INTRODUCTION
Dermatologists are often frustrated by payer constraints that limit their ability to optimize patient treatment. Matters are increasingly contentious between payers and physicians in this age when biologics offer patients great promise but place a substantial burden on pharmacy budgets. Patients with moderate-to-severe psoria- sis have an often debilitating, chronic, inflammatory condition that impacts their quality of life, through effects on their physical, psychological, and social well-being.1-4 A systemic illness, psoriasis is associated with an increased prevalence of comorbidities affecting different organ systems, resulting in a decline in overall health and increased risk of early mortality.5 Biologics have revolutionized the ability to safely and effectively treat psoriasis; however, they are costly and many insurance plans restrict their use. For commercial insurance, physicians and patients who are unhappy with coverage decisions can register complaints with their state health commissions. Such an assertive approach leads to defensive posturing on the part of payers, perpetuating an antagonistic relationship. Recognizing that dermatologists and payers share the goal of optimizing patient care is a key step toward constructive collaboration that can benefit individual patients and potentially shape drug coverage policy for all patients. Many dermatologists are experienced in appealing on behalf of an individual patient, but they may not know how to influence overall payer policies. Understanding the payer formulary process gives insight into entryways where physicians can make a difference (Figure 1). In this paper, we discuss the steps of the formulary process and suggest ways in which dermatologists can impact payers’ coverage policies.
Formulary Process and Intervention Opportunities for Dermatologists
Critical to medication access is generation of the formulary, a list of covered medications under a particular payer plan and the policies under which drugs are at least partially reimbursed. The process is set in motion at scheduled intervals, generally within 90 days of Food and Drug Administration (FDA) approval of a drug or if there is a significant change in the marketplace. Because dermatologists are knowledgeable about skin diseases, their treatment, and patients’ medical needs, they are in a unique position to influence the formulary process. This influence is most effectively exercised when common goals of both parties (payer and patient) are recognized. To achieve positive change, dermatologists need a good understanding of the payer formulary process and the steps at which they can intervene.
Pharmacy and Therapeutics Review
The health plan’s clinical pharmacists provide the initial review of a medication before it is referred to the Pharmacy and Therapeutics (P&T) committee. This committee includes payer pharmacists, pharmacy and medical directors, other payer representatives, as well as physicians (internal and external to the plan) represented. The P&T committee makes all final formulary decisions. The plan’s pharmacy team is primarily responsible for sharing with the P&T committee their review of clinical trial results, outcomes research, clinical compendia evidence, treatment guidelines, and FDA-approved labeling. The team is also responsible for understanding the current treatment landscape, the pipeline for new medications, and the potential future landscape. P&T committee pharmacists may have little clinical experience with dermatology patients and their issues.
