Non-Medication Switching is a Patient Safety Issue

Update May 16: PPAHS understands that as of July 1, 2022, CVS Caremark will add apixaban (Eliquis®) back to its formulary, reversing its decision to non-medically switch thousands of patients using direct oral anticoagulants. Please follow our blog for updates on this issue.

By Michael Wong, JD (Founder/Executive Director, Physician-Patient Alliance for Health & Safety)

Has Non-Medication Switching Impacted You?

In a recent post on non-medication switching, I posed this question – “Is CVS Caremark Illegally Practicing Medicine?”

I asked this question because CVS Caremark recently decided to exclude Eliquis® (apixaban) from its Preferred Drug List. CVS Caremark’s decision to exclude Eliquis means that patients who are filling their prescriptions through CVS Caremark will need to transition to Xarelto® or be willing to pay 100% of the cost of Eliquis. This means that CVS Caremark has decided that Xarelto must be used by all such patients requiring a DOAC, even though none of these patients has a physician-patient relationship with CVS Caremark.

PPAHS does not endorse any specific medication, pharmacy, or pharmacologic product. The choice of which medication to prescribe must be with the physician in consultation with each patient, and not be dictated by a person or company that has no physician-patient relationship. 

By not allowing patients to be prescribed Xarelto, is CVS making medication decisions for patients or should that decision be left to each patients’ physician? How do you feel about non-medication switching?

Non-Medication Switching Hurts Patients
Sanctity of the Physician-Patient Relationship & Non-Medication Switching

I believe that there should not be any impediments to the physician-patient relationship and the ability of physicians to prescribe medications that they believe are in the best interests of their patient’s health and care. In discussing the sanctity of the physician-patient relationship, Dr. Christopher Ryan Caruso (an internal medicine provider in Aurora, Colorado) writes:

No other institution in our country demands as much scrutiny as healthcare. No other profession has so much expected of one individual as medicine. We, as a community, require that our physicians and our health institutions meet standards. Rightfully so, these bastions of education and expertise make decisions that are, for lack of a better phrase—life and death. We, as patients, trust that the highest quality care possible is being given because of the systems in place, the rigorous checks and balances, require our medical care meet the highest standards in the world.

Non-Medication Switching Violates Sanctity of Physician-Patient Relationship
For more on the physician-patient relationship, please visit

Although there are many ways that the sanctity of the physician-patient relationship may be restricted, such as Step Therapies and Prior Authorizations, the CVS exclusion is an example of Non-Medication Switching:

Non-Medication Switching occurs when, without the consent of the patient and the prescribing physician, the prescription is filled by a drug other than the one prescribed. In such cases, the health insurer requires a stable patient to switch from his or her current, effective medication to a less costly, alternative (but not generic) drug by removing the medication from the formulary list, moving a drug to a higher cost tier, or increasing the out-of-pocket costs owed. 

The Alliance for Patient Access has found that medication switching has resulted in higher patient costs. The American Heart Association and the American College of Cardiology oppose therapeutic substitution, believing that “only the prescribing doctor is equipped to determine the best drug or combination of drugs” and that therapeutic substitution “may result in the patient receiving a drug that doesn’t work well enough, produces life-threatening toxicity, or interacts dangerously with other drugs the patient is taking.”

Has Non-Medication Switching Happened to You or a Loved One?

The FTC (Federal Trade Commission) invites you to submit your comments on whether the practices of pharmacy benefit managers (PBMs) have impacted your life or business. More particularly, the FTC would like public feedback on these eight issues:

    1. “The impact of PBM rebates and fees on net drug prices to patients, employers, and other payers. 
    2. “The impact of PBM rebates and fees on formulary design and patients’ ability to access prescribed medications without endangering their health, creating unnecessary delay, or imposing administrative burdens for patients or prescribers. 
    3. “Whether patients are being forced to substitute different prescription drugs to maximize PBM rebates and fees. [emphasis added]
    4. “PBMs’ use of potentially unfair, deceptive, or anticompetitive contract terms and all related practices when calculating pharmacy reimbursements and disbursements, including the use of Average Wholesale Price, Wholesale Acquisition Cost, Maximum  Allowable Cost, and Usual and Customary Pricing as well all types of claw backs, fees, discounts, and performance metrics, such as Direct and Indirect Renumeration, Generic  Effective Rate, Brand Effective Rate, Dispense Fee Effective Rate and all other similar provisions. 
    5. “PBMs’ use of other potentially unfair, deceptive, or anticompetitive practices, including audit provisions; pharmacy network design and exclusions; use of gag clauses,  confidentiality clauses, and non-disparagement clauses; and other potentially unfair  provisions. 
    6. “PBMs’ use of methods to steer patients away from unaffiliated pharmacies and methods of distribution and toward PBM-affiliated specialty, mail-order, and retail pharmacies. 
    7. “PBMs’ policies and practices related to specialty drugs and pharmacies, including criteria for designating specialty drugs, reimbursements to specialty pharmacies, practices for encouraging the use of PBM-affiliated specialty pharmacies, and practices relating to dispensing high-cost specialty drugs over alternatives. 
    8. “Potential conflicts of interest and anticompetitive effects arising from horizontal and vertical consolidation of PBMs with insurance companies, specialty pharmacies, and  providers.” 
Comments about CVS Exclusion of Eliquis

As of the time of writing this blog post, there have been 129 comments submitted to the FTC in answer to their request for comment on the practices of PBMs. I read two comments on CVS actions impacting a medication decision: 

  • From Melissa Panko – “I have Aetna insurance. They require I go to CVS to get my daily meds rather than the pharmacy I have used for years (and who knows me and my family by name). If I don’t go to CVS, I cannot use insurance. I have found that with my daughter’s prescription, it was less expensive to go to my home pharmacy and pay the cash price versus CVS and use the insurance price. I figured out they are overcharging on that, but I’m sure tons of people don’t pay attention. That is bad practice.” – 
  • From Rush Roberts – “I am a heart patient with a history of arrhythmia. I have been on Eliquis a number of times over the years as part of treatment before and after receiving catheter ablations to address the arrhythmia. I have tolerated Eliquis better than other anticoagulants I have been on, and it is the preferred drug of my electrophysiologist who performs these procedures. Thus, I was outright shocked when I received a letter in January of 2022 from CVS Caremark stating that they would not fill this prescription unless the prescribing doctor provided written proof that I could not tolerate Xeralto, the brand they are pushing because they get kickbacks from that company. This is ludicrous to anyone who has ever been a patient at any point in time. As if doctors and nurses don’t have anything better to do in the middle of a pandemic besides write up documentation to satisfy the greed of a PBM. It’s simply not feasible, it would take hours of their time every week just to ensure their patients received the drug they were supposed to receive. I was lucky in this instance because a nurse was able to supply me with enough free samples to last the 3-4 months I would need to be on the drug. Others who take the drug long-term are not so lucky, and I may not be the next time I need to go on Eliquis. The fact that this is even legal is a travesty. Being a patient with a chronic condition is stressful enough these days. Having a PBM override the directive of a medical doctor is the exact opposite of acting in a patient’s health. It must be stopped now, before they start this practice for even more commonly-used prescription drugs.” – 
Have PBM’s Practices Impacted Your Life or the Lives of Your Patients?

If the CVS Caremark exclusion of Eliquis has impacted you or PBM’s practices have impacted your life or the lives of your patients, please let the FTC know. Although PPAHS has expressed concerns the non-medication switching, the FTC wants to hear how the practices of PBM’s have impacted your life or the lives of your patients.

Please submit your comments to the FTC by April 25, 2022, by clicking here


Leave a Comment, if You Care About Patient Safety