Insurance Sets Road Blocks for Psoriasis Healing

Patient Expert
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When I finally had the chance to try a biologic, I felt like I had broken through some psoriasis-cool-kids-club hierarchy. For years, I heard my psoriasis friends talk about how well and fast biologics worked to relieve the itchy, flaky, dry, painful symptoms of psoriasis, while I myself was still suffering, unable to access injections due to insurance restraints.

Many of my friends shared stories like mine that involved “step therapy” — being forced by insurance companies to try less expensive treatments, such as topicals or pills, before being approved for an injection.  This process can take several months of treatment, progress reports, and potential paperwork snafus.

Meanwhile, treatment could be failing the patient, leading them down a discouraging path to possible mental and emotional health issues while awaiting better care.

The goal of this “fail first” method of treatment is to save insurers money, but in the meantime can hurt patients. So how can a person living with psoriasis navigate the course of step therapy?

Amy Prentice is the state government relations manager for the eastern region of the National Psoriasis Foundation (NPF). She shares some facts on how to successfully navigate step therapy.

Be aware of your options

Get ahead of the game. “Patients should look up their insurance formularies to see if step therapy protocols are required,” Amy says. Check with your insurance company to verify what prescription drugs require the process of step therapy.

You may be unknowingly taking the steps

There is a reason you have to try topicals first. I often wondered why the first treatments doctors generally prescribe for psoriasis are topicals, even when a person’s flare is severe.

“A lot of times doctors know a prescription may get denied, so we see patients who may have to go through step therapy without even knowing it. The doctor may just prescribe that way rather than going through the whole denial process,” Amy says.

You can appeal or navigate around the process

You don’t have to do this on your own. Amy says that, because many do not realize they are going through the step therapy process, they are unaware of their rights and ability to avoid this process altogether depending on the circumstances. The NPF patient navigation helps people living with psoriasis maneuver through the process, but the doctor should also be a partner in this.

The NPF is fighting for patient rights

It’s time for a change. The NPF has introduced new legislation, H.R. 2077, titled Restoring the Patient's Voice Act of 2017.

“It’s specifically for patients who maybe have a chronic illness like psoriatic disease or maybe a very severe illness, that really shouldn’t have to go through the process,” Amy says.

The decision of the right treatment should be between the patient and doctor

There is a time and place for step therapy, but those decisions should be expressed between the patient and doctor, not solely the insurance company. So talk to your doctor.

“Each patient is unique, and what we are really trying to do with these bills are protect the patient/provider relationship. They have [healthcare providers] all the patient’s information — what works, what doesn’t work based on medical needs and lifestyle. So, we really want the patient and provider to make those decisions on what they should try, including lower level treatments before moving up,” Amy says.

You have a voice in the battle

You too can take a stand against step therapy. Although the NPF is taking action, they can’t do it without patients like us! You have the power to take a stand by getting involved with the NPF’s efforts. Also, step therapy varies state-to-state. Although there has been much progress made in some states, there are many that need improved legislation. The NPF provides a guide to which states currently need the most attention.

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