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Off-Label Prescriptions

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Paul Gileno, of the U.S. Pain Foundation, published this letter in my local Concord Monitor.  He discuses a new state law that will go into effect this month that prevents insurance companies from mandating a patient try other (read cheaper) prescription drugs (ones that are not listed by the FDA as treatment for your condition) before they will pay for the medicine that you and your doctor know you actually need.  Interestingly, it also prevents insurance companies from refusing to cover a prescription that is also not listed by the FDA as a treatment for your condition, but that you and your doctor know is best for you.  Sounds like NH legislators did a thorough job with their research.  Well done.

(On the lighter side of the off-label issue, remember the episode of House, MD where House is called before a furious Medicare judge who wants to know why he prescribed Viagra to a 70 year old woman?  His answer was that it lowers her blood pressure.  And apparently he wasn’t wrong – Harvard agrees.)

Letter: New law protects patients

Prescribing medicines requires extensive medical training, clinical experience and direct knowledge of a patient’s personal medical history, all of which is best understood by a patient’s own health care provider.

But that doesn’t stop insurers from trying to interfere. I should know. I’ve been battling health insurers almost as long as I’ve been battling pain – nearly 12 years.

Yet, insurers still find ways to astonish me with schemes that put dollars over patient health. Luckily for residents of New Hampshire, a new law goes into effect this month (SB 91) that will help protect patients from an especially egregious cost-containment practice: forced off-label prescribing.

Forced off-label prescribing occurs when insurers require that patients try and fail on one or more prescription medicines that are not approved by the Food and Drug Administration for the treatment of their medical condition before granting access to those that are. Insurers require this extra step not because the off-label treatment is better, but because it is cheaper.

New Hampshire’s new law protects patients living with pain and other medical conditions by putting restrictions around this practice.

Of course, off-label medicines are often the best option for patients. Just ask anyone living with cancer or an autoimmune disorder.

The new law also limits insurers’ ability to refuse coverage for off-label use when prescribed by a health care provider. The bottom line is this: Providers must have the discretion to prescribe the medicines that are best for their patients, not an insurer’s balance sheet.

PAUL GILENO

Middletown, Conn.

(The writer is CEO of the U.S. Pain Foundation in Connecticut.)

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