TOPLINE:

The vast majority of insurance companies require patients with Crohn’s disease and ulcerative colitis to fail conventional treatment with steroids and immunomodulators before starting biologic therapy, despite guidance to the contrary.

METHODOLOGY:

• Treatment of moderate to severe IBD has transitioned from step-up therapy to first-line use of a biologic agent for the induction of remission, but insurance coverage for this recommended approach varies.
• Researchers searched the 50 largest US insurance companies for publicly available policies on five biologic/small molecule agents.
• Data on coverage requirements were compared with the current treatment guidelines for Crohn’s disease and ulcerative colitis from the American Gastroenterological Association (AGA) and American College of Gastroenterology (ACG).

TAKEAWAY:

• Policies were available for 34 insurers. Almost all (91%) required failure of at least one conventional therapy or other biologic before specific biologic use.
• Just under 15% of policies permitted any first-line biologic therapy in Crohn’s disease, with approximately 18% permitting it in ulcerative colitis. Adherence to ACG/AGA guidelines ranged from 6% to 59% across the different policies.
• The most common reason for guideline discordance was the need to fail conventional therapy before starting biologic therapy.

IN PRACTICE:

“Given most patients have employer-sponsored insurance with limited plan choice, our data elucidate a system-level issue requiring legislative change, not individual action. Comprehensive insurance policies in line with current guidelines are necessary to reduce costs, increase access, and increase compliance rates to help prevent poor outcomes in this high-risk patient population,” the authors wrote.

SOURCE:

The study, with first author Kelsey L. Anderson, MD, from Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, was published online on February 29 in the American Journal of Gastroenterology.

LIMITATIONS:

The study was limited to publicly available policy data. Government insurance plans and pharmacy benefit managers were not included.

DISCLOSURES:

The study received no funding. The authors reported no relevant financial relationships.