Most of the nation’s top health insurers and PBMs receive a failing grade in providing access to medicines at the pharmacy counter for patients with autoimmune disease, according to a new report card from Let My Doctors Decide. The analysis, based on research from Dr. Kenneth E. Thorpe and Manasvini Singh of Emory University, highlights the extent to which private and Medicare health plans utilize coverage limitations on medications for five of the most serious autoimmune diseases: Crohn’s disease, multiple sclerosis, psoriasis, psoriatic arthritis and rheumatoid arthritis. The coverage limitations evaluated include prior authorization, formulary status, tier placement and step therapy – a practice whereby insurance companies mandate that patients, many of whom are seriously ill, try a series of drugs before covering the cost of doctor-recommended medicines.
The report card was released in conjunction with a new initiative, Let My Doctors Decide, which will focus on three core areas: 1) educating patients and doctors about step therapy 2) proposing solutions to prevent step therapy and other harmful practices from being used by health insurers and PBMs and 3) providing tools and resources to help patients overcome these access challenges.
As policymakers in Washington consider proposals that would expand the use of step therapy within Medicare Part D’s “six protected classes” and Medicare Part B, the report card released today demonstrates how the vast majority of private and Medicare health plans, including AARP Medicare Rx Preferred, Humana Walmart Rx Plan, Blue Cross Blue Shield Federal Employee Plan Standard and others, impose significant to severe restrictions on access to the most appropriate medicines for the diseases evaluated in the study. According to the findings, 86% of Medicare Advantage and Part D plans received an “F” for access to medicines at the pharmacy. All plans within Medicare Advantage and Part B received an “A” for access to medicines that are administered in a doctor’s office.
The five autoimmune diseases studied do not fall within Medicare Part D’s “six protected classes,” however, the findings show how coverage for drugs within these therapeutic classes may changes if reforms are enacted. Patients who need medicines that fall within the “six protected classes” may see higher access restriction (similar to Part D). Furthermore, the “A” grade that Part B plans received would be jeopardized if step therapy were expanded and physician-administered drugs were treated more like Part D – as outlined in one of the Administration’s proposals.
“We are bringing critical attention to step therapy and other restrictive practices that undermine the doctor-patient relationship and give insurance companies the ability to make treatment decisions,” said Randall Rutta, Chair of the Advisory Task Force, Let My Doctors Decide. “When recommended by doctors for medical reasons, step therapy can be the right choice. However, there is an important
distinction between sound medical protocol versus economically-driven decisions that do not take into consideration what is medically best for the patient.”
Let My Doctors Decide is driven by an advisory task force of patient advocacy and provider groups led by the American Autoimmune Related Diseases Association. The expanded task force includes the American Behcet’s Disease Association, American Gastroenterological Association, Coalition of State Rheumatology Organizations, Dermatology Nurses Association, International Foundation for Autoimmune and Autoinflammatory Arthritis, Lupus Foundation of America, National Organization of Rheumatology Managers and Sjögren’s Syndrome Foundation.
To read the full results of the report card and learn more about this new initiative, visit letmydoctorsdecide.org.
About Let My Doctors Decide
Let My Doctors Decide is a national partnership of leaders across health care working in support of a simple goal: treatment decisions should always be made by patients and trusted health care professionals, not insurance companies or pharmacy benefit managers.