Insurance Coverage of Biologics for Moderate-to-Severe Psoriasis: A Retrospective, Observational 5-Year Chart Review
- 272 Downloads
With the variability in health insurance coverage for psoriasis systemic therapies, recent changes in coverage for biologics have yet to be evaluated.
To determine changes in insurance coverage of biologics for moderate-to-severe psoriasis between 2009 and 2014, with a focus on insurance policies as stated in prior authorization (PA) forms, coverage denials, and time course of approval process.
A retrospective chart review was performed on patients with a diagnosis of psoriasis (International Classification of Diseases [ICD], Ninth Edition, code ICD 696.1) seen at the Department of Dermatology, Medical Faculty Associates, George Washington University between January 1, 2009 and December 31, 2014. Exclusion criteria included <9 % body surface area, loss to follow-up, lack of biologic treatment, biologic treatment via a clinical trial, and lack of health insurance. For all other patients, metrics collected included age, sex, body surface area, health insurance plan, prior therapies, prescribed biologic, PA necessity, time in days between PA submission and coverage decision, and denial justifications.
Eight hundred and sixty-four patients with a diagnosis of psoriasis within the time period were identified, 114 of who met the inclusion criteria. PA requirement increased from 16 % of patients prescribed a biologic in 2009 to 75 % of patients prescribed a biologic in 2014. The mean duration in days between PA submission and coverage decision from the insurance company increased from 3.7 days in 2009 to 6.7 days in 2014. PA denial rates increased from 0 % in 2009 to 19 % in 2014. The most common reason for coverage denial was failure to attempt alternative therapies prior to requesting biologics.
Insurance coverage of biologics for moderate-to-severe plaque psoriasis has become increasingly regulated between 2009 and 2014. Given both the cost burden and potential benefits of these therapies, further examination of healthcare coverage and treatment accessibility is warranted for optimal patient outcomes.
KeywordsPsoriasis Etanercept Body Surface Area Adalimumab Plaque Psoriasis
Compliance with Ethical Standards
No funding was received to support the preparation of this article.
Conflicts of interest
The authors Dr. Mai Abdelnabi and Dr. Monica Rengifo-Pardo declare no conflict of interest. Dr. Ehrlich discloses that she is a speaker for Abbvie and Celgene. She is a Principal Investigator for Merck, DUSA, Regeneron, Lilly, Abbvie, and Janssen. Mr. Aakash Patel received a Health Services Scholarship from the George Washington University School of Medicine and Health Sciences for a summer research fellowship during 2015.
- 5.Goff CV, Hoffman JC, Vogenberg R. Biologic therapy management: the need for value-based health benefits models. A peer-reviewed white paper by the Biologic Finance and Access Council. Manage Care. 2008;17(3):14–27.Google Scholar
- 9.National Association of Insurance Commissioners. http://www.naic.org. Accessed 28 Mar 2016.