New Data Quantify Prevalence, Cost of Non-Medical Switching

A new report out of Maine paints a daunting picture of non-medical switching – and how it affects patients.

In just a single quarter, the state’s insurers reported more than 300 formulary changes, increasing the out-of-pocket cost burden for 80% of affected patients.  In some cases, insurers completely removed drugs from their formulary.  In other instances, insurers added barriers that make it harder for patients to access their medication.  These included requiring prior authorization, imposing step therapy and moving drugs to a higher tier.

The data, compiled by the Maine Bureau of Insurance, are available because of a 2018 state law that requires insurers to report changes in prescription drug coverage.

Patients can file for an exception, but data show that insurers denied half of exception requests.  For some medications, they denied every exception request. This included medications for arthritis, gout, eczema and psoriasis – to name a few.  Those patients must choose between paying out of pocket for the medication that keeps their condition stable or switching to their insurer’s preferred medication.  

Patients’ non-medical switching was often a “business decision,” according to the report.  But policy changes like these have a tangible impact on patients’ health and their pocketbooks.  

Patients can work with their doctors for months, sometimes years, to identify which medications best treat their conditions.  When their course of treatment is interrupted, patients risk re-emerging symptoms and new side effects. Non-medical switching can also disrupt patients’ lives.  On the other hand, those who remain stable on their medicine have the lowest per-member, per-month cost to their insurers.

Maine’s reporting requirement is still new, but initial numbers suggest that insurers take a cavalier approach to formulary changes.  Perhaps increased scrutiny and greater focus on the harmful effects of their decision-making will encourage stronger legislative protections.  


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