Getting the Care You Need and Deserve

“I will contact insurance companies when needed to dispute denials and will also pursue assistance options when there is an issue with the cost of the medication,” Holton says. He also checks in with people who may be due for follow-up appointments or lab work to maintain their current treatment.

When first connecting with someone, Holton says he reviews the overall process of starting a biologic, which includes assessing the treatment plan. He will also provide a timeline for how long the various steps may take to access the biologic.

For example, many insurance plans require a prior authorization, which is a required approval by the health insurance company before a treatment can be acquired and the cost covered. Holton helps with this process and informs patients about how long this takes – typically a week to find out if it is approved or denied.

Once the treatment is approved, Holton works to identify which specialty pharmacy can process and dispense it.

“I try to emphasize that patience is needed, as this is not always a quick, smooth process,” he says. “It is common for delays to occur in our attempts to obtain approval and also in the amount of time it takes for a specialty pharmacy to process the [prescription] and set up home delivery. I encourage patients to proactively contact the specialty pharmacy or insurance plan to periodically check the status of their medication.”

The step therapy requirement is a common issue that can prevent patients from accessing their treatment, Holton adds. This is an insurance plan requirement that a patient must try and fail a specified list of treatment options before the insurance company will cover the cost of the prescribed treatment. Unfortunately, it means that people must spend time trying treatments that may not adequately treat their disease, or that are associated with significant side effects or toxicities, Holton says.

“In this scenario, we typically will submit an appeal to the insurance in hopes that they will overturn their decision,” he says.

In addition to assistance beginning a biologic therapy, patients may need help to continue their current treatments. Holton will submit prior authorization renewal requests to an insurance company to help people continue their prescriptions. He also may help an individual investigate new insurance plans when changing employment or going on Medicare.

While some practices employ biologic coordinators, others may have individuals who fulfill this role or provide referrals. People who experience psoriasis who are discussing biologic treatment with their providers can ask for recommended resources to help them navigate access to treatment. Another way to connect with a biologic coordinator is through the drug manufacturer and patient support groups, Holton explains.

While he says it is hard to witness the frustration and challenges that people face when they are denied treatment, Holton enjoys his role because it allows him to build relationships with people and to serve as a valuable resource to them. 

“I hope to be someone that patients can rely on and trust to effectively manage their treatment plan and to help them overcome any barriers to their care,” he says.