What to Know: Non-Medical Switching

Commercial health plans and pharmacy benefit managers (PBMs) are switching the medications of stable patients with complex, chronic, or rare medical conditions for non-medical reasons. This unjustified, potentially dangerous practice is becoming increasingly common.

In the modern healthcare environment, insurance companies regularly review and change coverage tiers and policies regarding specialty medications, or ‘biologic’ drug coverage.
When prescription drug coverage changes are made, insurance companies notify patients that they may need to switch medications to one less expensive (based on how they’ve evaluated and reorganized their drug coverage policies) to avoid an increase in out-of-pocket costs. This is known as “non-medical switching”.

  • In 2016, patients of two major national PBMs may see their medications cease to be covered. CVS announced it will exclude 124 medications from its 2016 formulary list, and Express Scripts announced it will exclude 80 medications.
  • Managing diseases, particularly for certain chronic conditions, is a difficult process. Many patients with complex or chronic conditions have been through years of painful trial-and-error treatments with their physician to find the therapy that works for them with the least amount of side effects.


Yes, unnecessary medication switches can erode patient health & increase costs.

  • When dealing with patients who have complex, chronic, or rare conditions, changing a stable patient’s medication puts the patient’s health at risk, potentially causing adverse side effects and decreased effectiveness of their medication. One recent study of Crohn’s Disease patients found that switching from one therapy to another was associated with loss of effectiveness within one year.
  • For a patient on a biologic medication, a switch can result in immunogenicity, which is an immune response that can lead to a severe allergic reaction and potentially cause patients to no longer respond to therapy.
  • These unintended health consequences translate to increased ER visits, hospitalizations, physician visits and lab tests – which also drive up health care costs.



  • States need legislation to protect commercial patients with complex, chronic, and rare medical conditions from non-medical switching practices by commercial health plans and PBMs. State laws governing commercial health plans and PBMs must be changed to ensure the following:
  • CONSISTENT COVERAGE: If the commercial health plan of a patient with complex, chronic or rare medical condition has previously approved a specific medication that is effective in stabilizing the patient, they will be able to continue use of the medication while under the health plan’s coverage.
  • FAIR OUT-OF-POCKET COST POLICIES: For these patients, out of pocket costs set by the health plan or PBM during open enrollment will not increase during the respective health plan year.
  • STABLE FORMULARIES: Patients who are stable on certain medications will not have those medications moved to a more costly insurance tier during the respective health plan year.

[1] Van Asshe, Gert, Vermeire, Severine, Ballet, Vera, Gabriels, Frederik, Noman, Maja, D’Haens, Geert, Claessens, Christophe, Humblet, Evelien, Vande Casteele, Niels, Gils, Ann, Rutgeerts, Paul (2011) Switch to adalimumab in patients with Crohn’s disease controlled by maintenance infliximab: prospective randomized SWITCH trial. Gut Online, 10.1136/gutjnl-2011-300755

[1] Rendas-Baum R, Wallenstein GV, Koncz T, et al. Evaluating the efficacy of sequential biologic therapies for rheumatoid arthritis patients with an inadequate response to tumor necrosis factor- α inhibitors. Arthritis Res Ther. 2011;13(1):R25.

[1] Signorovitch J, Bao Y, Samuelson T, Mulani PM.Abstract presented at: EULAR 2012, Berlin, Germany. Ann Rheum Dis. 2012;71(suppl 3):717.