A common treatment for Crohn’s and colitis won’t be covered by Excellus BlueCross BlueShield much longer.
The painful diseases flare up when the immune system attacks parts of the digestive tract, causing extensive bleeding. It can take years to find a successful treatment.
That’s why Morning KROCK host Josh Grosvent is worried.
“10 years ago, I was 50 pounds lighter. I was on the couch all day, I couldn’t move,” Grosvent recalls. “I’ve had friends who have been hospitalized by the disease because they can’t find a drug that works to put it in remission.”
Grosvent did quickly find a treatment that worked called Remicade. But just last week he received a letter from a doctor’s office with news that Excellus BlueCross BlueShield is phasing out coverage of the drug for adults.
“Knowing that I’ve been great and in remission for 10 years, to see that I’m not going to be able to get that medication anymore, that’s scary,” Grosvent says.
The insurance company will offer a similar treatment called Inflectra, which they say is a safe and effective, FDA approved alternative to Remicade, for a lower cost.
Doctor Robert Dracker from Infusacare, where many patients are treated in the Syracuse area, says he is concerned about switching patients to any alternative when they are already using a treatment that works, particularly with such sensitive diseases.
“I completely understand why people get nervous when their insurance company says we’re no longer going to be covering the medication you need in order to feel like you’re getting the best quality healthcare,” says Eric Israel, Executive Director of the local branch of the Crohn’s and Colitis Foundation. “That is a conversation you should have with your medical team. Then, if for whatever reason your doctor feels you should be on a different medication or stay on the one you’re on, that is absolutely something you could appeal with the insurance company.”
An exception will be made for pediatric patients to continue using Remicade, when prescribed.
Otherwise, adults will lose coverage when their existing authorization date expires.
Grosvent has been told he’s covered until 2020. Knowing how painful the disease is, he’s anxious to see how his body will react.
“It’s just scary to change anything, without knowing what it is,” he adds.
A spokesperson for Excellus BlueCross BlueShield offered the following information for this story:
Effective Feburary 1, 2018, Excellus BCBS implemented a clinical medical drug policy change for coverage of Remicade.
This change did not affect existing users. Members who are currently prescribed Remicade may continue receiving Remicade as a covered benefit through the end of their existing authorization date.
Members enrolled in commercial, Exchange, Medicaid managed care and Child Health Plus lines of business, who are newly prescribed Remicade, are required to start treatment with Inflectra. The U.S. Food and Drug Administration has approved Inflectra, produced by Pfizer, as a biosimilar to Remicade, based on rigorous safety and effectiveness data. Inflectra is proven to be a safe, effective, well-tolerated and lower-cost alternative to Remicade, and patients can expect similar results to Remicade.
Pediatric patients with a diagnosis of ulcerative colitis are not required to initiate Inflectra. They will be able to have Remicade covered if prescribed.
While relatively new to the United States, biosimilars like Inflectra have been used in Europe and other countries for years. Clinical studies were conducted on patients who had never received Remicade and also patients who were switched from Remicade to Inflectra. The studies concluded that switching from Remicade to its biosimilar Inflectra is possible without negative effects on safety or efficacy.
This change in drug policy criteria was reviewed and approved by the Health Plan’s external Pharmacy & Therapeutics Committee, which is composed of local physicians and pharmacists.