Biologics like Skyrizi are specialty medications: expensive drugs used to treat complex, chronic conditions like psoriatic diseases. My insurance provider, Anthem, won’t cover the cost without first agreeing that the medication is medically necessary. Ideally, my dermatologist sends the required paperwork to the insurance provider and gets a quick approval. I can then fill my prescription for the duration of the authorization (currently mine is for one year). But that’s not always how things work out.
So Many Roadblocks, So Much Frustration
Sometimes the insurance provider denies approval for a new prescription, requiring that I first take another, lower-cost medication and show it doesn’t help, an approach called step therapy. There can be other obstacles. Once my insurance provider denied covering a prescription because I was already taking a different specialty medication, and there weren’t studies showing that the two drugs would work well together. Other times I’ve run into problems with current prescriptions. Late last year, the specialty pharmacy I rely on, IngenioRx, could no longer use my active prior authorization when the dose delivery changed from two smaller syringes to one larger syringe. This shift required a new prescription from my dermatologist and a new prior authorization approval from Anthem. My frustration level peaked when the insurance provider told me after several phone calls that the new prior authorization would take three extra days — expedited from seven.
How to Get the Meds You Need
I’ve learned a lot from my almost 20 years of taking specialty medications for psoriasis. Here are five tips I’ve gleaned that I hope will make the process of getting your medication as smooth as possible.
1. Find a Healthcare Provider Who Will Help You
A healthcare provider who will go to bat for you is incredibly helpful when you’re seeking prior authorization for a prescribed specialty medication. My dermatologist, Christie Carroll, MD, and the dermatology clinic office are my best specialty medication advocates. Dr. Carroll not only prescribes my Skyrizi but also prepares the paperwork required for the prior authorization process. In addition, the clinic office employs a full-time staff person who helps with specialty medications. I’m confident that the clinic team can handle any difficulties with filling my medication. They are good at their jobs and have built trust with me by quickly responding to my messages (typically within a day). I know I have a team behind me if there’s a problem.
2. Keep Track of Your Medication Information and Schedule
Receiving my next Skyrizi dose on time takes planning and organization. I keep information related to my prescription in an online document. Any paperwork, such as prior authorization approval letters, goes into my paper files. It’s crucial that I keep track of when I take Skyrizi so I know when to request a refill. I currently inject every eight weeks. I create two calendar entries and set phone and email alerts: one to call for a refill and another for injection day. IngenioRx also texts me when my medication is available for a refill. I’ve worked out my system over the years; you may need to find your own method for staying organized and on schedule.
3. Request a Refill from the Specialty Pharmacy Early
My wife tells me I need to get ready earlier for meetings or appointments because I have a bad habit of arriving 5 to 10 minutes late. If I only woke up with my alarm or packed my bag the night before, I could be on time. The principle of planning ahead applies to getting specialty medications, too. If I have an active prescription and prior authorization in place, I call the specialty pharmacy one week before I need my medication. In certain circumstances, I call even earlier. For example, a new year can bring about changes to insurance coverage, like it did for me. In January, the pharmacy needed extra time to figure out how to bill for my Skyrizi with the new coverage. I also build in extra time when I need a new prescription or updated prior authorization. Knowing my current prior authorization ends next January, I’ll message my dermatologist to make sure her office has sent a request in December. Be sure to request your specialty medication refills early so you don’t miss or delay a dose.
4. Determine How Much the Specialty Medication Costs You
A major concern with specialty medications is out-of-pocket costs. You might have a prior authorization approved and an efficient organization system, but if you haven’t planned for a high copay or deductible, you could be in trouble. Many drug manufacturers have financial assistance programs with information posted online about how to apply. These programs help cover the patient’s share of the cost of a medication or even offer it for free. With my employer-provided insurance coverage, I am eligible for a savings card that allows me to pay only $5 for each Skyrizi dose. In addition, my state, California, passed a cap on copays for a month’s worth of an individual medication; you may want to check if your state has a similar provision. It’s also helpful to check your insurance provider’s drug formulary to see which medications it includes and how much they cost with your coverage.
5. Reach Out to a Patient Navigator
You might face addition challenges in getting your specialty medication, such as going through the appeals process for coverage denials or choosing the right insurance plan. One great resource to turn to is the National Psoriasis Foundation’s Patient Navigation Center. Patient navigators are available through email, chat, and phone. My assigned patient navigator is Savanna, whom I talked to in preparation for this blog post. She reminded me to always be my own best advocate, especially when changing insurance companies. Negotiating the specialty medication system can take patience, assertiveness, and perseverance — but clearer skin makes it worth it.
