Ontario Rheumatology Association and Private Payers: An update

As many of you know, major changes to the reimbursement of biologics via third party payers have been occurring, with many insurance companies providing group health plans moving to a “prior authorization form” system, similar to the Exceptional Access Programs implemented by many provincial governments. In order to ensure that these changes are being implemented with evidence-based medicine and patient welfare in mind, an Ontario Rheumatology Association  committee was struck, which has engaged in ongoing dialogue with 3 of the largest  insurance companies. We have presented them with the CRA guidelines for the treatment of Rheumatoid Arthritis, as well as commented on their proposed forms, to try and make their questions rational and appropriate. The insurance companies have, to variable degrees, accepted our comments. They have modified their forms and criteria to, we hope, minimize the difficulties that we and our patients will face nation-wide when all these changes take effect.
The realities of escalating expenditures and increasing prescribing have made the third party payers very aware of the use of biologics for the treatment of rheumatic disease. It may interest you to know that one of the biologic drugs that we frequently use is currently poised to become the world’s biggest-selling drug, with sales that will top more than $9 billion in 2012  and more than $10 billion in 2013. With further biologics in the pipeline, one can understand the insurance companies’ desire to have more control over their use.
Despite our involvement, there will undoubtedly be  changes in biologic prescribing that will pose challenges for Canadian rheumatologists and their patients. The ORA plans to maintain an ongoing relationship with the third party payers, and will strive to make the situation as transparent and open as possible as we move forward in this challenging time