Patients Lose When Insurance Company Forces Drug Switch

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This past June, a 64-year-old man with a history of psoriatic arthritis and severe arthritis appeared at our clinic for his regular follow-up with concerns about a letter from his insurance company. The letter stated the company wouldn’t pay for the patient’s secukinumab (i.e., Cosentyx) prescription anymore and suggested he take ixekizumab (i.e., Taltz) instead, which the insurer would cover.

The patient had been tolerating secukinumab with no side effects for more than a year. He had previously been maintained on a TNF inhibitor, rituximab, for several years before it lost efficacy and he transitioned to the interleukin (IL) 17 inhibition therapy provided by secukinumab. He’d been stable for the past year without flares or side effects. He’d received his last injection two days prior to presentation. His physical exam was unchanged compared with prior exams, with no significant active/new skin lesions or joint effusions or bony spurs/erosions.

The proposed new agent works similar to IL-17, but there was no medical indication to attempt a different agent because the patient had been stable and benefiting from secukinumab therapy. Exposing the patient to a new agent would be unnecessary and potentially dangerous.

What Now?

What would most providers do next? Switch drugs, or file an appeal? Most file an appeal and attempt to pressure the insurance company to cover the current drug. We attempted to obtain such an approval. After two months, we finally obtained a discussion with the insurance company experts. It wasn’t fruitful, and the discussion wasn’t patient focused. The expert tried to justify treating the patient with a different agent as being more cost effective, which was irrelevant in this case because there’s no moral or medical reason to expose someone to a different class of biological medication if they’ve been stable on a different agent.

Sadly, insurance companies can change medication coverage at any point by making deals with competing drug companies. This might not be terrible when the medication is the same, such as different brands of aspirin. When it comes to biological agents, such as IL-17 inhibitors, though, a change between different manufacturers is a change between agents, and we all know these agents aren’t similar.

Even worse? Ixekizumab wasn’t even FDA approved to treat the patient’s condition at the time! Ixekizumab didn’t receive FDA approval to treat psoriatic arthritis until December 2017. At the time the insurance company suggested the switch, it was FDA approved only for plaque psoriasis treatment. Of course, secukinumab was FDA approved for psoriasis, ankylosing spondylitis and psoriatic arthritis.

While we were requesting approval from the insurance company, I contacted Eli Lilly and Co., the company that developed ixekizumab, to request any information it might have regarding ixekizumab approval for psoriatic arthritis. Eli Lilly representatives said ixekizumab was not approved for psoriatic arthritis treatment. I told them their drug was being proposed and imposed by the insurance company for psoriatic arthritis, and they didn’t react to that other than sending me data from the SPIRIT studies. I asked whether they could send representatives to explain their strategy. Their answer was clear: They weren’t visiting rheumatology practices because ixekizumab was approved for dermatological conditions only.

Ixekizumab wasn’t even FDA approved to treat the patient’s condition at the time!

Final Thoughts

I’m writing this column to raise awareness and call for more oversight and transparency when it comes to insurance companies and drug coverage. I strongly believe patients shouldn’t be exposed to different biological agents unless it is medically indicated.

The exorbitant costs of such medications as secukinumab make it difficult for patients to retain freedom of choice and say no to insurance companies when they’re bullied. Changing insurance companies may sound like a solution, but it’s much more difficult for patients with chronic conditions requiring such medications to change insurers.

Bottom line: Once an insurance company commits to a patient by approving medication coverage, changing that commitment for financial reasons is nothing short of failure.

Roy Souaid, MD, is a second-year resident in internal medicine at Brown University. He is interested in patients first, as well as healthcare policy.

Editor’s note: This article expresses the opinions of the author and doesn’t necessarily represent the views of the editors or the ACR.