Payer Coverage and Authorization for Severe Asthma Biologics

This episode, "Payer Coverage and Authorization for Severe Asthma Biologics," features the panel comparing their experiences securing coverage, from routine approvals to formulary redirection.

Dr. Bernstein asks Dr. Wechsler about working with payers. Dr. Wechsler believes the prior authorization burden has lessened over time. Payers now recognize the value of biologics in preventing exacerbations, emergency visits, and hospitalizations.

Providers are also more comfortable prescribing than they were 20 years ago, when the first biologic arrived.

His interactions with payers have been generally positive. His team rarely needs to appeal, provided documentation is thorough. That means confirming standard-of-care therapy, poor control, the number of exacerbations, and any prednisone use.

Required step edits, where one therapy must be tried before another, have become much less common. He credits both the growing number of therapies and physicians' improving ability to match the right drug to the right patient at the right time.

Dr. Mosnaim offers a contrasting view. If you have seen one US health care system, she says, you have seen one health care system. Where she practices, she often receives letters denying the biologic that she and the patient selected together. The payer instead lists alternative biologics it would consider. She must then return to the patient, explain the denial, and discuss whether to pursue another option.

Dr. Bernstein asks whether switching a stable patient from a monthly biologic to a 6-month agent might meet resistance. Dr. Wechsler says much depends on each payer's cost for each therapy. He believes payers should recognize that longer intervals improve adherence and thereby prevent exacerbations.

He has not seen denials for such switches so far. The switch still requires shared decision-making, and it may be initiated by the patient or by a provider who recognizes suboptimal adherence.

Dr. Chupp reports a similar experience. Approval has resembled that of other biologics, with only a few denials. Dr. Bernstein concludes, "We shall see."

In "Choosing an IL-5 Inhibitor for Asthma: Evidence, Comorbidities, Convenience," Dr. Chupp lays out his stepwise approach to choosing among IL-5 agents, and Dr. Wechsler and Dr. Mosnaim explain how logistics shape the decision.