People with severe asthma insured by BlueCross BlueShield of Illinois may soon face a new hurdle in accessing a treatment that providers say is critically important to keeping certain patients alive and well. Starting in April, BCBSIL plans to change its coverage to require pre-approval for in-person administration of four biologic medications for asthma, used to aid patients who don’t respond to the more common treatment via inhalers. Those biologics — sold under the brand names Fasenra, Nucala, Tezspire and Xolair — are delivered either intravenously or injected into the skin, similar to an insulin jab. Many patients are treated with those medications in a health care setting, with providers saying there are several crucial reasons an in-person treatment can be necessary to keep patients safe and healthy. Now, BCBSIL plans to mandate all patients taking those drugs self-administer at home — unless they get prior approval from the insurance giant.
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“Physicians, nurse practitioners, physician assistants and all of our nurses and clinical staff are already overburdened with mountains of insurance paperwork just to get our patients access to the care they need,” said Dr. Sakina Bajowala, a west suburban allergist and immunologist currently serving as president of the Illinois Society of Allergy, Asthma, and Immunology. “What we need is more respect for patient autonomy and patient choice.” According to the most recent data available from the Centers for Disease Control and Prevention, those patients number more than 860,000 in Illinois — with an estimated 5-10% of them suffering from severe asthma. Those patients may have more persistent symptoms like coughing, wheezing and shortness of breath, suffer from diminished lung function, and require more frequent use of rescue medication or even hospitalization. Severe asthma can be targeted by the medications BCBSIL patients will now need pre-approval to be treated with in person. For its part, the insurer says the policy doesn’t apply to Medicare, Medicaid or HMO coverage, and noted that these drugs are approved for self-administration by the FDA. “Blue Cross and Blue Shield of Illinois is committed to expanding access to quality health care,” the company said in a statement to WTTW News. “Our policy revision is being made with the interests of our members in mind—promoting access to treatment that is convenient and effective.” For some patients, at-home treatment is safe and convenient. But critics say the new policy overlooks genuine safety concerns. All four drugs carry a risk of adverse effects, including the potentially deadly allergic reaction anaphylaxis — in particular Xolair, not only upon first administration but further into the course of treatment. That’s why providers commonly have patients begin taking the medication in person. “In the respiratory biologic space, many of our patients have already experienced severe allergic reactions,” Bajowala said. “For these patients in particular, we want to be very careful when we’re thinking about administering these medications that may cause allergic reactions, because we don’t want them to be alone at home when they have an allergic reaction. We want them to be in a medical setting.” Other patients may simply lack the capacity to administer at home due to factors like age, disability or fear of needles. “I primarily have worked in safety net hospitals where some of our patients don’t have a large support system that would be able to assist them,” said Dr. Sharmilee Nyenhuis, an allergist and immunologist who is an associate professor of pediatrics and medicine at UChicago. “I’m always concerned about access to quality care, and to what I would say is guideline-based care.” Another concern critics raise is that patients might not stick with their treatment plans if they have to administer the medication at home — something Nyenhuis said she witnessed during the COVID-19 pandemic when providers were trying to reduce in-person visits as much as possible. She added that having patients come into the office also creates a rapport that can offer providers important information. “They’ll be talking to the nurses and we’ll find out, oh, they’re on this medication which may contribute to or increase asthma symptoms, or we find out that they were recently hospitalized,” Nyenhuis said. “We are able to get that added touchpoint with the health care system.” “Health plans are always looking for a way to reduce costs, particularly in the area of prescription drugs, (which) are increasingly more expensive — not because of the cost of the basic stuff that’s been around forever necessarily, but because of the biologics,” said Nadereh Pourat, associate director at UCLA Center for Health Policy Research. “(They) are more likely to be infusions … they’re expensive, they could have side effects.” And, Pourat said, the costs of self-administration will be far less for an insurer than the costs associated with office visits. Other more specialized providers are also upset about the move, which affects BCBS patients not just in Illinois but in Montana, New Mexico, Oklahoma and Texas. Because the drugs can be administered at infusion centers, one of their trade associations has been pushing back against the move. “It’s once again an example of insurance companies driving that wedge between the patient and the physician, and second-guessing the clinical decisions made by the doctor,” said Brad Traverse, executive director of the Infusion Providers Alliance. While the BCBS policy says patients can still get in-person treatment if it’s medically necessary, Traverse says getting approval will create a barrier to treatment some patients may not clear. “If you’ve ever been on the business end of an appeal with a health insurance company, it’s a nightmare for physicians, let alone these patients who really don’t understand the process,” he said. “You’ve got to provide records, you’ve got to provide proof that you’re incapable of doing the injection, it’s time-consuming, and it’s often delayed and can take weeks and weeks … if the patient just doesn’t give up and decide it’s not worth it.” “These medications have already been covered under the standard pharmacy benefit for members with pharmacy coverage,” BCBS said in its statement to WTTW News. “This medical policy update promotes access to the treatment via the most convenient and effective benefit for the member.” The policy is scheduled to take effect April 15.
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