Some Blue Cross Blue Shield Patients to See Coverage Change Next Week

Starting April 15, Blue Cross Blue Shield (BCBS) patients in five states will need prior authorization for in-clinic asthma treatments or will be required to shift to self-administering injections at home. The policy shift has prompted safety concerns from doctors and patient advocates.

Newsweek reached out to BCBS via email for comment.

Why It Matters

The policy change affects asthma patients who rely on biologic medications like Fasenra, Tezspire, Nucala and Xolair. These are typically administered monthly in clinical settings to control moderate to severe asthma.

Physicians warn the insurer's move could lead to life-threatening situations for some patients and hinder adherence to treatment regimens.

BCBS, which insures millions of Texans, says the update will make treatment more convenient and cost-effective for members, though critics argue it prioritizes savings over safety.

What To Know

Under the revised policy, Blue Cross Blue Shield of Texas will treat asthma injection medications as pharmacy benefits instead of medical benefits. This will force most patients to inject the medications themselves at home unless they receive a medical exemption.

Similar changes will occur in Oklahoma, Illinois, Montana and New Mexico.

"Those reactions can be potentially severe and even life-threatening," Dr. Amin Mery, an Austin-based asthma specialist, told the Fort Worth Star-Telegram last month. "We can manage those in the office, but it's very difficult for them to manage them at home."

Dr. James Haden of the Allergy and Asthma Clinic of Fort Worth, who administers 20 to 25 of these injections daily, said the change "significantly compromises patient safety" and "takes away the choice of the patient and the physician as to what might be the best for each individual patient."

Previously, BCBS emphasized that the Food and Drug Administration has approved all the drugs for self-administration.

"Our policy revision is being made with the interests of our members in mind—promoting access to treatment that is convenient and effective," the company said in a statement to FOX23 Tulsa.

However, that reassurance has not quelled concern among health professionals.

"There have been people who have anxiety...I do like for patients to have options and to not be fearful of having to do this at home," Dr. Christina Barnes, a nurse practitioner at Tulsa's Allergy, Asthma & Immunology Center, told the local station.

The change exempts patients covered under Medicare and Medicaid. Those with private plans can still receive in-clinic injections if they demonstrate, through a formal appeals process, that such administration is medically necessary.

What People Are Saying

Alex Beene, a financial literacy instructor for the University of Tennessee at Martin, told Newsweek: "The decision to require some asthma medications be administered at home as a part of its coverage rather than in a clinic seems like a smart one from both a financial and regulatory perspective. After all, if the FDA has cleared at-home injections for certain medications, it would save the clinic, the insurer, and the patient time and money.

"However, concerns from the medical community are also logical ones. Questioning both how safe some of these are for at-home use and the frequency of taking them going down outside of a clinic are valid ones."

Lawren Geer, interim executive director of the Infusion Providers Alliance, told Newsweek: "This change presents a huge risk for many patients, particularly those who have multiple allergies or a predisposition to having an allergic reaction to the medicines. Imagine you're at risk for getting an allergic reaction and you have to self-inject at home, by yourself."

Kevin Thompson, the CEO of 9i Capital and the host of the 9innings podcast, told Newsweek: "Patients should be aware that the responsibility for taking these medications will now fall directly on the individual. The days of having a health care provider administer these injections in a controlled environment are ending for many. Moving forward, patients will need to manage their injections on their own or with the help of a caregiver."

Michael Ryan, a finance expert and the founder of MichaelRyanMoney.com, told Newsweek: "For patients, this is going to be a mixed bag. I'm thinking about my friend Meredith's daughter who has severe asthma. She's terrified of needles and the thought of self-injecting makes her anxiety skyrocket.

"You know what this reminds me of? It's like when a coffee shop raises prices but calls it an 'enhanced customer experience.' The marketing spin doesn't change the reality that something is being taken away."

What Happens Next

As the policy takes effect April 15, advocacy groups such as the Infusion Providers Alliance are encouraging patients to contact lawmakers to oppose the change.

"The worrying trend here is increasingly patients are having less of a say with their physician in terms of their own health care, and it's becoming more about what will be covered by an insurer instead of what's best for their welfare," Beene said.