23-04-2025
Insurance change could jeopardize 12-year-old's life-saving treatment
(NewsNation) — The life of 12-year-old Maddie Krelle, who has life-threatening food allergies and severe asthma, depends on in-office asthma injections, and she is at high risk for anaphylaxis.
Her health insurance company, Blue Cross Blue Shield of Illinois, will begin requiring prior authorization for in-office treatments, according to a release. Blue Cross Blue Shield offices in Texas, Oklahoma, New Mexico and Montana will likely follow next.
The insurance company would prefer patients to self-administer the medication at home rather than in a medical setting, even if a doctor may not agree.
The sixth grade student is a patient who will be directly impacted by these policy changes once they go into effect. Krelle takes the allergy medication Xolair, which is one of the drugs listed under Blue Cross Blue Shield's new policy.
Krelle is pushing to keep her coverage for in-office shots, saying she's afraid to self-administer them, even with the assistance of a caregiver.
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'I would be really scared to do them at home because it would be so much more of a risk of having an allergic reaction because there wouldn't be any people to supervise you,' Krelle told NewsNation.
Krelle's physician, Dr. Priya Bansal, is an allergist and immunologist in Illinois. She said the main concern is anaphylaxis, where a patient has a bad reaction and could have trouble breathing and swallowing.
'The sad thing is that is the reason that Maddie is taking it right? She's trying to prevent that from happening to herself for a food allergy,' Bansal said.
Bansal added, 'Obviously, for somebody who's been through that type of reaction in their life, they don't have any interest in going through that type of reaction again.'
In a statement to NewsNation, Blue Cross Blue Shield of Illinois stated the change was 'made with the interests of our members in mind—promoting access to treatment that is convenient and effective.'
Dr. Purvi Parikh, a New York-based immunologist and allergist with the Allergy and Asthma Network, who does not treat Krelle, said that with any injectable medication, there is a possible risk of anaphylaxis.
'In fact, Xolair has a boxed warning on it for anaphylaxis, which is the most serious the FDA gives out,' she said.
'… If you do not inject it correctly, you can harm yourself or not get the correct dose. A physician should determine if a patient can safely take the medication at home, not an insurance company.'
Krelle plans to appeal the policy. Dr. Bansal said her practice has 38 patients with Blue Cross Blue Shield whose authorizations are going to expire from April 2025 all the way through March 2026.
Patients can submit an appeal to the insurance company. However, Parikh says, 'often the appeals go nowhere. Every time I appeal, they still deny. They don't care. It's a rigged system that's meant to make both the doctor and patient give up.'
Bansal argued a similar point.
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'I have to prove that she (Maddie) has anaphylaxis to something else in order for her to get it (the medication) at home or that the caregiver is unable to do it. Again, how am I going to provide that burden of proof?' she said.
A written statement provided to NewsNation on Friday from David Van de Walle, a spokesperson for Blue Cross Blue Shield of Illinois, read, 'These medications already have been covered under the standard pharmacy benefit for members with pharmacy coverage. There is not one singular pharmacy benefit manager or specialty pharmacy that would be used by all our members eligible for self-administration of these asthma medications.'
Dr. Marion Mass, a pediatrician in the Philadelphia suburbs and patient and physician advocate, told NewsNation that as long as there is no risk for anaphylaxis, drugs like Xolair can safely be administered at home. But she cautioned that it is important for health care insurance companies to be transparent.
'If the drug is able to be administered safely in the home environment, after ensuring by first injection that there is no risk for anaphylaxis, this can save significant money on the cost to administer in a hospital or clinic setting,' she said.
However, Mass said that Americans deserve the right to 'follow the money' on insurance companies and highlighted the Blue Cross Blue Shield of Illinois policy that states, 'Pharmacy benefit coverage guidelines will continue to apply and may include limiting patients to using a network specialty pharmacy.'
Blue Cross Blue Shield of Illinois has their own in-house Pharmacy Benefit Manager (PBM), which Mass said creates lists of drugs covered on a tiered basis.
But PBMs also have an exemption from the anti-kickback statute, Mass added.
'The PBM can make formulary decisions and even create a monopoly situation for any class of drug based on the colossal conflict of interest of a kickback instead of affordability for the patient,' Mass said.
Mass explained it's based on the cost of the drug, which could incentivize insurance companies to choose a costlier medication, meaning, 'It is the patient, the vulnerable sick patient, who gets stuck with a bigger bill.'
Blue Cross Blue Shield of Illinois did not respond to questions about the PBM.
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