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

Medication access a problem

The problem with access to medication is not only an insurance issue, but also a financial issue for the patient. Many patients have signed up for insurance plans where they must pay $2,000+ out of pocket to meet a prescription deductible. The concept of a pharmacy deductible is new to many patients. This means patients must save up financial resources to cover all medicines out of pocket before the deductible is met.

It is amazing, but a tube of generic high potency topical corticosteroid costs around $100 for a 60gm tube. This price makes me LOL, especially since the same tube cost $40 last year. It is possible to select less expensive medication alternatives, but sometimes they are simply less effective.

READ: The tale of the $220 tube of clobetasol cream 

Ideally, the patient wants an inexpensive medication that works great; however, this is not always possible. Either way, I seem to lose as a physician because the patient is unhappy with an expensive medicine that works and equally unhappy with a cheaper medicine that does not work.

In the end, I find myself COL.

The insurance formulary has one goal: To make money for insurance companies. In this regard, it has been very successful, as exemplified by the 25% increase in 2014 in the Vanguard Health Care Fund with a continuing upward trend in 2015. However, this investment gain comes at a steep cost in terms of patient satisfaction and physician emotional well-being.

The only person LOL-ing is the insurance administrator who got a raise.