Getting approval for Xolair

[Guest guest]

One thing to consider when trying to get approval for Xolair - if

you are working, try talking with the person in your organization

who is in charge of benefits and health care insurance.

Fortunately, in my organization, I am that person. Despite the fact

that I make all the decisions about coverage, my insurance company

still had to run it through the paces! My company is self-insured,

so we literally pay the bills directly. This made it easier to

justify, since I had done the economic calculation of savings vs.

cost. The only thing I did was to review it with my boss so that

everything would be above-board.

What I have learned in going through the process is that insurance

companies have a lot of information about what is coming along in

terms of different medications. My rep told me that there is a host

of injectable drugs that are coming along, not for asthma, and all

very expensive. When one drug is approved of one type, that sets a

precedent for others.

The insurers are choking on the cost of pharmaceuticals. The

biggest problems are the 'designer' drugs like prilosec and nexium

that are promoted with heavy advertising, 'off label' prescriptions

where a drug is prescribed for symptoms that the drug is not

designed for, and over-extending prescriptions beyond a reasonable

treatment time.

Our prescription drug cost is up 60% over last year, with the same

number of employees. The cost per prescription is within pennies of

the cost last year, so the increase is all in utilization.

I am in the unfortunate position of having to make decisions about

the necessity of certain medications and changing availability /

copays. Were I not personally benefitting from Xolair, I might have

a difficult decision to make about its effectiveness, and whether we

would offer it. As I mentioned in a previous post, even though I am

the only one on Xolair in my company, the drug shows up as #6 on our

list of most costly medications for this year.

Hopefully, over time, the insurance companies will recognize the

benefit of Xolair and promote it as a cost-effective means of

managing asthma. Unfortunately for many asthma sufferers, since the

drug has only been on the market for a year, we are very early on

the experience curve as there is not a lot of data to support the

effectiveness of Xolair across the broad population.

Many physicians probably don't even know about it, especially if

people are getting their asthma treated by their General

Practitioner. Plus, given the mis-information about the potential

side-effects, I am afraid that Xolair is still several years away

from becoming a mainstream asthma medication.

What we need is an article in Time magazine or some other major

publication, complete with hard data, and an honest explanation

about the alleged cancer link. All I have seen in print so far are

blurbs with anecdotal summaries.

Just my opinion on where the insurers may stand. You know my

opinion and results on the effectiveness of Xolair for me personally.

Clear breathing.

Greg