Analysis: Payers Restrict Medications for Autoimmune Diseases


Three out of four health plans scored a “C” or an “F” because of utilization management restrictions they place on medication for autoimmune conditions.

Health insurance plans and PBMs receive poor grades for ensuring access to medications for patients living with autoimmune diseases, according to a newly released scorecard. Conducted by Let My Doctors Decide, a partnership of patient advocacy organizations, and the Autoimmune Association, the scorecard assesses the restrictions payers place on therapies that help patients managed their conditions. They found that three out of four plans scored a “C” or an “F” because of those restrictions.

Quardricos Driskell

Quardricos Driskell

“Autoimmune conditions can cause permanent, disabling damage to joints and major organ systems when not properly treated,” Quardricos Driskell, executive director of Let My Doctors Decide and vice president of public policy & government affairs at the Autoimmune Association, said in a press release. “Unfortunately, many patients – regardless of insurance type – face significant barriers to accessing the medicines they need to keep their conditions under control.”

Data analytics firm MMIT performed the analysis using health plan formulary information from the fourth quarter 2022. The conditions studied in this analysis include: Crohn’s disease, lupus, multiple sclerosis, psoriasis, psoriatic arthritis, rheumatoid arthritis, and ulcerative colitis. The autoimmune diseases covered by this analysis collectively affect an estimated 15.9 million Americans.

The analysis looked at both commercial and Medicare plans and evaluated both the medical benefit and pharmacy benefit for each plan. The scorecard examined formulary placement, step therapy, and prior authorization placed on therapies for the seven autoimmune conditions.The analysis does not include actual out-of-pocket costs such as the size of deductibles, coinsurance and copayments, and deployment of copay accumulator or maximizer policies, which they said would provide additional barriers to care.

The analysis found that in traditional Medicare, which covers physician-administered drugs under the medical benefit, placed fewer restrictions on treatments than Medicare Advantage plans across all conditions, the analysis found. In commercial plans, across all conditions, about 25% of plans scored an “A” or “B” under the pharmacy benefit, while only 17% of health exchange plans did so.

“Our scorecard shows that many well-known insurers like Humana, Aetna, Anthem, Cigna, and AARP – and their PBMs – are among those plans whose formularies put up significant access barriers,” Driskell said.

A full list of the plans that were assessed and the grades provided by this analysis can be found here.

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