Fighting for Coverage: Combatting private insurance to get patients on the drugs they need

Alopecia areata can be a horrible condition for a woman in her mid-30s. Baricitinib had worked wonders for one of my patients with alopecia, a 35-year-old nurse who had taken the JAK inhibitor for more than a year—until she had to switch to a new private insurer that refused to cover it. The insurance company insisted that she try methotrexate, which we knew would be less effective. The patient ended up suffering from alopecia totalis, which was psychologically devastating. The insurance company eventually covered ritlecitinib, and the patient regrew her hair, but it took almost a year to regrow what she had lost in only 2 or 3 months. The emotional toll it took on the patient was significant and had a lasting impact.

Aside from decreasing reimbursement rates, obtaining prior authorization from private insurance for medications that our patients desperately need to improve their lives, improve their skin conditions, and improve their wellbeing is probably the greatest challenge that dermatologists face today. We have many wonderful new therapeutics available, but getting them paid for is a significant challenge in probably 80% of cases. For my 12 practices, I employ four people whose only job is to deal with insurance companies. Usually, we are able to get the appropriate treatment covered eventually, but the delay of care can have lasting physical consequences and also often erodes patient trust in the healthcare system as a whole.

BRIDGE OPTIONS

Sometimes the most effective solution is to simply go around the insurance companies by enrolling a patient in a pharmaceutical manufacturer’s patient assistant program (PAP), also known as free drug or bridge programs. PAPs are often available for newer agents as the manufacturers aim to demonstrate to insurers that they should be added to their formularies. I have successfully utilized these programs for ritlecitinib, abrocitinib, and secukinumab, among others. They are typically for commercially insured patients, but these programs also can provide assistance to Medicare Part D enrollees and interface with Part D plans by operating “outside the Part D benefit.”1 While these programs can be very helpful, they can be challenging to utilize, involving multiple prior authorizations that take a lot of staff time. They are also more of a short-term solution to buy time for proper coverage.

STRATEGIES AND RESOURCES

With so much back and forth and so many delays, it can be easy to lose track of a prescription; we call it the leaky bucket effect. I strongly recommend that any practice utilize some sort of software that helps track prior authorizations. With everything in one centralized system (we use RxNexus from Lyceum Health ), there is no leaky bucket. At one point in our clinics, the average time from when we write a prescription to when the patient gets the first fill of a biologic was around 6 weeks, but with the help of an organized system, we have gotten that to less than 2 weeks. RxNexus says prior authorization acceptance rates increase to approximately 90% with RxNexus biologic coordinators. Our system also sends a reminder when it is almost time to refill the prescription, (another pain point). It also utilizes artificial intelligence (in part) to help us formulate our prior authorization and appeal letters. ChatGPT can also be a useful resource for this.

With that said, the job of the biologic coordinator remains important because any system will only be as good as the information that goes into it. Biologic coordinators must follow careful protocols regarding charting, ordering labs, and, of course, including the proper ICD-10 code.

Perhaps the most common pitfall, when attempting to obtain prior authorizations, regardless of system, is insufficient documentation of what medications have been tried and failed. If you only say that the patient has been on six medications, but you don’t provide enough details about those medications and how they failed, you will get an almost automatic rejection.

The second piece that I instruct my clinics to include in any prior authorization application is body surface area. The third piece is how the disease is impacting the patient’s quality of life. The dermatology life quality index (DLQI) can be helpful in expressing this. I also often note the specific social and physical impacts, such as reduced ability to interact and function in society. The key is to ensure that the insurance company does not interpret the condition as non-essential just because it may not be life-threatening.

APPEALING DENIALS

Even with the proper measures in place, insurance companies will still often deny coverage, and an appeal becomes necessary. One of the biggest challenges when we appeal a denial is that the people we are dealing with at the insurance company almost never know much about dermatology, nor do they seem to care. They are paid to review the case and they often deem something not medically necessary because they do not understand the burden of some of the diseases we are treating. I have also encountered insurance representatives who tell me a certain therapeutic is not FDA-approved, when I know that in fact it is. In all of these cases, the key is to be confident, thorough, and persistent in our communications. It takes a lot of time and effort on the part of both the clinician and the staff, but it is what is necessary to get patients the drugs that they really do need.

My biggest specific recommendation is to match the language from the denial letter and note if you are including a letter of medical necessity along with the appeal letter. For example, if a denial for risankizumab states that the patient has not tried infliximab, you might say:

We understand that the reason for your denial is that you want us to try infliximab instead of risankizumab. However, we believe that risankizumab is the appropriate treatment for the patient. In support of our recommendation of this treatment, we have provided an overview of our patient’s relevant clinical history below.

Send the patient’s medical records and discuss your rationale for why they need treatment. Photographs are helpful because a picture is worth 1,000 words.

Again, artificial intelligence can be a useful tool. The American Academy of Dermatology (AAD) also makes available a prior authorization appeal letter tool that, at the very least, can be a helpful starting point.

THE FIGHT GOES ON

The best strategy is to be as proactive as possible in our initial documentation and then as thorough and persistent as possible in any appeals. I had one patient with severe hidradenitis suppurativa who had failed adalimumab, and while secukinumab was not approved by the FDA at the time, there were extensive studies on it. We presented the data from those studies and said this patient needed to be prescribed secukinimab, and it was approved for coverage. It took 3 or 4 months, but we got that patient on the treatment she needed.

Insurance companies likely will continue to challenge dermatologists for the foreseeable future. Devoting the necessary time and resources to prior authorizations and appeals needs to be viewed as simply part of running a practice. Patient satisfaction scores can increase substantially when they receive the recommended medications as quickly as possible. Fighting insurance companies is an absolute necessity to provide the best care for our patients, and with persistence and the right strategies, it is a fight that usually can be won. 

Disclosure: Dr. Blattner has been paid as a consultant for Lyceum Health

1. Pharmaceutical Manufacturer Patient Assistant Program Information. Centers for Medicate & Medicaid Services. https://www.cms.gov/medicare/coverage/prescription-drug-coverage/patient-assistance-program. Updated September 10, 2024. Accessed July 2, 2025.