We are fortunate to have plentiful acne treatment options available that cater to each patient’s clinical examination, predispositions, and triggers, but the choices are daunting amidst the vast prescription and over-the-counter (OTC) topicals available along with disparate insurance and cost nuances. In addition, when prescribing generic oral therapies, it is complicated to parse out regional differences in price, supply, and insurance coverage to advocate best for each patient and land upon the delicate balance between efficacy, safety, and financial stewardship, both at an individual and community level. I will outline some challenges and solutions to the management of acne amidst these complicated factors.
For isotretinoin, generic choices, cost, and tiering within insurance plans are perpetual moving targets despite the drug being the only member of its class.1 Prescriber resources include tandem searches of electronic medical record price estimates within each insurance formulary, individual pharmacy search engines, and compilation mobile applications such as GoodRx to select the most affordable version for each patient. As an example of a regional trend, isotretinoin generic coverage by one provider in Pennsylvania shifted earlier this year so that every patient, whether new to isotretinoin or midcourse, required a new prior authorization with more stringent coverage requirements including failure of 2 oral antibiotics. Swiftly thereafter, efforts across the state driven by the Pennsylvania Academy of Dermatology and Dermatologic Surgery and its members and fueled by poignant patient vignettes about fragmented and substandard patient care helped to reverse this policy and remove the prior authorization mandate.2
Tetracyclines have experienced broad cost swings, mostly based on disruption of manufacturing at the limited number of distribution sites in the United States. In 2011, a tetracycline shortage arose due to a major manufacturer’s recall3 and persisted with subsequent material shortages, as doxycycline became the preferred and cheaper member of the class. Doxycycline price tag hikes then occurred following Hurricane Sandy when an East Coast manufacturing site was damaged.3 Spironolactone backorder also has been frequent due to recent raw material shortages and delays in production,3 forcing pharmacies to refill small amounts of medication in various dosage forms despite patients owing the same copayment per prescription.
Topical retinoid prescription affordability has always been fraught with difficulty owing to age cutoffs because it is often restricted to patients younger than 25 or 40 years, depending on the plan,4,5 but the availability of adapalene gel 0.1% as an OTC preparation in 2016 has broadened retinoid access and use.6 Prescription benzoyl peroxide (BPO) products alone or in combination with retinoids or topical antibiotics (or other combination topical therapies) comprise a large number of branded prescriptions often not covered by insurance or are only affordable using proprietary and intermittently available coupon cards (eg, BPO-clindamycin, clindamycin-tretinoin, BPO-adapalene); therefore, prescribers tend to dispense the individual ingredients and instruct the patient to compound them at home. Furthermore, BPO products can be purchased in effective concentrations as OTC products, and patients looking to procure more affordable, albeit less effective, topical retinoids that also have less irritation potential reach for OTC nightly retinol creams nestled in the antiaging section of the pharmacy.7
Opportunities to be involved in the larger scaffold of patient advocacy also are plentiful at the state and national levels. For example, with the support of dermatology state societies and the American Academy of Dermatology Association, Pennsylvania House Bill 22118 and similar bills in other states call for reversal of the gag clause that prevents pharmacists from disclosing the best medication price to patients. Also guided by the American Academy of Dermatology Association, prior authorization model legislation to promote transparency across insurers in this haphazard process is emerging across the country.9,10
These examples of acne medication access and cost quandaries serve to embody the daily problem-solving that dermatologists execute as part of their growing administrative and economic duties. They also represent worthy efforts to consider on behalf of patients, their pocketbooks, and the prudent use of their dermatologists’ time.