What is Non-Medical Switching?

By Tim Boughton, M.Sc.Reviewed by Dr. Liji Thomas, MD

Non-Medical Switching (NMS) is the act of compelling a stable patient to change medications for reasons other than their health and safety. This change usually occurs to a chemically distinct alternative (not a generic alternative), that is expected to have similar effects.

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Why and how does NMS occur?

NMS is often driven by insurance companies who aim to switch stable patients to less expensive medications, in the hope of lowering costs. This is common for specialty medications or treatment plans for conditions such as rheumatoid arthritis, Crohn's disease, asthma, or those treated by biologics. Insurance companies may attempt to compel NMS in several ways during the contract year:

• Insurance companies review and change the coverage of their policy, removing a current medication from the formulary altogether on policy grounds
• The insurance company increases the patient’s out-of-pocket costs by moving the product to a non-preferred tier of the policy, so that the medication becomes unaffordable  
• The insurance company blocks the use of co-pay coupons which provide  discounts on the preferred medication
• There have even been reported incidences of insurance companies offering financial incentives for pharmacists or health care providers to switch a patient’s medication to a different drug preferred by the pharmacy or insurance company.

What are the potential consequences of NMS?

Stable patients may have to endure several short and long term negative consequences as a result of NMS. This is because:

• The replacement chosen for a specific medication by the insurance companies is often a chemically distinct alternative, instead of a generic version of the same medication. This means that the patient’s body may react differently to the new medication, causing new side effects.
• The new medication may also not be as effective at treating your underlying condition, causing a reemergence of your previous symptoms.
• One biologic may more immunogenic than another, which can result in a severe allergic reaction.
• NMS has also been shown to increase the chance of a second medically-motivated switch in medication in the two years following the switch.

This may have significant consequences on the course of your treatment and recovery, and can significantly slow treatment response times while pushing up the overall costs.  

Does NMS reduce costs?

While NMS is undoubtedly a cost-motivated move from the insurance company, research suggests that it is not an effective strategy for reducing costs. Due to the reduced overall health experienced by many patients convinced into NMS, they often:

• Visit the doctors more often in the same year
• Undergo more scans and tests to evaluate their health
• Have an increased chance of hospitalization
• Visit the emergency room more frequently

Therefore, cost-motivated NMS often results in an increase in overall medical costs per patient to be met by the insurer. For example, research has found that patients with rheumatoid arthritis who were switched to a less expensive medication had Medicare payments that increased by over $8,000 from the previous year. This was found in contrast to the $201.24 yearly increase seen in rheumatoid arthritis patients that stayed on the same medication.

Further Reading

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