Speaking at the recent Biologic & Small Molecule CME Bootcamp on May 3-4, 2024, Rosa Oxlaj, a biologic coordinator at Schweiger Dermatology in New Jersey, highlighted the critical role she and other biologic coordinators face in ensuring patients receive necessary medications in a timely way.
The biologic coordinator is a pivotal part of the intricate processes of obtaining prior authorizations, discussing treatment plans with patients, and managing the logistics of acquiring treatments from specialty pharmacies. The coordinator’s role is to act as a mediator between patients, healthcare providers, insurance companies, and pharmacies to streamline the drug acquisition process.
Ms. Oxlaj pointed out that each patient’s case could vary dramatically based on their insurance plan and the specifics of their medical condition. She shared insights into the appeals process, the critical need for timely submission of medical tests like the tuberculosis (TB) test, and the frequent requirement of insurance companies that prescriptions be filled through specialty pharmacies only.
Patients are often anxious about their treatment, so Ms. Oxlaj highlighted the importance of clear communication, particularly in explaining the reasons behind insurance follow-ups and the specifics of the prescribed biologic treatments, including how she discusses this with patients. She emphasized the role of electronic and physical documentation in expediting these processes, underscoring the need for accurate and timely paperwork.
Some of the key take-aways include:
- Submit prior authorization requests to insurance companies with required documentation. Some examples include:
- Starting BSA % and location of body
- For prurigo nodularis: Itch score, number of nodules and quality of life.
- If the prior authorization is denied, prior to appeal, have provider amend chart note as to why the specific drug is requested rather than what the insurance prefers (i.e., avoiding liver toxicity).
- Provide all additional relevant clinical information.
- Some insurance companies require patients to sign an appeal letter to give the provider’s office authorization to appeal on their behalf.
- Prescribe or document trial medications if required by insurance before approving biologics.
- Refer patients to patient assistance programs if insurance or Medicaid will not cover medications. Ms. Oxlaj discussed several bridge program examples and how she utilizes each.
- Schedule follow-up appointments as required by insurance to maintain approvals.
One of the key points made during the presentation involved the use of patient assistance programs. These programs are crucial for patients who face denials from insurance companies or who cannot afford the high cost of biologics. These programs often require proof of income and other financial documentation.
The presentation concluded with an overview of the collaborative efforts required among different healthcare staff members to manage biologic treatments effectively. This includes medical assistants, doctors, and external pharmacies, all coordinated by the biologic coordinator to ensure that each patient receives their medication and understands every step of the treatment process.
Ms. Oxlaj highlighted some of the biologic programs that offer quicker options to get a patient started on therapy only with commercial insurance. They include:
- Guselkumab (Tremfya®) Janssen Care Path: Offers a free starter dose to start the patient on therapy while PA is being processed. The requirements for this option are minimal as long as the patient has active commercial insurance, and the enrollment forms are properly signed and filled out.
- Dupilumab (Dupixent®) “Quick start program”: Patients with commercial insurance who are approved will get the medication for free for 6-12 months until denials and appeals have been submitted/approved.
- Ixekizumab (Taltz®) “Taltz Together” $25 copay card: Patients are able to get medication for $25 even with denials or pending appeals. If their medication is approved this copay assistance card will bring medication as low as $0-$5.
- Ruxolitnib (Opzelura) Cream On Trac Patient Support Program: Eligible patients with commercial insurance may pay as little as $0 per tube and the program provides resources to help patients get access, start treatment, and stay on track with their medication. It includes the Commercial Bridge Program which is exclusively available through Incyte’s Enhanced Services Specialty Pharmacy Network.
For more on this and additional information on the DEF Biologic & Small Molecule Bootcamp Series, visit our website at dermnppa.org to register and watch highlights from the live in-person meetings.
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