What The Hell America!

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 $1000 per month.

“We have like one hundred 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 twelve-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.”

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.