BOISE, Idaho — The Blue Cross of Idaho and the Epilepsy Foundation of Idaho are scheduled to meet on Dec. 8 to discuss recent changes to the insurance provider’s coverage of the anti-seizer medication cenobamate.
The Food and Drug Administration (FDA) approved cenobamate in 2019; it is a popular drug for people diagnosed with epilepsy, often clearing their seizures entirely with comparatively fewer side effects than other competing drugs, according to epileptologist Dr. Robert Wechsler.
Dr. Wechler is one of four such specialists in the state of Idaho. Patients flocked to his Northend Boise office - Consultants in Epilepsy & Neurology - for help upon receiving a letter from Blue Cross of Idaho.
"The letter says your drug will no longer be covered as of January 1, and you will be responsible for all of [the cost] - period," Dr. Wechsler said. "There's no misinterpreting that. There's no nuance. It's very straightforward. Was it poorly written? Yes. Was it misinformed? Yes. Are they going to fix it? I'm sure."
Dr. Wechsler clarified with Blue Cross the company will still cover the drug for some clients depending on multiple factors including the clients’ plan. However, Dr. Wechsler and his colleagues drew a hard line. They consider the practice - while not entirely unique to the industry - unacceptable.
"We can't say to people that can afford the most expensive insurance they can have the drug, and the people who have to buy the cheaper insurance they aren't allowed to be on it. That's not okay," Dr. Wechsler said. "As a medical community. I don't think we push back often enough or hard enough."
For the clients that will no longer receive coverage of cenobamate, the letter suggests clients try the alternative drug felbamate. Dr. Wechsler, and his three other colleagues statewide, all agree the replacement drug is an inferior product.
"It's not as effective. It's not as safe. It requires a lot more blood monitoring to make sure that it's not causing bone marrow failure or liver failure. And that's the only alternative that is offered [in the letter]," Dr. Wechsler said. "Imagine you're a patient who's been having uncontrolled seizures for 10 years. You're finally seizure-free, you just got your driving privileges back, and you get a letter from your insurance company saying in two months, we're not paying for your medicine anymore."
Dr. Wechsler and his colleagues wrote an open letter to Blue Cross of Idaho in response detailing their disappointment in the decision; however, they further expressed an overall complaint with the insurance industry. Coverage denial is a normal function of the insurance process. Dr. Wechsler employs an additional employee for the sole purpose of fighting against insurance coverage denials.
Between 20-30% of his clinical practice is focused on this 'back-and-forth' with insurance providers.
"Red tape," Dr. Wechsler said. "The system is designed to wear us down to the point where we give up."
The vast majority of people diagnosed with epilepsy receive medication on the first or second effort that largely eliminates their symptoms and seizures, according to Dr. Wechsler. His specialty is to assist the remaining less fortunate patients in finding effective treatment.
Cenobamate often fills that role.
"We're pleased to sit down and discuss this complex issue and ensure they have an understanding of our coverage and formulary," Blue Cross of Idaho spokesperson Bret Rumbeck wrote in a statement.
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