Highmark Ramps Up Prescription Digital Therapies Coverage

Highmark, a Pittsburgh-based health and wellness company, has announced that it will increase insurance coverage for certain prescription digital therapeutics that have been approved by the Food and Drug Administration (FDA).

Although Highmark isn’t the first payer to cover PDTS, it is the first big insurer to publicly state its intentions to pay for claims for the usage of applications that help treat psychiatric conditions and other complex illnesses. The firm has over 6 million members spanning Pennsylvania, New York, West Virginia and Delaware.

Eddie Martucci, the CEO of Akili Interactive – a firm that developed a gamified treatment for hyperactivity disorder – lauded the announcement, saying it’s a huge win for the entire industry. Although other companies have been added to the formularies or are already in Medicaid plans, Highmark is actually the first large company that has created an entire medical policy by emphasizing the importance and medical necessity of FDA-approved products, he said.

According to Highmark’s policy – issued in August and initially reported by Stat – the company intends to pay medical claims for FDA-cleared PDTs only if they are prescribed by licensed medical professionals and used in accordance with their approved methods.

Up till now, eight products have been named by the policy. In addition to EndeavorRx, these include a treatment for nightmares used in conjunction with the Apple Watch; Pear Therapeutics’ CBT application that treats opiate addiction; other applications targeted towards irritable bowel syndrome and VR-based treatments for lazy eye.

Claiming that the list of firms the policy covers will grow with time, Matt Fickie – senior medical director at Highmark – said, “This is a whole new modality of care. If you think about the biggest subjects addressed by these apps, it’s behavioral health, and that’s where access is our biggest problem. And, here we are pushing behavioral health out to everyone’s phone. So that’s a lot of potential. Through discussion and research, we landed on the FDA standard as, at least, our starting point to try to map this field and we issued a policy”

Fickie did point out a recurring criticism of digital therapeutics; there’s a difference in usage in clinical trials and real-world settings. Normally, patients don’t use them as frequently outside of the trials once they are rolled out on the market, so they don’t function as well. However, Highmark aims to bridge this gap through consistent communication with all stakeholders.

In recent years, investors worldwide have shown increasing interest in PDT startups, which is a testament to their growth in the health tech sector. However, most of these organizations face major hurdles to widespread adoption, mostly because the majority of big commercial payers don’t end up covering them.

In this regard, Pear Therapeutics has done excellent work, having as many as three FDA-approved PDTs to its name. SelectHealth, one of Intermountain Healthcare’s subsidiaries, recently penned a deal with the company to cover one of the PDTs – namely the reSET-O tool for opioid use disorder.

As the U.S. continues to stare a burgeoning mental health crisis in the face, it has become even more critical that Highmark’s new policy – along with increasing efforts by others in the PDT space, like Pear Therapeutics – paves the way for better healthcare for patients in the country.