American Autoimmune Related Diseases Association

Jan 26, 2023

Three out of four plans scored a “C” or an “F” due to the access restrictions they placed on patients January 26, 2023 09:24 AM Eastern Standard Time DETROIT--( BUSINESS WIRE )--As the U.S. experiences a winter of significant health challenges that stand to impact millions of patients, a new national scorecard from Let My Doctors Decide (LMDD) found that health insurance plans and pharmacy benefit managers (PBMs) receive poor grades across the board when it comes to ensuring patients living with autoimmune diseases are able to access the medications prescribed to manage their conditions. The scorecard examines three common types of medication access barriers that patients often encounter with their insurer: restrictive formulary placement, step therapy, and prior authorization. Data analytics firm MMIT performed the analysis using health plan formulary information from the fourth quarter of 2022 and evaluated both the medical benefit and pharmacy benefit for each plan and for each condition (Crohn’s disease, lupus nephritis, multiple sclerosis, psoriasis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis). “Autoimmune conditions can cause permanent, disabling damage to joints and major organ systems when not properly treated,” said Quardricos Driskell, Executive Director of LMDD and Vice President of Public Policy & Government Affairs at the Autoimmune Association. “Unfortunately, many patients – regardless of insurance type – face significant barriers to accessing the medicines they need to keep their conditions under control. Our scorecard shows that many well-known insurers like Humana, Aetna, Anthem, Cigna, and AARP – and their PBMs – are among those plans whose formularies put up significant access barriers.” Key findings include: Three out of four plans scored a “C” or an “F” for treatment accessibility under their medical benefit for all conditions studied, whether covered by Medicare Advantage, commercial insurance, or a health exchange plan. This reinforces how health plans give little deference to patient-physician decision-making in selecting medicines for autoimmune diseases, even for those administered in a doctor’s office. Traditional Medicare (also known as Medicare fee-for-service) which covers physician-administered drugs under the medical benefit, placed fewer access restrictions on treatments than Medicare Advantage plans across all conditions. The overwhelming majority of commercial and health exchange plans received a “C” or an “F” for all conditions. The only exception was commercial pharmacy benefit coverage of medications to treat lupus nephritis where 67% of plans received a “B” and 4% received an “A.” Health exchange plans fared far worse than commercial employer-sponsored insurance. Across all conditions, about 25% of commercial plans scored an “A” or “B” under the pharmacy benefit, while only 17% of health exchange plans did so. Yet under the medical benefit, only 3% of both commercial and exchange plans scored an “A” or a “B” across all conditions. The autoimmune diseases covered by this scorecard collectively affect an estimated 15.9 million Americans. Even with health insurance coverage, many patients struggle to access medications they need due to their insurers using “utilization management” techniques such as step therapy or prior authorization, or by having these medications placed on restrictive tiers with high cost-sharing. “We convened Let My Doctors Decide to give a voice to patients struggling to access needed treatment and empower them to advocate for a healthcare system where patients and their doctors – rather than insurers or PBMs – are in control of their treatment plan,” said Molly Murray, President and CEO of the Autoimmune Association. Health insurers and PBMs are facing increased scrutiny by federal and state policymakers, with Members of Congress and a number of state legislative leaders working to advance reform proposals. Last June, the Federal Trade Commission announced a formal investigation into whether the PBMs who manage prescriptions on behalf of health insurance plans are using their market power to restrict access for patients. “Given the access challenges that permeate our health care system, it is critical that stakeholders and policymakers work together to ensure that patients are able to get the treatment they need and deserve,” Driskell added. The full scorecard can be reviewed here . About Let My Doctors Decide Let My Doctors Decide is a national partnership – convened by the Autoimmune Association – 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. Founded in 2017, Let My Doctors Decide (LMDD) brings together patients, providers, and advocates – especially those from the autoimmune disease community – to raise awareness about affordability and access issues. Learn more at letmydoctorsdecide.org About the Autoimmune Association For over 30 years, the Autoimmune Association has been a pioneer in serving autoimmune patients, sponsoring research, advocating for access to healthcare, and fostering collaboration to identify and explore the common threads that link autoimmune diseases. Established through the remarkable determination of Founder Virginia T. Ladd, the Autoimmune Association has transformed into an internationally recognized leader, reaching over 60 countries worldwide. To mark its 30-year legacy and global impact on the autoimmune community, the name of the organization was changed from its original name, the American Autoimmune Related Diseases Association (AARDA). Learn more at: autoimmune.org Contacts