Blue Cross Blue Shield now requires prior approval for severe asthma drugs in some states

Yahoo

15-04-2025

Starting today, Blue Cross Blue Shield will mandate that severe asthma patients self-administer their drugs at home, unless their provider gets prior approval from the insurance company. (Courtesy of Dr. Priya Bansal)
Patients in five states who have severe asthma and are covered by Blue Cross Blue Shield are facing a new obstacle to getting treatment.
On Tuesday, BCBS began mandating that severe asthma patients self-administer their drugs at home, unless their provider gets prior approval from the insurance company.
The patients affected are those covered in Illinois, Texas, Oklahoma, New Mexico, and Montana, but not those with Medicare or Medicaid, the insurance giant says.
Given as injections, the treatments in question are Fasenra (benralizumab), Tezspire (tezepelumab), Nucala (mepolizumab) and Xolair (omalizumab). All belong to a class of drugs known as biologics.
The decision is expected to affect thousands of patients. It's estimated that between 5% and 10% of asthma patients have severe asthma, characterized by more flare-ups and hospitalizations. In Illinois, for example, about 860,000 patients have asthma, according to the federal Centers for Disease Control and Prevention. That means between 43,000 and 86,000 of them have severe asthma.
Clinics already have loads of prior authorizations to process that often delay care, said Dr. Priya Bansal, a pediatrician and asthma and allergy physician in Illinois. Her practice sees many rural patients and those with chronic disease.
'On any given day, we'll have anywhere from 30, to my highest was 130,' she said.
The change interferes with a provider and patient decision on whether in-office or at-home treatment is best for the patient, Bansal said.
'That decision that's supposed to go on between the physician and the patient is getting taken away,' she said. 'If I have a pediatric food allergy patient and they want to get the medication in the clinic, I want to be able to have the flexibility to do that.'
States try to rein in health insurers' claim denials, with mixed results
The sickest asthma patients are often on biologics, explained Dr. Bridgette Jones, past chair of the American Academy of Pediatrics' drug committee and the American Academy of Allergy Asthma and Immunology's asthma cough diagnosis and treatment panel.
'These are the patients that have failed at other therapies,' said Jones, a pediatric allergy and immunology physician at Children's Mercy Hospital in Missouri. 'Once you're getting to a biologic, it means that your asthma is not under control, having frequent flare-ups.'
Black and Indigenous adults and children, as well as Puerto Rican people have higher rates of illness and less access to care.
For people who suffer from severe asthma, the typical inhaler is often not enough. The affected drugs can help manage severe, uncontrolled asthma by reducing airway inflammation,
While the drugs are approved by the U.S. Food and Drug Administration for self-injecting at home, they also come with risks for the uncommon but life-threatening anaphylaxis.
That's why providers typically start patients on these drugs in-office for monitoring.
But for at least one of the drugs, Xolair, the reaction can also happen up to a year into treatment.
Many families are not comfortable administering biologics to their kids with severe asthma, Jones said.
Clinics serving higher-need or underserved populations may often lack the resources to deal with more prior approvals, she added.
A recent study by Massachusetts General Hospital and funded by Amgen, which developed Tezspire with AstraZeneca, suggested that in some states, the percentage of asthma patients with severe asthma is higher than 10%. In Texas, for example, about 23% of severe persistent asthma had severe uncontrolled disease.
Stateline reporter Nada Hassanein can be reached at [e-mail].
SUPPORT: YOU MAKE OUR WORK POSSIBLE