Shrinking insurance formulary limits Rx options

Zoe Diana Draelos, M.D.Dermatologists offer a tremendous service by improving the quality of life for people with skin disease. The dermatology quality of life scales demonstrate increased patient perceived benefit more quickly than almost every other area of medicine because patients cannot only observe their medical improvement first hand, but also feel their medical improvement with the reduction of itching, stinging, burning, and pain. Lowering blood pressure may look better in the numbers on the cuff, but many taking beta-blockers will comment they feel less energetic and worse than before initiating the hypertensive therapy. Few would comment they look better with lower blood pressure. Dermatology is truly unique in patient satisfaction, but I am concerned that our ability to deliver this high level of performance is being eroded by factors beyond our control.

READ: Rx insurance woes

The main factor eroding this high performance is the ever-shrinking insurance formulary, especially for acne and rosacea. Last week I received notice from Blue Cross Blue Shield of North Carolina that topical azelaic acid gel and foam, metronidazole gel, and ivermectin were now off formulary and all my patients on these medications would no longer be able to refill currently active prescriptions.  The reason provided was “a re-evaluation of cost containment strategies.” I think this is “business speak” saying these medications are expensive and the insurance company does not want to pay for them anymore. This means that basically the only medication I can use for rosacea topically is generic metronidazole 0.75% cream, since my practice has become 85% Blue Cross Blue Shield.

Well, all of my rosacea patients have now been switched to metronidazole cream and my phone has not stopped ringing.  Patients want to know why they cannot have their old prescription, they want to know why the metronidazole cream costs more than the old medication they liked better, they want to tell me how bad their rosacea has become since I switched their prescription without their approval, they want to know why I have become uncooperative in providing prescriptions, they tell me I must be in some type of financial relationship with the manufacturers of metronidazole cream, they want to switch to another dermatologist who will surely give them the medication they need, they tell me how bad of a dermatologist I have become recently. This is very disheartening.

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I actually participated in the phase III trials for azelaic acid gel and topical ivermectin, even serving as the lead site for the phase III azelaic acid foam research. I know a lot about the new rosacea medications and can readily spot patients who will need something more than generic metronidazole 0.75% cream. The beauty of modern dermatology is that we have developed several treatments for many skin conditions, allowing the dermatologist to select the best medication for a given patient presentation. This is the art of dermatology that is learned over the 3-year residency. If only one treatment is affordable and available for patients with common skin diseases, it would be best to make a table of the single treatment option for each diagnosis and print prescriptions for the six available medications: acne=clindamycin phosphate solution, psoriasis=triamcinolone 0.1% ointment, eczema=triamcinolone 0.1% cream, rosacea=metronidazole 0.75% cream, seborrheic dermatitis=2.5% hydrocortisone cream, tinea=clotrimazole cream. 

Dermatology would become mundane and force all of us to become well-trained bad dermatologists.