One of the Largest Health Insurers Is Making It Harder to Get Asthma Medicine

Madison, a 12-year-old from Illinois, visits a medical clinic every other week to get injections of Xolair, a powerful asthma and allergy medication. The drug helps protect her from severe asthma attacks as well as serious allergic reactions to peanuts, tree nuts, and sesame seeds. Medical professionals at the clinic monitor her response to the injections, since the drug can trigger life-threatening anaphylactic shock.

But now, thanks to a policy change by her insurer, Blue Cross Blue Shield, Madison may have to self-administer the expensive injections at home.

Without access to in-clinic injections, “I don’t think I would want to do the shot at all,” Madison said. “I don’t know if I would be comfortable even doing it.”

Blue Cross Blue Shield, one of the country’s largest health insurers, just made it much more difficult for patients like Madison to get potentially lifesaving medications. The move will force many patients to self-inject at home, cutting costs for the insurance giant and, experts say, channeling more profits toward a single specialty pharmacy contracted with the insurer.

Patient advocates worry this policy change may inspire other insurers to restrict access to other vital drugs to boost revenues.

“This is a significant concern for our members.… These decisions could also eventually expand beyond just these asthma injections,” said Lawren Geer, interim executive director of the Infusion Providers Alliance, a leading voice for drug infusion providers. “Ultimately, patients and their doctors should determine the most appropriate setting for administering medication rather than the insurers.”

Typically, patients with moderate to severe asthma and allergies receive injections of specialty medications at a clinic by a medical provider, who then monitors the patient for signs of anaphylaxis, a fast-acting, potentially life-threatening reaction that can involve swelling, vomiting, breathing difficulties, and shock. For patients who need this type of treatment, going without the drugs can lead to severe allergic reactions, debilitating asthma attacks, and even death.

However, Blue Cross Blue Shield implemented a new policy on April 15 across five states requiring patients and providers to go through a burdensome prior authorization process to receive these in-clinic injections — or else self-administer the injections at home. The new rule covers the insurers’ 29 million members in Texas, Oklahoma, Illinois, New Mexico, and Montana.

In a statement emailed to The Lever, a spokesperson for Blue Cross Blue Shield’s parent company, Health Care Service Corporation, said they are “committed to expanding access to quality, cost-effective physical and behavioral health care” and are “updating medical policies for some medications that are FDA-approved for self-administration.”

Increasing Barriers to Care

Many health insurers have long required prior authorizations, in which providers must obtain insurance approval for services or medications, to ostensibly guard against unnecessary procedures. However, many experts say the real reason for such requirements is to create barriers to care and reduce coverage costs.

According to the American Medical Association, which represents physicians and medical students, prior authorizations have been around for decades, but have expanded massively over the past several years and cause “unnecessary waste and avoidable patient harm.” Last January, former President Joe Biden’s administration passed a rule to better regulate the practice, though doctors argue more reforms are needed.

Thanks to Blue Cross Blue Shield’s new policy, millions of its members with moderate to severe asthma and allergies must now obtain prior approval for specialty injections, which are complex medicines that can cost more than a thousand dollars per month.

“We have like 100 prior authorizations … at any time, and that’s just with allergy drugs,” said Priya Bansal, an allergist and immunologist in St. Charles, Illinois, one of the states impacted by the policy change. “This is going to be an extra burden to our office staff, who are already burdened.”

Asthma and allergy patients whose prior authorizations are not approved by Blue Cross Blue Shield will now have to administer the injections at home. John Simley, director of communications for Blue Cross Blue Shield Illinois, said this change does not reflect a desire to cut costs and pointed to the fact that the FDA has approved these drugs for self-administration.

Simely also noted that, “If you have a medication administered by a doctor in an office, they bill for a facility fee.”

Research shows that medication adherence drops when a patient administers the drug at home versus in a clinic, thanks to a variety of factors, including anxiety and limited hand movement.

One study of more than 57,000 patients who gave themselves injections at home found that they were 25 percent more likely to end up in an emergency department or hospital than patients who received injections in a clinic. Those who self-administered were also 28 percent more likely to discontinue the drug after the hospital visit.

To make matters more difficult, many specialty asthma drugs like Xolair must be stored at specific temperatures.

“I would be scared because you wouldn’t be qualified to give an injection,” said Madison, the 12-year-old prescribed Xolair. “[Doctors] can’t track if you had a reaction or not … if I did get a reaction from the shot, no one would be there to help.”

Steering Profits

Blue Cross Blue Shield’s new prior authorization policy may also funnel more profits toward the specialty pharmacy Accredo — a subsidiary pharmacy of the powerful pharmacy benefit manager Express Scripts that acts as a middleman between drug manufacturers, insurers, and pharmacies to determine which medications health insurers will cover and their cost. Express Scripts is owned by Cigna, one of the largest health insurers in the nation.

Accredo specializes in dispensing specialty drugs that are self-administered at home, offering a team of pharmacists and nurses that “help patients manage their health condition and therapies independently and confidently,” according to its website.

Prior to the policy change, many patients across the five impacted states were already required to order their asthma and allergy drugs through Accredo or else risk higher out-of-pocket costs, according to insurance documents.

“Blue Cross and Blue Shield of Montana supports members who need self-administered specialty medication and helps them manage their therapy. Accredo is the specialty pharmacy chosen to do just that,” the Montana insurance plan reads. “Your plan may require you to get your self-administered specialty drugs through Accredo or another in-network pharmacy. If you do not use these pharmacies, you may pay higher out-of-pocket costs.”

Blue Cross Blue Shield’s parent company, Health Care Service Corporation, also contracts with other select specialty pharmacies, but in the experience of Bansal, the Illinois-based allergist, they “will only allow you to send [these prescriptions] to Accredo,” she said. “If you try to send it to a different pharmacy, they won’t allow it to go through. They’ll deny it.”

Cristina Vlad, a nurse practitioner from an Oklahoma-based asthma and allergy clinic, noted the same thing, stating in an email to The Lever that the insurer “is having us send the [medications] through Accredo.”

Now, as prior authorizations potentially bar many patients from receiving in-clinic injections, the volume of prescriptions filled through Accredo may rise, according to Geer from the Infusion Providers Alliance.

The Infusion Providers Alliance “is concerned that this will set a precedent and allow [pharmacy benefit managers] to control drug channels and patient access more and more,” said Geer.

Cigna and Evernorth Health Services, the insurer’s subsidiary division that operates Express Scripts and Accredo, did not respond to multiple requests for comment.

In exchange for steering patient prescriptions to Accredo, Blue Cross Blue Shield may receive discounted drug prices or other fee reductions, said Benjamin Jolley, a pharmacist and senior health care fellow at the American Economic Liberties Project, a nonprofit that advocates for corporate accountability and antitrust regulations.

“That’s a pretty obvious benefit to Blue Cross,” said Jolley.

Health Care Service Corporation did not respond to questions about whether it receives financial benefits from its relationship with Accredo.

According to numerous Reddit posts, patients have suffered from a plethora of issues when ordering specialty medications through Accredo, including canceled refill requests, long phone wait times, and billing disputes. There is even a Facebook group, “DOWN WITH Express Scripts and Accredo!,” with nearly 3,000 members dedicated to “anyone who has fallen victim to the horrible business practices” of the pharmacy benefit manager and specialty pharmacy.

“Due to large insurance companies … contracting with Express Scripts and Accredo, thousands of consumers are being forced to receive terrible customer service at the hands of Accredo/Express Scripts,” the group description reads. “Let’s stop this terrible company from disrupting our treatments and affecting our health. Let’s be heard by our insurance companies: Stop contracting with Express Scripts/Accredo!”

In response to a request for comment, a Health Care Service Corporation spokesperson noted in an email, “There is not one singular pharmacy benefit manager or specialty pharmacy that would be used by all our members eligible for self-administration of these asthma medications.… Our policy revision is being made with the interests of our members in mind — promoting access to treatment that is convenient and effective.”

This is not the first time that Blue Cross Blue Shield has tried to limit patients’ coverage. Last December, the insurer said it would no longer automatically pay for patients’ anesthesia in some states if a medical procedure exceeded a predetermined time limit. That policy was reversed following The Lever’s reporting on the issue.

Doctors and patient advocates worry the insurers’ efforts to limit coverage may inspire others to follow suit.

“The main factors influencing policy decisions made by insurers should include patient choice, access to treatments, patient safety, and improved health outcomes,” said Geer. “However, this policy change does not seem to be guided by any of these considerations, and we are concerned it could lead to similar decisions by other insurers.”