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Nonmedical switching

The issue

NonNMS5medical switching occurs when insurers reduce prescription coverage in a way that forces a patient to switch to a different treatment without any medical reason. Examples of coverage reductions include eliminating the drug from coverage; increasing the copay; or moving the drug to tier with more restrictions around access, like requiring prior authorization. These changes often take place in the middle of the plan year, outside of open enrollment, when the patient is already locked into the plan.

The problem

Patients and their clinicians may work closely together for years to find the right medication. When a patient is forced onto a new drug without any regard for their health or the knowledge of their clinician, it can mean unnecessary additional symptoms, side effects, and even relapse. These poor health outcomes can actually increase overall health care costs because of additional appointments, testing and imaging, trips to the emergency room, and/or hospitalization. The practice undermines clinicians’ expertise and makes it nearly impossible for patients to effectively compare plans and choose the right one for them.

Our position: Oppose

Nonmedical switching is bad for patients, the health care system and society at large and should not be allowed. If it does occur, it should be with the full knowledge and agreement of the clinician in consultation with the patient and there should be a standardized appeals process. Read our full position statement here.

Examples of U.S. Pain’s efforts

Resources

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