeed face extra costs for drugs by opting out of mandatory mail-order programs. But, she said, "if it is valuable enough and important enough to the consumer, then they should bear that cost."

But there is time to work on bill language to address the cost issue, she said. "There are examples in other states where it's working and been successful and not broken the bank for health-care costs."

Others see cost savings when consumers can choose where to fill prescriptions.

Eve Bukowski, vice president of state governmental affairs for the California Healthcare Institute, said she is not convinced that excessive costs will result. The institute represents pharmaceutical, biotech and other life sciences companies.

People are more likely to take medications correctly when they get them from pharmacists, avoiding emergency hospital visits and hospitalizations, she said.

Medication noncompliance is a $290 billion problem in the U.S., said Jon Roth, chief executive officer for the California Pharmacists Association.

Johnston said mail-order deliveries are convenient for many people. To claim that a brief conversation with a pharmacist at a supermarket will correct the problem of medication noncompliance is "a gigantic leap of logic," he said.

But Bonilla said some consumers prefer to discuss their medications with pharmacists. They have fragile health conditions and want reassurance and advice. AB 2418 "just says there's a portion of the population that would like to be able to have that choice," she said.

It's unlikely a huge number of people would choose to "opt out" of mandatory mail-order programs. According to the California Health Benefits Review Program, less than 1% of refills would switch from mail order to retail pharmacies.

Helm said he wants that choice.

As a pharmacy technician who co-owns Herndon Pharmacy, Helm said his business could benefit if people were allowed to opt out of mail order, but his support for AB 2418 is as a consumer.

He spends an hour to 90 minutes a month placing his own prescription orders by telephone for mail order.

Helm said his insurance company pays about $65,000 a month for his hemophilia medications, about 40% more than what it would cost him to buy locally. In addition to significantly higher costs, "it's not convenient for me. It's a nightmare for me to order my medicine," he said.

Two settled court cases specific to HIV patients will allow people with HIV to opt out of mail-order programs. In March, UnitedHealthcare reached a settlement in a proposed class-action lawsuit and in May 2013, a similar settlement was reached with Anthem Blue Cross of California.

UnitedHealthcare said in a statement that members with HIV/AIDS will continue to have access to medications through mail order, but there will be options for those who have privacy, delivery or mental health concerns.

The court is expected to complete its review of the settlement no sooner than July, UnitedHealthcare said. The agreement will be effective one month after the court's final approval.


The reporter can be reached at (559) 441-6310, or @beehealthwriter on Twitter.

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