Step therapy, insurance exclusions hinder effective drug access in JIA
ORLANDO — Treatment of pediatric patients with juvenile idiopathic arthritis with medications available to their adult counterparts is often blocked by exclusions in insurance policies and outdated step therapy requirements, according to a presentation at the Rheumatology Nurses Society Annual Conference.
“In pediatrics, we do not have the same availability of medications as providers in the adult world, as very few of the medications used for adult patients have pediatric indications,” Cathy Patty-Resk, MSN, RN, CPNP-PC, a pediatric nurse practitioner at Children’s Hospital of Michigan, told attendees. “When we are looking at medication use for kids, we often have to go off-label, and it’s extremely difficult in the current health environment to get approved for off-label use of medications, even for children, because insurance companies often demand that you stay on-label.”
According to Patty-Resk, one in 1,000 children in the United States will develop some type of chronic arthritis, with approximately 300,000 children diagnosed with JIA. However, with fewer than 350 pediatric rheumatologists practicing nationwide, children with rheumatic diseases are often relegated to rheumatologists who typically treat adults and, in the absence of a pediatric specialist, do their best to provide care to pediatric patients.
“Many of the drugs commonly used in the adult rheumatology world do not have a safety profile for pediatrics, or they are not indicated, or insurance would not authorize it,” Patty-Resk said. “There are many different reasons why that child may not have been given that particular drug. When you get these kids in your office and ask why they weren’t prescribed more effective drugs, please understand that we didn’t start them on your wonderful riches of drugs because we don’t have them available to us.”
Patty-Resk noted that, in addition to the sparse collection of approved pediatric rheumatology drugs, insurance companies often pose obstacles to adequately treating patients with JIA.
“Another challenge we have is that insurance companies can have exclusions for certain diagnoses for medications,” she said. “I have little girl right now with [temporomandibular joint] arthritis, and she actually has facial asymmetry as a result of the disease. However, her insurance has actually excluded TMJ arthritis.”
While speaking with the insurance company, Patty-Resk asked, if “arthritis” was covered under the policy, how was TMJ arthritis not covered? The company spokesperson responded that TMJ arthritis was an exclusion in this particular policy. Even when she noted that spondyloarthropathy — which includes TMJ arthritis — was covered under the policy, the spokesperson persisted in saying that TMJ arthritis was excluded.
“We also have step therapy to contend with,” Patty-Resk said. “I actually had an insurance company tell me that they did not want to pay for the drug I had selected for a pediatric arthritis patient, and proceeded to give me a list of appropriate step therapy drugs. You will never guess what drug was on the list — gold.”
“I couldn’t believe it,” she added. “I even thought to myself that I should take them up on their offer: ‘Hey, I’d really like to start this kid on gold — where do I send this prescription?’”– by Robert Stott
Patty-Resk C. What the adult clinician needs to know about juvenile of immunology. Presented at: Rheumatology Nurses Society Annual Conference; Aug. 7-10, 2019; Orlando.
Disclosure: Patty-Resk reports no relevant financial disclosures.