Prescription Acne Medication: Why Your Insurance May Deny Coverageby Anne Windermere Patient Advocate
In a previous post I discussed my on-going battle with adult acne and how I was successfully treated by my dermatologist. It may be unbelievable to some, but it is true, adults get acne too. As my dermatologist tells me, there are patients who come to her office who are in their eighties and still have acne. This is not a skin disease which only affects teens. One of the medications I have used over the years to treat my adult acne is called Tazorac or Tazarotene. Tazorac is a topical retinoid which comes as a cream or a gel. There may be some initial side effects to using Tazorac such as burning, redness, or dry flakey skin. If you can tolerate some of these temporary side effects, it has been my experience that this medication really worked to prevent and control my acne outbreaks.
Note:** What works for me may not work for you. Speak to your dermatologist about which acne medications are right for your particular skin type.**
I have been successfully using this prescription acne medication now for almost ten years. So imagine my surprise when I get a notice from my insurance company that my request to have my prescription filled had been DENIED. Actually the insurance denial letter had come after several unsuccessful attempts to get my prescription filled and making numerous calls to my pharmacy, my dermatologist, and my insurance company.
Figuring out why a particular prescription cannot be filled is somewhat like a Scooby Doo mystery. There are usually twist and turns in the story as well as the leaving out of vital information and clues. Only at the end do you finally get to understand what really happened. Come with me on my journey through insurance red tape to find out why my prescription was denied. You too could be faced with a similar challenge especially if you are a woman who is prescribed a retinoid type of acne medication.
My story begins with our insurance changing which pharmacy we could use to fill prescriptions. Although I had been using Tazorac for almost a decade, my insurance company was viewing me as a brand new patient. When I went to get my prescription filled I was told that I would need pre-authorization from my doctor. Okay. So I call my doctor who tells me that she has completed this pre-authorization step and to call the pharmacy back. This begins a week long phone tag where one party sends me to another party and back again. I go to my pharmacy in person and they tell me they have not received any such pre-authorization for my Tazorac and that I need to call my doctor again and/or my insurance company. The pharmacist there added his speculation that the insurance company doesn't want to pay for acne medication for someone who is older. Thanks Bud. So ahem older people can't get acne? We know this is not true.
Hypothesis #1 for the insurance to deny my prescription acne medication: I am too darn old to have acne.
I then call my insurance company who assures me that I can get my prescription filled as soon as my doctor fills out that pre-authorization form of only eleven questions. I continue to wonder what could be holding up this process which had previously worked for years. The next call is to my doctor. It seems she had filled out this pre-authorization form weeks ago. I audibly sigh in frustration. The nurse on the phone is compassionate. She tells me she does not understand this hold-up either and will look into it. She then offers her theory as to why the insurance company may be giving us a hard time. In the nurse's opinion, Tazorac is one of the best retinoids out there and along with treating acne; it is also one of the best anti-aging treatments.
Hypothesis #2 for my insurance to deny coverage for my Tazorac gel: They think I am using this medication for cosmetic concerns (wrinkles) instead of acne.
By now I was so incredibly frustrated and nothing was making logical sense. I called the insurance company a second time. The second insurance receptionist only added to my confusion. At first she said my request was accepted and the medication should be at the pharmacy. I told her that it was not filled and the problem was something to do with the pre-authorization request. She could give no answers so of course I was advised to call my doctor once more.
Upon my third call to the doctor, one of the nurses had found the cog in the wheel. One of the questions in that pre-authorization process was whether or not I was pregnant.
"Pregnant?" I asked incredulously. "I am most certainly not pregnant" I assured her.
But then the nurse asked, "Did you have a hysterectomy?" I replied in the negative.
"Are you past menopause?" Again I answered negatively.
"So you could be pregnant" she surmised.
I tried to use logic to tell her that I am 47-years old, I just had my period, am peri-menopausal, and I am also taking birth control pills. But the most obvious thing was that I have been using this particular acne medication for almost ten years now. The nurse totally understood but was simply trying to explain how the insurance company was making this decision to deny coverage.
Hypothesis #3 for not being able to get my Tazorac: I need to prove that I am not pregnant before the insurance will pay for my prescription acne medication that I have been taking for years.
Turns out that the nurse's theory was the correct one. But the thing that gets me is that nobody told me this reason at any time during this weeks-long process. When I called my insurance company three times, nobody told me the real reason for my denial of coverage. I called the pharmacy once more.
"How much does this drug cost out of pocket?"
The pharmacist looked it up and shyly said, "I don't want to tell you." For a 100 gram tube it would cost over $800 out of pocket
One of the nurses from my dermatologist office called back and told me they would send me an order to get a pregnancy test so that I could go to a lab and get my blood drawn. I assume I would pay out of pocket for the test.
Meanwhile back at the ranch I finally receive the written denial from my insurance company (the same company who had covered this same medication for almost ten years). Here is what they said and the capitalized words are theirs:
"Current plan approved criteria does NOT allow coverage of Tazorac if a negative result for a pregnancy test having a sensitivity down to at least 50mlU/ml for hCG has NOT been obtained within 2 weeks prior to Tazorac therapy, beginning during a normal menstrual period."
There are so many things that are perplexing about this situation that I don't know where to begin. Such as: Why did they cover this medication for almost a decade and I was never required to take a pregnancy test? Once a patient is taking this medication, what is there to ensure that the patient doesn't get pregnant during the time they take Tazorac? Why is this medication so expensive? Why is the insurance company demanding a pregnancy blood test from a woman who is not taking this medication for the first time and is taking birth control pills? How could three separate people from my insurance company miss telling me the real reason for being denied coverage for my acne medication?
I may never know the answers to these questions. But one thing is clear. I have to take a pregnancy test. So when people ask me what I am doing lately I can nonchalantly say: "I am proving that I am not pregnant for my insurance company."
Tazorac works for me. I will jump through this hoop if that is what it takes. I do not want my severe acne to come back.
If you are a woman who has been denied coverage for your prescription acne medication, the reason may be that you have not had a negative blood pregnancy test two weeks before initiating drug therapy. If you are using any sort of prescription retinoid for your acne it is important to make sure that you are not pregnant. There is evidence to show that these types of medications can be potentially harmful to an unborn fetus. Speak with your doctor about any concerns that you may have about your medication.
Do you have a story about insurance coverage or denial for prescription skin medications? Share your story here. It just may help someone else going through a similar struggle.