With non-medical switching, insurance providers direct pharmacists to dispense a cheaper drug in the same therapeutic class, but which may have an entirely different chemical structure, as the medication the doctor prescribed. In many cases, pharmacists are not even required to notify the patient or the prescribing doctor before making the switch.
Doctors are frequently being required to obtain prior authorization from insurance companies before they will cover certain treatments or medications. Despite their medical expertise and personal experience with their patients, prior authorization cedes much of the treatment decision to insurers.
Also known as “Fail First” policies, step therapy requires patients, to try cheaper alternative to the treatment or medication prescribed by their doctors, before moving on to more complex and costlier options. This practice robs doctors of their autonomy in treatment decisions and forces patients into playing trial-and-error with therapeutic outcomes before they can receive the doctor’s preferred treatment or medication.
Adverse tiering involves insurers placing all the treatments for a particular medical condition (i.e. HIV/AIDS or hepatitis C) on their most expensive formulary tiers, requiring higher co-payments or patient cost-sharing. The use of adverse tiering can place heavy financial burdens on patients with chronic conditions, and can deter doctors from prescribing the most effective treatment options for their patients out of fear they will not be able to afford them.
Within the past decade, insurers have added hundreds of medications to formulary exclusion lists, indexes of all the treatments they will not be covering. Many of the excluded medications are for severe, chronic conditions—including most recently, prostate cancer. By withholding coverage, formulary exclusions prevent many patients with these chronic conditions from obtaining the medications they need.