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News

Variations in health insurance policies regarding biologic therapy use in IBD

The latest issue of the Inflammatory Bowel Diseases examines variations in health insurance policies regarding biologic therapy use in inflammatory bowel disease.

News image

The American Gastroenterological Association (AGA) has developed guidelines for the management of ulcerative colitis and Crohn's disease recommending anti-TNF therapy in moderate-severe disease.

However, which drug is used is often dictated by insurance company policies.

Dr Joseph Feuerstein and colleagues determined the insurance policy requirements prior to approval of biologic therapies.

Using the National Association of Insurance Commissioners report of the top 125 insurance companies by market share in 2014, the team reviewed the first 50 that had online policies regarding anti-TNF and vedolizumab available.

Policies were reviewed for criteria needed for approval of anti-TNF or vedolizumab therapy, and for compliance with the current AGA clinical pathway recommendations.

Only 8% policies allowed starting vedolizumab without initial failures of an anti-TNF agent,
Inflammatory Bowel Diseases

The researchers found that 98% of policies are inconsistent with the AGA ulcerative colitis pathway and require step-wise drug failure before approval of an anti-TNF.

Only 11% of the policies allowed starting vedolizumab without initial failures of an anti-TNF agent, and 21% required the failure of 2 or more anti-TNF agents.

The team noted that 90% of the policies are inconsistent with AGA Crohn's disease pathway, and require step-wise drug failure before approval of an anti-TNF.

The research team found that 74% allowed for initiating infliximab specifically for fistulizing Crohn's disease.

The team observed that 28% required failing of at least 2 or more drugs before starting anti-TNF.

Only 8% of policies allowed starting vedolizumab without initial failures of an anti-TNF agent, and 28% required the failure of two anti-TNF agents.

Dr Feuerstein's team concludes, "The majority of the policies reviewed fail to adhere to the current AGA pathway recommendations for ulcerative colitis and Crohn's disease."

"Further interventions are needed to better align policies with optimal evidence-based drug therapy."

Inflamm Bowel Did 2017: 23(6): 853–857
01 June 2017

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