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More Data, More Non-Medical Switching for Patients in Maine

Insurers continue to manipulate their formularies to boost profits, new data from Maine suggest.

In its second report on formulary changes in the state, Maine’s Bureau of Insurance notes that more than 300 changes occurred between April and June 2019.  Not all changes were restrictive. More than 170 new drugs were added to insurers’ formularies, expanding patients’ options. But more than half of patients affected by formulary changes faced a choice between paying more or switching their current medicine for one preferred by the insurer.

Specifically, the report found that:

  • 48 prescription drugs were removed from formularies
  • 58 drugs became subject to barriers such as prior authorization, step therapy or higher co-pays
  • Changes impacted 2,886 patients
  • More than 1,300 patients will now pay more out of pocket for their medicine, with 242 responsible for the full cost of their medication.   

The three drugs targeted with the most changes were for chronic conditions such as asthma, diabetes and high blood pressure.  

Data were reported to Maine’s Bureau of Insurance by the state’s insurance carriers, including well known plans such as Anthem, Aetna, Cigna, Harvard Pilgrim and United Healthcare, as well as the pharmacy benefit manager Express Scripts.  The data are available because of a 2018 state law that requires insurers to report changes in prescription drug coverage.  

Maine was one of the first states to acknowledge the problem of non-medical switching.  The tactic plays out when insurers push stable patients to a different medicine in hopes of protecting their profits.  They may compel the switch by eliminating coverage for the patient’s medication or by shifting it to a higher tier, where cost-sharing is prohibitive for patients.

Research suggests that, when patients’ course of treatment is interrupted, they risk re-emerging symptoms and new side effects. Non-medical switching can also disrupt patients’ lives.  On the other hand, those who remain stable on their medicine have the lowest per-member, per-month cost to their insurers.

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