What consumers need to know about Rx drug substitution – National Consumers League

If you take prescription medication, there’s a good chance that someday you’ll be asked to switch from your current drug to a new one. There are many reasons, including costs to you or your insurer, changes in your insurance coverage, or new drugs coming on the market. Therapeutic substitution can offer benefits, but it can also pose risks. The key to ensuring your safety when making a switch is full transparency.

What do we mean by therapeutic substitution?

Here’s an example. Say you have acid reflux and have been taking omeprazole, a proton pump inhibitor to treat it, for several years. Because the cost of another proton pump inhibitor, lansoprazole, is less for your health insurer, your doctor is contacted by your health insurer and asked to switch you to another proton pump inhibitor, lansoprazole, in an effort to save costs.

The availabilty of another drug at a lower cost to your insurance program is one of the top reasons for therapeutic substitution. Among others:

  • Another drug is available to your insurance program at a lower cost.
  • A medication is no longer covered by your insurance program.
  • A cheaper medication is available.
  • You may be offered discount coupons on a different drug, or your doctor may be offered financial incentives for prescribing a particular drug instead of others. This is a practice that concerns some advocates, because it is important that when a switch is considered, your health is always the top priority.
  • Your doctor wants to switch you to a drug that may be more effective or a better fit for your needs.

How does therapeutic substitution happen? There are several ways:

  • Your health insurance company may contact your doctor and urge her to switch from the prescribed drug to another drug in the same therapeutic class.
  • Your health insurance company may contact you, the patient, directly to say you can save money by switching your current prescription drug (a brand name) to a generic version of a different brand name drug. The new recommended drug is in the same class as the one you’re taking, but it’s chemically different. Learn more about drug classes here.
  • Your health insurance company may call or write you to say that your current drug is no longer covered, and you should talk to your doctor about switching you to another drug in the same class that is covered. Otherwise, you’d have to pay out-of-pocket to stick with your current medicine.
  • In some health insurance plans, your doctor and pharmacist all follow the same coverage rules, which include a pre-approved list of drugs. If your doctor prescribes a certain drug that isn’t covered, your pharmacist could substitute it with one that’s on the pre-approved list. In this case, you might not find out that you’ve been switched until you go to the pharmacy.