The ACR Insurance Subcommittee (ISC) of the Committee on Rheumatologic Care advocates to payers on behalf of the ACR and its members, addressing the most pressing coverage and reimbursement challenges facing rheumatology practices. Following is an update on the ISC’s recent advocacy work to help address concerns about reimbursement and administrative burden while ensuring continued access to critical therapies for rheumatic disease patients.
Aetna Whitebagging Requirements for Evenity & Remicade
On July 1, Aetna implemented a new Combined Benefit Management Drug List, which resulted in several clinic-administered drugs being moved from the medical benefit to the pharmacy benefit. Rheumatology practices are now required to obtain romosozumab (Evenity) and infliximab (Remicade) through an approved specialty pharmacy; buy-and-bill is not permitted for these drugs.
The ISC sent a letter to Aetna and met with the payer’s leadership to express opposition to these changes. While Aetna has not conceded to any policy modification, the payer did note that certain biosimilar versions of these drugs, including infliximab-dyyb (Inflectra), infliximab-axxq (Avsola) and infliximab-abda (Renflexis), remain available under patients’ medical benefit. However, reimbursement for these specific drugs has fallen below acquisition cost for many rheumatology practices, meaning that administering them would leave practices underwater.
Cigna Evaluation & Management Downcoding
Cigna announced a new reimbursement policy, Evaluation and Management Coding and Accuracy (R49), which will go into effect on Oct. 1. The policy will subject claims billed with Current Procedural Terminology (CPT) evaluation and management (E/M) codes 99204–99205, 99214–99215 and 99244–99245 to additional scrutiny and may result in some claims being adjusted to a single level lower.
The ACR opposes the inappropriate reduction of payment for rheumatology services and increased administrative burden for practices to appeal these downcoded claims. The ISC sent a letter to Cigna advocating for rescission of the policy in favor of more measured and appropriate strategies for ensuring claims accuracy.
Systemic Lupus Erythematosus Treatment Access
Blue Cross Blue Shield (BCBS) plans in numerous states have implemented policy changes requiring patients to step through a six-month trial of belimumab (Benlysta) before approving anifrolumab (Saphnelo).
The ISC has reached out to BCBS plans in five states to express concerns that these excessive step therapy requirements may create inappropriate and unnecessary treatment delays. Follow-up discussions with plan leaders are ongoing to seek modifications to the policy requirements to ensure appropriate and timely access for patients with systemic lupus erythematosus.
Independence Blue Cross/HelpScript Medical Benefit Copay Accumulator
Independence Blue Cross (IBC), a Blue Cross Blue Shield plan based in Pennsylvania, has contracted with HelpScript to contact patients and ensure they are enrolled in any relevant drug manufacturer copay assistance programs. IBC and HelpScript are suggesting that this is a benefit to patients, aimed at reducing cost sharing. However, plan documents state that copay assistance amounts are excluded from the patients’ deductible and out-of-pocket maximum, exposing patients to a copay accumulator for medical benefit drugs. The ISC sent a letter to IBC and is pursuing a follow-up call with the health plan’s leadership.
Working for You
In addition to the issues outlined above, the ISC has been active on numerous formulary and drug coverage issues, as well as other payer coding and reimbursement concerns. The ISC is committed to supporting ACR members by advocating for timely and appropriate resolution to insurance issues that increase administrative burden and disrupt patient care.
For more information about the issues above or to request ACR’s help on other payer issues impacting your practice, reach out to [email protected].