Medical Benefit of Office Administration of Tildrakizumab



James Song, MD, FAAD: What we have done, we’re not buying and billing at this point. It may be something we consider in the future, but if you can find what they call an ASOC, that’s an Alternate Site of Care, so like a local rheumatologist or a hematologist, and they could inject them there, they’re just going to be paying their copays. And I think it’s the matter of having that relationship with an Alternate Site of Care. I go through the same thing, it’s really challenging. I don’t have a great solution.

Mark Lebwohl, MD: I will tell you what we do at Mt. Sinai. Tildrakizumab by the way is the only drug that is only approved for in-office use. It’s not supposed to be given in the patient’s home. The insurance company cannot say to you, “Oh, you have to give it to the patient to give it home.” Because once it’s given in the patient’s home, they can call it a pharmacy benefit and then they’ve got to pay the copay, they’ve got to pay the donut hole, and they can’t do that to tildrakizumab. So tildrakizumab is always a medical benefit. The other biologics that until now have been treated that way are ustekinumab, Risankizumab, and the other.

Leon Kircik, MD: Infliximab.

Mark Lebwohl, MD: And infliximab, of course; and I’m missing one of them. But the 323 blockers are TILDRA, guselkumab – they can be given in the office. The problem is that they’re also approved for at-home administration. And Medicare is threatening to remove that and put them on the self-administered drug list December 5th.

Leon Kircik, MD: Actually, that’s going to have January 1st, right with the new year.

Mark Lebwohl, MD: We’re worried that that’s going to happen because until now we are able to give those drugs. I will say, particularly applying to tildrakizumab, but also those other drugs, we actually had a dermatologist in Connecticut who’s having difficulty getting the drug. She does not want to pay the drug and take the risk that he won’t get reimbursed. And I told him at Mt. Sinai, you know the hospitals do great with this. They get 340B dollars they’re called. I told him, “You know we’d be happy to take care of your patients for you.” And he now sends his patients for one visit a year to what is called “The Biologic Therapy Clinic.” And it can even be done by video. And they take every insurance. They will pay for the drug, have the drug administered. And, of course, if it’s going to be tildrakizumab, they’ll have to come in four times a year to have it at Mt. Sinai.

But he continues to be their doctor and give them all their care. They actually never see any of us in the departments. They go to an infusion center where they get the drug administered there. He is the supervising physician. We’ve arranged for him to get an appointment in the department, so he’s joined my voluntary faculty. And it solves the problem for his patients because his patients have no other way of getting the drugs that they need.

It’s complicated, it’s difficult. The rules, by the way, Erin, are different in every State. But it took us a while to fight this at Mt. Sinai and we got it done for the good of our patients, and we were able to get it done so that they; a lot of our Medicare patients, like you said, are unable to afford those drugs because of the copays and donut holes and all of those rules.

Transcript Edited for Clarity

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