Casey Butrus, PharmD: I know you mentioned, Amy, that prior authorizations are on every dermatological medication right now, and I think mainly it’s due to the cost, such as with topical corticosteroids. There are some corticosteroids that are pennies and others may be $600, so if we can promote the use of a cost-effective steroid, understanding the appropriate dosage for them in areas that can cover the patient’s area of atopic dermatitis [AD], that could be an easy cost-saving opportunity where all topical corticosteroids can pretty much be considered similar for most patients.

With the new biologics and systemic orals coming to market, these are also drugs that are very expensive and not without costs, so some things that I consider when I’m writing a prior authorization is, are we making sure this is the appropriate FDA-approved age? Is this the appropriate FDA-approved indication? How are we defining the severity? Are we allowing attestation? Are we requiring, as we mentioned, those IgA [Immunoglobulin A] scores or EASI [Eczema Area and Severity Index] scores to be submitted by providers, and also step therapy? Are we promoting the use of cost-effective agents that can be used potentially before these biologic therapies? I’m wondering, from your perspective, how you navigate the prior authorization process of different health plans that may be requiring different information.

Amy Brennan: You’re right, it is so nuanced. There’s a reason why these utilization management criteria are in place, and as you said, it is to limit the cost and to make sure that the medications that are being prescribed are for the appropriate patient and the appropriate dose, the appropriate duration. So it is oversight, but I think it’s good oversight, as long as you know how to work the process, so it really can be a simple process. It is a lot of times as simple as just filling out yes or no check boxes on the prior authorization requests. You get into electronic prior authorizations. That eases the burden of access as well because you’re getting real-time criteria questions from that insurance company. Just easily proving to them that the patient meets the criteria that they have in place, and then they get that approval on file, as well as you’ll see the automatic electronic adjudication for some of those, where the insurance companies are smart and they have the step therapy in place, but they will do a look back through the claims.

So if your patient has filled that drug in a time period, as you said, the 90 days or 180 days, or whatever it may be, if they see that claim history, that insurance company can automatically approve it without going through a traditional paperwork prior authorization process, which I think is a great avenue for your patients.

Casey Butrus, PharmD: I agree. I think the electronic adjudication is definitely helpful at the point of sale to reduce the amount of paperwork burden for these provider offices, but also from the health plan perspective. Reducing the amount of utilization management cases that we get, so we can prioritize our cases to those requests that maybe require more pharmacist attention, so do you notice topical vs systemic agents? Where do you find the adjudication to be most useful?

Amy Brennan: Definitely the topicals. Systemics here and there. I would say it is not a great space for the specialty drugs or the biologics or the injectables because that’s where it gets, I think, very convoluted and complicated and nuanced to the patient case, and the reason why you’re prescribing one modality over another, but topicals, definitely. I think if you can eliminate or limit the prior authorization paperwork and the workload for the payer, the provider, and the pharmacies, that will leave you more time and more energy to focus on the cases that should be having manual oversight.

Brian Keegan, MD, PhD: I think, if I can jump in, one thing that would be helpful from providers is better guidance on where they want us, where insurers may want to direct us. I don’t want to get in trouble with Dr Cameron, I’m giving up my choices in the world, but if the insurance companies are going to have input on which medicines we’re going to put our patients on, then I would appreciate more clear feedback from them. What do I mean by that? Sometimes the medicine just says “rejected” and leaves me shrugging my shoulders with where I’m supposed to go next, or I’m told I can have an appeal, but if it’s rejected, because I haven’t done this topical medicine or that topical medicine, then I would love the input to tell me the pathway that I need to have.

Or if they want to preemptively tell me now, “Here’s the pathway. He can do this, then do this, then do this,” then that would work for me but at a minimum when I get feedback, I’d love to know where I’m going to go next because sometimes I get feedback, and then I prescribe another medicine, and then that gets rejected, and then I prescribe another medicine, and that gets rejected, and I’m left shrugging my shoulders going, “What am I supposed to do? How can I get them to the next step? I don’t want to make it sound like it’s terrible all the time, but there are ones that are trouble that you remember in your head.

Michael Cameron, MD, FAAD: I’m lucky to have pretty good support with the approval process, so I’m not too involved, and so I think I probably know the least at this table about getting it approved because my institution does a lot for me, thankfully. But I have to say, look, I know the payers are trying their best, and there’s a finite supply of financial resources to pay for all this. But I do think sometimes the step therapy process makes no clinical sense, honestly, and I wonder who developed it.

And so, I’ve had instances where I’m trying to write Dupixent [dupilumab], and they say, “The patient must fail crisaborole first,” and I’m like, “That’s not going to work.” Because they have very severe atopic dermatitis, and it may burn to put it on. So, there are instances where I encounter a clinical step therapy process that is not only a waste of the patient’s time, but sometimes, honestly, it could be harmful to the patient.

Brian Keegan, MD, PhD: And a potential waste of the insurance company’s money…

Michael Cameron, MD, FAAD: Money and time, exactly.

Brian Keegan, MD, PhD: …to fill a medicine that has a very low probability of success.

Michael Cameron, MD, FAAD: Exactly. I think that’s not happening all the time, but it certainly does happen sometimes. So I think just continuing to work with clinicians on developing these step therapy processes so that they make sense in terms of containing costs, obviously, which is a goal for all of us, but then also putting the patients first.

Amy Brennan: I think that’s a big part of this landscape is understanding, like you said, what the insurance companies are looking for, but also where they stand on those criteria, is it a hard stop? Is it something that they’re willing to look at to have a discussion about? Because some of those criteria are put in place because they are for a specific patient population, where it wouldn’t make sense for other patient populations. So sometimes just taking the extra step to say, “This is your criteria, but this is why it doesn’t apply to this specific case,” is usually how you get past that.

And that’s where I think a key part of that, as you mentioned, is the support staff in the office, because this is a complicated landscape. It’s not possible to do it yourself, you don’t have the time, the capacity to be waiting on hold, calling for peer-to-peer review, setting up those schedules, so it’s important to have the support staff in the office to be able to take some of that burden from you and do that for you, and sometimes even guide you in the right direction. Because that is my job on a daily basis to know the specific criteria for each specific insurance plan in my region. So I know, “This payer is looking for this, this payer is looking for that,” and how we go about working that into our clinics, specifically for each and every patient.

Brian Keegan, MD, PhD: And I think you make another valuable point out there, how much staff this can require. In 14 years of dermatology, I’ve seen the number of people in our office balloon in terms of support staff vs the number of prescribers that’s stayed relatively consistent. This has created a financial burden on the health care system as well…in order to move from the perspective of people working within offices or institutions, how many people does it take to move through, which indirectly raises the cost for everything and everyone.

Casey Butrus, PharmD: I think you bring up a good point just about the inner insurer variability of what insurers are requiring. Realistically, if you have 20 patients coming into your office, all 20 of them can have different insurance. How are you expected to manage your patients and know what the insurance is going to require? I think that’s a really valuable role of having a biologic coordinator. But, unfortunately, not a lot of practices have that role available, and it’s left to the burden of the administration and the staff that’s in that office.

Michael Cameron, MD, FAAD: Not only insurance but regions. I do a lot of talks all over the country, and when I go visit other regions, they have different requirements. I was down in Texas recently, and they were telling me that they required failing calcipotriene before going on to Betadine [povidone-iodine] for psoriasis, and I haven’t written calcipotriene in 10 years; it just doesn’t even enter my mind anymore at this point. I’ve never seen that up here in New York, so it’s not just the insurance payers, but it depends on where you are in the country as well.

Casey Butrus, PharmD: I think that goes back to the transparency, and I think that’s where we’re seeing the future of electronic prior authorization or even real-time pharmacy benefit checks, real-time authorization to let the prescriber know, at the time of prescribing, “Hey, this is the criteria that you need to meet to get approval. This is where you went wrong. This is what’s on our formulary-preferred tier. This was not approved because it was nonformulary.” Having that transparency and utilizing the technology we have available, hopefully in the next 10 or so years, will be the future of dermatological prescribing. Of course, it’s always a slow process, but I think we’re trending toward there, and I know some of the more innovative insurance payers are starting to use this technology.

Transcript edited for clarity.