Insurers make prescribing biologics difficult

July 8, 2016

A new study suggests that insurance coverage of biologics for psoriasis is becoming more challenging. The need for prior authorization is increasing, as are the average time from prior authorization submission to coverage decisions and prior authorization denial rates.

Dermatologists at George Washington University, Washington, DC, say they sensed that their biologic denial rates might be increasing, so they conducted a study on insurance coverage of biologics for moderate-to-severe-psoriasis.

In their study looking at a database of 864 patients diagnosed with psoriasis between 2009 and 2014, in which 114 patients met the inclusion criteria for biologic therapy, the researchers found their assumption was right. The need for prior authorization increased from 16% of patients prescribed a biologic in 2009 to 75% of those prescribed a biologic in 2014. The average time it took from prior authorization submission to coverage decisions (confirmations or denials) also increased, from 3.7 days in 2009 to 6.7 days in 2014. And prior authorization denial rates rose from none in 2009 to 19% in 2014, according to the study published online June 9 in the American Journal of Clinical Dermatology and presented during the March 2016 Annual Meeting of the American Academy of Dermatology.

This is a significant issue for psoriasis patients and their dermatologists.

“Biologic therapy is very important for the successful treatment of our patients with psoriasis and psoriatic arthritis,” says the study’s senior author Alison Ehrlich, M.D., M.H.S., professor and chair of dermatology at The George Washington University School of Medicine & Health Sciences.

Dr. Ehrlich and coauthor Monica Rengifo-Pardo, M.D., research assistant and clinical instructor of dermatology at George Washington University School of Medicine & Health Sciences, write in an email to Dermatology Times that they conducted a retrospective five-year chart review of patients seen in the clinic with a diagnosis of moderate-to-severe psoriasis (ICD-9 696.1).

“We evaluated the prior authorization denial rates, time course, reason for denials and variation between insurance company policies,” they write.

NEXT: Reasons for denials

 

 

Reasons for denials

They found that the most common reason for insurers to deny coverage was failure to try specific therapies before requesting biologics.

Some of the biggest challenges patients face when they’re prescribed biologics, according to Dr. Rengifo-Pardo, include the need to have attempted specific therapies prior to approval for biologics; variation between insurance companies on how they have tiered biologics; and the increased number of insurance requirements listed in prior authorization forms.

“In addition, copays for biologics have increased for many patients,” Dr. Rengifo-Pardo says.

Patients have expressed their frustration with current insurance barriers to coverage, Dr. Ehrlich says.

Dermatologists, according to Dr. Rengifo-Pardo, can take steps to help make sure psoriasis patients secure coverage for the drugs. These include: Clear documentation of body surface area

(BSA percent) in notes, prior authorization forms and treatment history.

“Important symptoms should be documented, such as pain and/or [difficulty] walking, any issues related to psoriasis on the hands impacting work (quality-of-life symptoms) and pertinent medical history, including psoriatic arthritis…,” the authors write.

The authors of the study conclude that given the cost burden and potential benefits of biologics, issues of healthcare coverage and access to treatment need further examination.

This isn’t the first study to draw attention to potential issues with biologic coverage. A study published in January in the Journal of the Dermatology Nurses' Association, notes the heavy cost of biologics can be prohibitive for especially patients with high deductibles. The National Psoriasis Foundation estimated in 2015 that average biologic copayments are $1500 annually and out-of-pocket costs can be more than $2500 a year for patients with insurance, according to the study.

The authors point out, however, that all biologic manufacturers offer programs for qualifying patients with commercial insurance that reduce per-dose costs. And with the potential for better health, psoriasis patients on biologics can improve productivity and reduce disability and need for healthcare, the authors of the Journal of Dermatology Nurses’ Association write.

Disclosures:

Dr. Ehrlich is a speaker for Abbvie and Celgene and a Principal Investigator for Merck, DUSA, Regeneron, Lily, Leo Pharma, Abbvie and Janssen. Dr. Monica Rengifo-Pardo reports no conflicts of interest.

Reference:

Abdelnabi M, Patel A, Rengifo-Pardo M, Ehrlich A. Insurance Coverage of Biologics for Moderate-to-Severe Psoriasis: A Retrospective, Observational 5-Year Chart Review. Am J Clin Dermatol. 2016 Jun 9. [Epub ahead of print]