How Do Payers, PBMs Stack Up for Coverage of Autoimmune Disease Drugs?

With the expanded use of step therapy on the horizon in 2020, an advocacy initiative of rheumatology, arthritis, and gastroenterology and other associations recently released a report “grading” payers and pharmacy benefit managers (PBMs) for the extent of their prescription coverage of medications for patients with autoimmune disorders.

Perhaps not unsurprisingly, most fail, according to the report, which was created by Kenneth E. Thorpe, PhD, and Manasvini Singh of Emory University and released by the group, called Let My Doctors Decide. The report examines drug coverage by Medicare plans as well as commercial plans, specifically coverage limitations on medications for Crohns disease, multiple sclerosis, psoriasis, psoriatic arthritis, and rheumatoid arthritis. The coverage limitations evaluated include prior authorization (PA), formulary status, tier placement, and step therapy.

The report calls attention to how coverage for those 5 diseases could change as CMS expands the use of step therapy in Medicare, the group said in a statement.

To cut healthcare costs, CMS wants to add PA and step therapy to Medicare Part D drugs for those receiving new prescriptions. Additionally, the rule includes a similar policy for self-administered Part D drugs (including biologics such as pegfilgrastim, etanercept, and adalimumab).

The 5 autoimmune diseases studied do not fall within the rule affecting Medicare Part D’s 6 protected classes—antidepressants, antipsychotics, anticonvulsants, immunosuppressants for treatment of transplant rejection, antiretrovirals, and antineoplastics.

CMS wants to give Part D plans more flexibility for which drugs must be included in the protected drug classes instead of forcing them to cover all of them; that creates an incentive to keep prices high, CMS has said. But the report says the findings show how coverage for drugs within those 5 disease areas may change if the CMS plan is implemented next year.

The report found that most Medicare Part B plans received “A” grades for their coverage of physician-administered drugs; Part B plans currently have no restrictions, but the Trump administration wants to additionally shift some Part B drugs to Part D, where they would have more limits.

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 report said 97% of plans impose “severe to austere restrictions” on access to therapies in all 5 conditions. Multiple sclerosis had the fewest plans that impose the highest level of restrictions (81%); psoriasis and psoriatic arthritis had the most plans with the highest restrictions on access (89%).

Commercial plans fared a little better, with 69% having the most restrictions for Crohn disease, 47% for psoriatic arthritis, 66% for rheumatoid arthritis, 28% for multiple sclerosis and 31% for psoriasis.

Let My Doctors Decide was created by patient advocacy and provider groups, led by the American Autoimmune Related Diseases Association (AARDA), to provide resources and education to patients and physicians about step therapy. The group 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.

“When recommended by doctors for medical reasons, step therapy can be the right choice,” said Randall Rutta, a federal policy consultant working for AARDA. “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.”