Seth Ginsberg: Biosimilars and Non-Medical Switching

Seth Ginsberg, co-founder and president of the Global Healthy Living Foundation, discusses non-medical switching of patients from high-cost reference biologics to biosimilars (or to other therapies). 
February 01, 2018


What is your position on non-medical switching from biologics to biosimilars?

Non-medical switching is when insurance companies reduce formulary coverage, which puts financial pressure on patients to switch their prescription medications to alternative therapies. In many cases, the alternative therapies that the patients are being pressured to switch to are made by manufacturers that have successfully produced lower bids than the existing preferred drug from a different manufacturer on the plan.

Reductions in coverage include increased out-of-pocket costs, eliminating a drug from the formulary entirely, or creating restrictions around access.

The Global Healthy Living Foundation is opposed to non-medical switching, particularly when a payer changes their formulary in the middle of a contract year because they are not honoring the contract their customers signed. Patients are not getting what they paid premiums for, or met deductible requirements to access.

This puts chronic disease patients at risk because it can often take months or years to find an effective treatment. Should access to that treatment be reduced or shifted suddenly, delays in treatment or needing to switch treatments could have very harmful health consequences.

Every year, there is something called the “open enrollment period.” (The 2018 enrollment period was between November 1 and December 15, 2017, for those purchasing health insurance through the federal marketplace.) Most people who purchase commercial health insurance will have at least a few weeks to read through proposed contracts, evaluate the doctors in the health plan network and review the available formulary to select a health insurance plan and provider from the options available to them.
Then, once the health insurance contract is signed, a patient and their covered family members, if applicable, are locked in for at least a year. But what may not be apparent is that in many states (such as Florida, Tennessee, and Massachusetts), in those states, the insurer is allowed to alter the contract by reducing their drug coverage at any time during the plan year. Therefore, not only is the contract unfair to consumers, but it puts patients’ health at risk when access to their medication becomes uncertain.

Health insurance companies claim that adjusting the formulary is a way to keep healthcare costs down. However, reducing drug costs to benefit their own profitability is quite shortsighted. Patients who get sicker (because of falling out of remission) if their treatment is altered are likely to see the doctor more, need more diagnostic tests and, generally, increase their healthcare utilization.


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