MYTH: Prohibiting nonmedical switching will increase health care costs.
FACT: There is no reason prohibiting nonmedical switching would increase costs. Several states, including California, Nevada, Louisiana and Texas, have similar laws, which have had no documented fiscal impact. Also, each year, insurers conduct actuarial assessments to determine a premium that will cover the benefits of a plan and turn a profit. Nonmedical switching legislation simply asks them to honor the results of their assessment. In addition, insurers regularly negotiate contracts that allow them to pay less for medications and include midyear pricing increase protections. These contracts will continue to be freely negotiated and provide another avenue for mitigating cost increases without raising premiums.
MYTH: Prohibiting nonmedical switching is unnecessary because the appeals process already protects patients.
FACT: Even if patients realize they have the ability to appeal and have the know-how to do so, the process can be complicated and lengthy, and, of course, the appeal is not always successful. In addition, patients aren’t necessarily allowed to stay on the original drug while they wait for a decision. In any case, patients shouldn’t have to go through an appeal process to receive the benefits they signed up for.
MYTH:Nonmedical switching legislation affects generic substitution.
FACT: Nonmedical switching legislation in no way affects or limits generic substitution. Insurers may continue to add new generics to their formularies at any time. The concern nonmedical switching legislation addresses is not that patients are being moved to generics, but that patients are being forced to switch to an entirely different medication as the result of coverage reductions.
MYTH: Prohibiting nonmedical switching is unnecessary because such prescription coverage reductions are rare.
FACT: Prescription coverage reductions affect an increasing number of patients each year. According to a 2015 survey by the American Gastroenterological Association, 60 percent of provider respondents reported that a patient’s biologic medication was switched due to insurance company rules. Also, CVS/Caremark removed 34 drugs from its national formulary in 2012; it removed 124 in 2016. Express Scripts, which removed 48 drugs in 2014, removed 80 in 2016. While these changes are formally announced for the following plan year, the drug removals often take effect during the policy terms, when patients are locked into a plan.
MYTH: Nonmedical switching legislation prohibits all formulary changes.
FACT: Although nonmedical switching legislation limits prescription coverage reductions during a policy term, it still allows insurers to add medications (including generics), to lower out-of-pocket costs associated with medications, and to remove any medications that pose safety risks as identified by the Food & Drug Administration throughout the plan year.