NEW ORLEANS Dermatologists who prescribe biologics for psoriasis need to be able to navigate the insurance maze so that most patients can benefit.

It is important to fully understand the patient and his or her needs, to adequately document the patient's condition, to submit adequate documentation to the insurer, to know the specifics of the insurance company and the patient copayments, and to be able to make a strong appeal when claims are denied, Carol F. Guidry, R.N., said at a dermatology update sponsored by Tulane University.

Each patient should complete a psoriasis questionnaire that describes his or her condition, comorbidities, and prior treatments, said Ms. Guidry of the department of dermatology at Tulane University, New Orleans, where she helps procure coverage for psoriasis patients needing biologics. This helps select the most appropriate agent and provides information that will be useful in seeking preauthorization. Body surface area should be adequately calculated, as many companies use this number to approve or deny a drug. Patients should expose palms, soles, and genital areas, which might be missed.

Because almost all insurance companies require prior authorization for injectables, forms for preauthorization should be completed while the patient is in the office; the patient's next visit should be scheduled no sooner than 2 weeks later to allow time for a response.

To submit a request, the nurse or office staff will need the chart and physician's notes, lab work and x-ray results, insurance demographics sheet, psoriasis questionnaire, and specific drug paperwork.

"Because most insurance clerks receiving this lack medical knowledge, I recommend completing the form yourself, rather than having the clerk take the information over the phone," Ms. Guidry said.

Most insurers require that the following criteria be met for approval of biologics: diagnosis of chronic moderate to severe plaque psoriasis; failure of phototherapy and/or at least one systemic therapy; for psoriatic arthritis, failure on at least one disease-modifying agent; and documentation of a negative tuberculin skin test. Most will deny injectables for plaque psoriasis in pediatric patients, she said.

"Make sure [body surface area] is written or dictated in the physician's documentation or referral form, and make sure to specify if the condition is plaque or guttate," she said. "Also, document dactylitis, enthesitis, and joint pain for psoriatic arthritis patients. Submit any x-ray findings that document erosions, joint deformities, and so forth, and submit laboratory values."

Ms. Guidry emphasized the need to be proactive and fully informative about the patient. Insurance companies will generally push for conventional systemic therapies to be administered instead of biologics. This should be anticipated, and the preauthorization request should present a strong case against it.

"Note preexisting comorbidities that may be contraindications for systemic therapy. You can make comorbidities [such as obesity and fatty liver] work in your favor," she said. "If the patient has to commute more than 50 miles for phototherapy, or if the patient's occupation requires travel or shift work that would make monthly monitoring difficult, this should be stated."

Although Medicaid does pay for injectables, Medicare is not likely to. Medicare patients usually cannot afford biologics because they must meet their initial yearly deductible, and after the deductible is met, the patient must satisfy the "doughnut hole"the $2,200 out-of-pocket gap. After the gap is satisfied, the patient is eligible to receive the drug, but 10% of the cost is the patient's responsibility.

Medicare recipients also are not eligible to use copay cards. They must go through the chosen drug company and complete that company's paperwork. The drug company will contract out for patient assistance. This process can take 6 weeks or longer. Infliximab might be an option for Medicare patients because it is usually considered under the major medical plan.

When preauthorization is denied, find out why. If conventional therapies have not been pursued, the patient might need to undergo a trial of these and then reapply. Decisions can be appealed, or physicians can request a "peer-to-peer" review if a decision seems unjust. The benefit of this is an immediate answer from the medical director.

More Prescribing Tips for Biologics

▸ To save time, check the patient's insurance coverage before starting to complete forms.

▸ Get to know drug company representatives who can help obtain copay assistance for patients.

▸ For infliximab, use an infusion center if possible; they do the legwork with the insurance company. Find one at

www.2infuse.com

▸ Use specialty pharmacies when possible. They help with paperwork, ship the drug to the patient (keeping physicians informed), and help obtain copay assistance.

▸ Use drug samples to augment treatment when response is waning.

Source: Ms. Guidry

Navigating the Insurance Maze of Biologics Tx