Insurers and pharmacy benefit managers (PBM) use a number of approaches to cut costs, such as nonmedical switching. Nonmedical switching occurs when an insurer or PBM requires a stable patient to switch from his or her current, effective medication to a less costly, alternative drug by removing the medication from the formulary list, moving a drug to a higher cost tier, or increasing the out-of-pocket costs owed. This switch occurs after the plan year has already begun or during the plan year’s renewal period. To be clear, nonmedical switching is not switching a patient from a brand medication to a generic version of a drug that exhibits the same levels of effectiveness and safety. It is switching a patient to an entirely different medication, oftentimes without informing the patient’s health provider. As such, this bait-and-switch tactic is a consumer protection issue.
Nonmedical switching can negatively impact patients’ health by triggering adverse responses or result in a lower quality of life. Oftentimes, a patient will have to switch more than once to find stability again.
States have begun to introduce legislation to limit insurers’ ability to make formulary changes that result in nonmedical switching. Please click on the map below for state-specific information on legislation introduced this session.