Sometimes the medication a patient is prescribed is not the medication they receive. Non-medical switching refers to a common tactic in which a patient’s medication is changed — typically at the behest of the health insurer — for reasons other than the patient’s health.

Many patients who are managing a chronic autoimmune disease such as MS are treated with a specialty medication such as a biologic, which is classified as a high-cost, high-complexity medication usually administered as an injection or infusion. Health insurers frequently review their formularies and adjust their coverage tiers and policies regarding specialty medications throughout the year. In most of the United States, health insurers can change their coverage at any point during the plan year, forcing a patient to switch medications or incur higher out-of-pocket costs. This tactic is often referred to as “bait-and-switch.”

Why most Americans are in danger

Only six states — California, Illinois, Louisiana, Maine, Nevada and Texas — have passed legislation that protects their patients from mid-year coverage changes made by a commercial health insurer. In the rest of the country, patients are susceptible to being switched off the medication that is effectively managing their condition, pushing them to a less expensive, alternative medication that might not be as effective.

For patients whose health depends on the timely administration of their prescribed specialty medication, a switch can result in a variety of adverse effects that can drive up the economic burden of disease, such as increased visits to the hospital or emergency room, re-emerging symptoms or new side effects.

Fighting the change

The National Infusion Center Association (NICA) is a national nonprofit organization that serves infusion patients and their providers through advocacy, education, and resource development. In 2018, we were active in improving protections against non-medical switching in Connecticut, Florida, Illinois, Indiana, Iowa and Pennsylvania. Additionally, NICA joined the steering committee of the Coalition for Stable Patients in Texas in order to improve statutory protections for patients against non-medical switching and will continue working with the Texas Legislature to protect patients against unnecessary non-medical switching practices.

In 2019, NICA will be active in every state planning to introduce a bill proposing patient protections from non-medical switching and “bait-and-switch” tactics. We believe that restricting non-medical switching for patients on specialty medications will not only protect their health but also the physician’s role in managing their care.