Non-Medical Switching

This topic has 2 replies, 3 voices, and was last updated 1 year, 2 months ago by Avatarstephaniet.

  • Author
  • #12345

    There are a number of variables to consider when discussing non-medical switching (cost of drugs, cost of failed treatments, risk to patient health, etc.). Bring your comments, questions and concerns here!


    Keeping stable patients stable is a constant effort.

    Some of our nation’s most vulnerable patients are being forced — by their insurance plan — to switch from a medication that works to effectively manage their condition to one that may not, because it costs their insurance company less money. This cost-driven utilization management strategy is an egregious practice referred to as “non-medical switching.”

    Non-medical switching occurs when an insurer requires a stable health plan enrollee, or “beneficiary”, to switch from their current effective medication to a less costly alternative drug. Insurers achieve this outcome in several ways, but mainly by removing coverage for the medication or making it too expensive for the patient to continue therapy on that medication.

    Non-medical switching negatively impacts patient health. Health care providers often work with their patients for years to find a therapy that helps stabilize a complex or chronic condition and manage progression of disease. Often, people living with mental illnesses, immunodeficiency disorders, epilepsy, cancer, and autoimmune diseases such as rheumatoid arthritis, inflammatory bowel disease, lupus, multiple sclerosis, and psoriasis, must try multiple medications before finding one that works.

    Forcing these stable patients to switch medications simply to save on cost can disrupt that delicate and arduous process. Even the slightest variation in treatment may result in serious reactions, adverse health outcomes, and/or decreased quality of life. As such, it is critical that patients be able to rely on the statutory protections provided to them by their state to continually support uninterrupted access to a medication on which their condition is stable.

    A switch that occurs at the beginning of a plan year is just as harmful as one that occurs during the plan year. Long-term stability is critical for anyone struggling to manage a complex or chronic disease. Therefore, patient protections against non-medical switching must limit switches that occur from year-to-year (during the re-enrollment period), as well as switches within the plan year, to have a positive and meaningful impact on all patients with complex or chronic illnesses.

    In 2011, Texas recognized this need and established statutory protections for patients against non-medical switching during the plan year, moving Texas ahead of many other states on this front. However, protecting patients is a constant effort that requires continuously improving protections as the health care environment changes. As biopharmaceutical technologies continue to shift away from conventional, oral medications to much more complex and targeted therapies, insurers are getting more aggressive with their strategies to intervene in the patient-physician relationship and force patients to switch to less expensive – but not necessarily equally effective — medications.

    Through collaborative efforts through the Texas Non-Medical Switching (TX NMS) Coalition, NICA is working to ensure that Texas remains on the forefront of statutory patient protections by supporting H.B. 2882 / S.B. 1967, the next step in Texas’ efforts to protect stable Texans against cost-driven medication management strategies like non-medical switching.

    H.B. 2882 / S.B. 1967 aim to expand upon the protections afforded to patients under state statute in two ways: (1) enhance existing protections against switches during the plan year; and, (2) establish protections against switches during the re-enrollment period.

    NICA believes that influencing the course of treatment for a patient constitutes the practice of medicine. Insurers should not be permitted to switch patients’ medications for reasons unrelated to health. Furthermore, we believe that insurers should not be permitted to make changes that result in non-medical switching for stable individuals during the re-enrollment period.

    States must continually improve the statutory protections afforded to their citizens against measures used by insurers to switch their medications for reasons unrelated to health. NICA is working with several other state coalitions across the nation to support efforts in continually improving statutory protections so stable patients can remain on the right medication — the one that works.

    Lead Goon, Team NICA


    What are your thoughts on biosimilars? We have a PBM in Kansas requiring remicade patients to change to renflexis 1/1/19. Kansas has no law regarding interchangeability as many other states do.

Viewing 3 posts - 1 through 3 (of 3 total)

You must be logged in to reply to this topic.

Log in with your credentials


Forgot your details?

Create Account