Blue Cross Blue Shield’s policy to reject coverage of Eylea treatment for patients who have lost three lines of vision on an eye chart may pose a significant threat of permanent blindness to these patients.
The published data do not support the policy, and the insurer has not offered a scientifically sound explanation for its decision. The American Academy of Ophthalmology has urged Blue Cross Blue Shield to reconsider this policy and requested an opportunity to further explain its dangers. They have denied our requests.
This policy is based on a misunderstanding that an incomplete response to therapy is the same as no response to therapy. Ophthalmologists know that even a partial response to treatment can be a life-changing improvement.
Eylea is an effective anti-VEGF agent for the treatment of age-related macular degeneration, diabetic retinopathy, and retinal vascular occlusion. In some situations and for some conditions, Eylea is more effective than intravitreal injections of Lucentis or Avastin.
Blue Cross Blue Shield has based its exclusion of Eylea treatment on two studies that were conducted to determine the drug’s efficacy prior to approval from the FDA. The insurer ignores the hundreds of studies completed after FDA approval that reflect the results seen in real-world ophthalmology practice and that are the basis for the treatment of patients. These studies were not meant to become a hard and fast metric to control exactly how individual patients are treated in the real world.
Even the ophthalmologists who conducted these two original research studies don’t treat patients now like they did more than a decade ago when those studies were published. They know now that even if a patient has lost three lines of vision on an eye chart, treatment with Eylea can save them from legal blindness.
Blue Cross Blue Shield should reconsider and reverse this policy.