Prior Authorization

Medical forms and prescription medication Patients often choose their health plan based upon a plan’s coverage of the medications that work for them. That’s even more likely for patients with chronic conditions such as MS, arthritis, epilepsy or mental illness.

For many of these conditions, forcing a patient to change a drug therapy because an insurer or pharmacy benefit manager (PBM) has a better financial deal can cause direct harm to the patient and add to the overall cost of treatment. Patients are bound by the terms of the health plan they’ve selected and cannot change coverage until the next open enrollment period. Yet, nothing currently stops PBMs or health plans from changing their drug formularies mid-year and requiring patients to switch drugs.

Sometimes called “non-medical switching,” changes to a drug’s coverage or benefit class can lead to compromised care by requiring patients to switch from medications with demonstrated effectiveness to ones that may not provide the same therapeutic benefit.

The MMA is advocating for legislation to prohibit health plans and PBMs from forcing a patient who is currently receiving a drug therapy from changing drugs until the end of the patient’s contract year.