Contributor: Dr. Staci-Marie Norman, PharmD, DCES
What is Non-Medical Switching (NMS)? It's the switching of a patient's medicine, often by a third party, for reasons other than the person's health and safety. Non-medical reasons for switching a medication may include increasing a private insurer's profits or reducing costs for a government agency or employer. As a pharmacist, I see this type of switching occurring on a daily basis.
Two types of Non-Medical Switching:
Brand Name to Generic: Imagine you are switched from a brand-name medication to a less costly generic. This brand to generic switch is common and can save both you and the insurance company money. However, when this occurs, the medication must be generically equivalent. For example, if you were prescribed the ACE-inhibitor Altace®, the pharmacist could automatically change that to its generic ramipril. But the pharmacist can't change to another generic ACE-inhibitor, such as lisinopril, because it is an entirely different medication. Even though lisinopril is in the same drug family, your pharmacist could not change it without contacting your physician and getting a new prescription.
Switching from One Brand Name to Another: Things get more complicated when there are no generic equivalents on the market for newer medications, but there are several brand name medications within a drug family. For example, there are three brand-name SGLT2 inhibitors (Invokana®, Farxiga®, and Jardiance®) but no generic equivalents approved on the market. Many insurance companies have medication formularies, with only one medication covered within a drug family. Often this is based on rebates that the drug manufacture offers, making the medication more affordable for the insurance company.
Imagine you are prescribed Farxiga® by your physician, but Invokana is the medication on your insurance formulary. First, the pharmacist will inform your physician of the issue. Your physician has two options:
- change your prescription from Farxiga® to Invokana® - this is often the easiest course of action if you are being prescribed this medication class for the first time.
- submit a prior authorization to the insurance company - your doctor will state why you need to be on Farxiga® instead of Invokana®. The insurance company takes this information into account and decides to approve or deny the use of Farxiga®.
How do prior authorizations work?
- Prior authorizations are more likely used when you have already tried other medications within a drug class, and they have not worked as well, or you had side effects.
- It typically takes 24-72 hours for the insurance company to respond to the physician's request.
- If the prior authorization is approved, you may have a higher co-pay than that for the preferred medication.
- If the prior authorization is denied but your physician feels you really need to be on that specific medication, an appeal can be filed, which will take more time. Again, the request may be approved or denied by your insurance company.
While this whole process can be confusing or frustrating, remember that your physician, pharmacist, and even your insurance company are working to ensure you receive the most appropriate medication while keeping an eye on costs.
Dr. Staci-Marie Norman, PharmD, DCES received her bachelor's from Purdue University (’94) and her Doctor of Pharmacy from the University of Oklahoma (’96). In 2000 Dr. Norman added to her credentials by becoming a Certified Diabetes Care and Education Specialist. She is currently the Clinical Coordinator and staff pharmacist for Martin’s Pharmacy. Dr. Norman is a national faculty member for the American Pharmacist Association, teaching certificate programs in both diabetes and cardiovascular disease. She serves on the advisory board that oversees development and revision of these programs. Along with teaching and development responsibilities for APhA, Dr. Norman serves as a peer reviewer for research grants and publication submission. Dr. Norman has also spoken for Abbott, Bayer, Lilly, Mannkind, and Lifescan as a diabetes specialist.