Help patients appeal denial of psoriasis drugs

Academy President Abel Torres, MD, JD, a Cleveland-based dermatologist and lawyer, discusses the issue of Pharmacy Benefit Managers (PBMs) changing their formularies by removing drugs, requiring stable patients to switch to another treatment based largely on economics and not the efficacy of the drugs.

Member to Member: Effective Jan. 1, 2017, CVS Health and its CVS Caremark Advanced Control Formulary stopped covering Enbrel, Cosentyx, and Otezla for psoriasis patients. What can be done in an effort to keep patients on these medications without having to pay the full cost for the drugs?

torres-abel.jpgDr. Torres: Regrettably, no blanket grandfathering is being offered by CVS Caremark. However, dermatologists do have the option of navigating a formulary exception process on behalf of their patients, a process which will require them to deal directly with a physician employed by CVS. While their physician(s) are appealing, patients will be permitted to continue on their current treatment and remain covered.

To help dermatologists appeal on behalf of patients, the Academy has developed downloadable template appeal letters for Enbrel, Cosentyx, an Otezla. CVS Caremark has indicated to us that appeals will be heard and responded to within 23 hours.

If your patients are being required to switch from these drugs following the January 1 formulary change, I encourage you to contact David Brewster at in the Academy’s Washington office. David is collecting data, including the length of time it is taking for appeals to be decided, to share with CVS Caremark regarding outcomes we are seeing as a result of this change.

 Download appeals letters

Click on the drug names below for template appeal letters.

Enbrel   Cosentyx  Otezla

MTM: What is the Academy’s position on the larger trend of PBMs requiring patients to switch treatments due to economics rather than efficacy?

Dr. Torres: This trend is quite problematic, of course, particularly when it comes to the switching of biologics. Forced switching poses significant risk to patients, possibly resulting in harmful outcomes like flaring of the disease, immunogenicity, adverse effects, and secondary nonresponse. It may also lead to the loss of effectiveness of the original medication, should the patient switch back at a later time.

The American Academy of Dermatology Association (AADA) is opposed to the non-medical switching of patients and mid-year changes to a formulary. Accordingly, we are working with partner organizations, including the National Psoriasis Foundation, to maximize our impact in addressing new formulary restrictions and helping make a meaningful difference on behalf of our patients.

Additionally, the AADA has received reports that some PBMs are removing coverage for certain existing grandfathered drug products with a long historical record of safety and value. Being excluded from some plan formularies will be several commonly-used topical dermatologic drugs including Dermazene, Proctocort, Alacort, hydrocortisone-pramoxine, and hydrocortisone-iodoquinol.

Upon review, most of these drugs are often available over the counter in different forms. For example, both hydrocortisone 1% (Proctocort) and pramoxine are available over the counter. The exceptions are products containing iodoquinol, an old monograph anti-infective agent long used in dermatology in combination with hydrocortisone, but lacking published studies of clinical trials to support its use. Dermazene, Alacort, and Vytone all contain a combination of hydrocortisone and iodoquinol. While these products will not be available on certain formularies, some may be available over the counter. I’d also note that the conditions for which these products are used can be treated with alternative over-the-counter and prescription drugs that remain available.

The AADA agrees that insurers’ and PBMs’ efforts to link treatment indication to whether or not a drug is approved is disrupting the patient-physician relationship and taking the treatment decision out of the hands of the physician. Therefore, the AADA’s Patient Access and Payer Relations Committee, which oversees the key advocacy issue of narrow networks, will be focusing their attention on narrow formularies and the attempt to interfere with the physician decision-making process for treating patients. The committee plans to highlight this issue to various medical directors over the coming months to ensure our position is made clear.

Related resources: