Stuck Inside the Drugstore With the Reimbursement Blues

Nathan Wei, MD


March 01, 2017

I just had an interesting experience with CVS Caremark. A few days ago, I saw a patient who had failed both Remicade® and Xeljanz® (she received the latter in a clinical trial at my practice). Given that her rheumatoid arthritis (RA) is still very active, I recommended that she try Actemra®, thinking that a different method of action might be in order.

Her insurance company said that for Actemra to be covered, she had to have failed both Enbrel® and Humira®—tumor necrosis factors (TNF) inhibitors that work on RA in the same way. I sent a letter of appeal to the insurance company, stating that a TNF inhibitor (Remicade) had already failed in this patient. Nonetheless, they replied that therapy with Enbrel and Humira would have to fail first.

Stumped, but aware of the insurance process, I had a talk with the patient, and we decided to give Enbrel a try and see what happened. At that point, the same insurance company denied covering this patient's Enbrel because they said that she needed to be taking at least 25 mg of methotrexate (she was on 15 mg).

I rarely, if ever, prescribe methotrexate at doses greater than 20 mg per week, because in my experience, that is when side effects like apthous mouth sores, liver function test abnormalities, and hair loss all begin to rear their ugly head. Furthermore, most people find that they have reasonable relief from their RA symptoms at lower doses of methotrexate.

So, here is the situation. I refuse to increase her methotrexate dose above 15 mg. The insurance company refuses to let her have access to Enbrel, and will therefore refuse to cover Actemra in the future, because her methotrexate dose is not at 25 mg. Is this a conundrum or what?

Needless to say, I was dismayed. I dislike writing letters, but in this case I decided to write to the Maryland state commissioner, the state Board of Physician Quality Assurance, and the state attorney general. And guess what? The insurance company saw the light.

Like most physicians' offices, my staff and I struggle with insurance company decisions on a daily basis, this being just one example. In the past 2 months, we've also had to get preauthorization for prednisone as well as methotrexate. In addition, I have made four peer-to-peer phone calls, all of which led to a positive outcome. It's sort of like going to traffic court. If you show up, you get your points taken away and pay a small fine. In our case, the fine is the time it takes us to contest decisions.

These incidents are frustrating, because they take me away from what I was trained to do—take care of patients.

I have a prediction: It's only going to get harder.


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