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Published On: Feb 21, 2017
Last Updated On: Jul 15, 2021
Late last year, the Food and Drug Administration (FDA) approved the non-steroidal topical treatment, Eucrisa for mild to moderate atopic dermatitis. This March, the FDA is expected to approve dupilumab, the first biologic drug for adults with moderate to severe AD.
As more treatments for AD are approved by the FDA, your health insurance company may restrict your ability to access new drugs in order to control costs. The following are some of the most common tactics health insurance companies use to restrict access to certain treatments and medical care.
Specialty drugs are defined by insurers as medications that are expensive, require special handling, and/or are very complex in nature. Biologic drugs, made out of living cells, are considered a specialty drug. Typically, insurers require doctors to follow a set of lengthy and detailed administrative procedures before the insurer will agree to cover the cost of a specialty drug.
Drugs are usually grouped into tiers in an insurer’s formulary. A formulary is the list of drugs that a particular insurer decides has the most benefit for patients relative to cost and how effective the drug is for certain conditions. There are usually four tiers in a formulary and the higher the tier, the more the patient will pay out-of-pocket to receive the medication. Specialty drugs are often placed on the highest tiers (3 and 4) by insurers.
Step therapy requires that a person try – and fail – other (usually less expensive) drugs on lower tiers, before the health insurance company will cover the cost of the medication originally prescribed. For example, a patient with AD may be required to try common treatments, such as topical steroids, before a biologic would be covered. This cost controlling measure may not take into account a patient’s individual medical needs, the potential side effects of the less expensive drug or if it is effective for the patient’s symptoms. To avoid step therapy, your doctor must receive prior authorization from your insurer.
Prior authorization requires that your doctor get approval from your insurer to prescribe a particular medication, therapy or service. Insurance companies usually require prior authorization for treatments and medications that are not covered by name or on higher tiers. If prior authorization is not received, your insurance company may deny coverage for your medication. Prior authorization equals more paperwork for the doctor’s office, which can delay a patient’s access to critical medications that provide symptom relief.
Increasingly, insurers are shifting a larger percent of the cost of treatments, usually for specialty drugs on higher tiers, to the patients. These increases in out-of-pocket costs for the patient can come in the form of higher copayments or requiring patients to pay “co-insurance” – which is a percentage (sometimes up to 30%) of the actual cost of the treatment.
National Eczema Association is working to curb cost-cutting measures by health insurance companies so that our community can access the care and treatment they need to best manage atopic dermatitis. Please join us in this important work. Sign up as a Grassroots Advocate today.