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    Rx insurance woes

    Zoe Diana Draelos, M.D.Unsuspecting consumers purchase insurance assuming they will get treatment and the appropriate medications for any health issue that arises during the coverage period. The only phrase that comes to my mind when I think about this assumption is “LOL,” the texting short-hand for “Laughing Out Loud.” 

    READ: Step therapy stalls appropriate patient treatment 

    In my coverage area of North Carolina, the only acne drug covered without prior approval in persons under age 23 is a benzoyl peroxide/clindamycin combination cream.  If you are looking for a non-prior approval medication for someone over age 23, the only first-tier therapy is benzoyl peroxide, not even a prescription treatment.

    For the current insurance policies sold to college students in North Carolina, acne is an uncovered diagnosis; therefore, no medications at all are covered. What does this mean? 

    This means acne is not a real medical condition, not worthy of treatment. LOL!

    At present, psoriasis remains a real disease, but the offered treatments make me LOL.  Even a patient with a PASI of 12 must use topicals and fail prior to moving along in step therapy.

    Phototherapy is a step that must be failed before access to biologics is granted even though the radiation exposure increases risk of skin cancer. Step therapy in psoriasis has set dermatologic treatments back 50 years. Now, when patients ask if their skin can be improved, I tell them, “Yes, but it will require patience on the part of both of us.” 

    Patients then report that the biologic they saw advertised on television is in their formulary and they do not want to delay receiving the best therapy. I try to explain their insurance rules, but all the while I am “COL,” my abbreviation for texting “Crying Out Loud.” 

    It is really hard to have the tools and the ability to improve a PASI 12 patient to clear in three months, but not be able to use them. The current psoriasis formulary step therapies also make me “LOL.”

    NEXT: Medication access a problem

    Draelos_Zoe-2.jpg
    Zoe Diana Draelos, M.D.
    Zoe Diana Draelos, M.D., is a consulting professor of dermatology, Duke University School of Medicine, Durham, N.C. She is investigator, ...

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    • "It is really hard to have the tools and the ability to improve a PASI 12 patient to clear in three months, but not be able to use them. The current psoriasis formulary step therapies also make me “LOL.”" Dr. Draelos if we don't use step therapy we will bankrupt the system. If you have tried and failed cheaper, traditional therapies there is no insurance company that will refuse your request for biologics. If you want to put every moderate-to-severe psoriasis patient on biologics just because it works faster, you have no knowledge of economics. You should be attacking the drug companies for their complete abuse of the system and skyrocketing costs of every medication we prescribe. Of course, they pay for this journal so you can't do that can you? Your article makes me LOL.
    • Mr. BCherson
      i realize this publication is supported by the drug companies, but a compounding pharmacy can offer options, both in dosage, combined drugs, and formulations that are very cost effective and can provide a huge therapeutic advantage to patients. With all the coupon co-pay programs, someone is paying for these over priced me-too products...Finding a compounder in your area is quite simple...www.pccarx.com
    • Anonymous
      I am not defending insurance companies, but they are not the ONLY guilty party. Just think of all the meds that cost thousands of dollars! Who would expect insurance companies to cover all these expensive medications UNLESS they raise premiums and/or increase deductibles. I am not sure who is responsible for reducing prices for generics. I know who is responsible for raising prices. I also know that we cannot afford to wait for OTHERS to bring prices down because we do not know how long it can take or whether they will succeed. There is something we can do in the meantime. Let's all dermatologists in the US agree to NOT PRESCRIBE one and the same generic for 1 month. I bet you the pharmaceutical companies would get the message. If they do not, there is more that we can do to make our case.....
    • Anonymous
      I am not defending insurance companies, but they are not the ONLY guilty party. Just think of all the meds that cost thousands of dollars! Who would expect insurance companies to cover all these expensive medications UNLESS they raise premiums and/or increase deductibles. I am not sure who is responsible for reducing prices for generics. I know who is responsible for raising prices. I also know that we cannot afford to wait for OTHERS to bring prices down because we do not know how long it can take or whether they will succeed. There is something we can do in the meantime. Let's all dermatologists in the US agree to NOT PRESCRIBE one and the same generic for 1 month. I bet you the pharmaceutical companies would get the message. If they do not, there is more that we can do to make our case.....
    • Anonymous
      I am not defending insurance companies, but they are not the ONLY guilty party. Just think of all the meds that cost thousands of dollars! Who would expect insurance companies to cover all these expensive medications UNLESS they raise premiums and/or increase deductibles. I am not sure who is responsible for reducing prices for generics. I know who is responsible for raising prices. I also know that we cannot afford to wait for OTHERS to bring prices down because we do not know how long it can take or whether they will succeed. There is something we can do in the meantime. Let's all dermatologists in the US agree to NOT PRESCRIBE one and the same generic for 1 month. I bet you the pharmaceutical companies would get the message. If they do not, there is more that we can do to make our case.....
    • Anonymous
      I am not defending insurance companies, but they are not the ONLY guilty party. Just think of all the meds that cost thousands of dollars! Who would expect insurance companies to cover all these expensive medications UNLESS they raise premiums and/or increase deductibles. I am not sure who is responsible for reducing prices for generics. I know who is responsible for raising prices. I also know that we cannot afford to wait for OTHERS to bring prices down because we do not know how long it can take or whether they will succeed. There is something we can do in the meantime. Let's all dermatologists in the US agree to NOT PRESCRIBE one and the same generic for 1 month. I bet you the pharmaceutical companies would get the message. If they do not, there is more that we can do to make our case.....
    • Anonymous
      I am not defending insurance companies, but they are not the ONLY guilty party. Just think of all the meds that cost thousands of dollars! Who would expect insurance companies to cover all these expensive medications UNLESS they raise premiums and/or increase deductibles. I am not sure who is responsible for reducing prices for generics. I know who is responsible for raising prices. I also know that we cannot afford to wait for OTHERS to bring prices down because we do not know how long it can take or whether they will succeed. There is something we can do in the meantime. Let's all dermatologists in the US agree to NOT PRESCRIBE one and the same generic for 1 month. I bet you the pharmaceutical companies would get the message. If they do not, there is more that we can do to make our case.....
    • Dr. Hoffman
      Step therapy also ignores the cost to the insurer of the ineffctive therapies which are required even though the physician knows based on their experience that they will not be effective
    • Dr. Hoffman
      Duplicate
    • Dr. Hoffman
      Duplicate

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