By Sheryl Hoyer, MD

“I can’t afford higher,” Bobby’s (identifying information changed) mom explains when asked about his low dose. As Bobby’s dermatologist, I prescribed Accutane, curing 80 percent of acne with a six-month course. Insurance denied, requiring doxycycline. I rarely give antibiotics, following World Health Organization (WHO) recommendations. Antibiotics build resistance and aren’t curative, resulting in more scarring. Rejecting Medicaid’s incorrect treatment, Bobby’s mom is paying for the appropriate treatment, albeit with suboptimal dosing.

We pay car insurance premiums to cover collisions, but paying health insurance premiums isn’t covering medicines. “Step therapy” (insurance requiring other treatments before the prescribed) increased 46 percent between 2005 and 2013 while insurance companies’ earnings surged. The WHO issues expert guidelines, but we follow profit-based rules.

Doctors fighting step therapy face prior authorizations (PAs). Physicians complete 33 PAs weekly. I cite research that my treatment is standard-of-care, and the insurance’s requirements are risky. My first prescription is automatically denied.

With car insurance, the first claim isn’t denied. Appeal letters are followed by delays. After escalating to a “peer-to-peer,” I reach a nurse or emergency medicine doctor reading off “rules,” but never a peer, a board-certified dermatologist.

The rules are profit-based but confusing. Mable has a top-of-the-line Medicare supplement, but she couldn’t afford her 5-fluorouracil “chemo cream” ($800 through insurance) for precancerous actinic keratoses (AKs). I directed her to a coupon: $52.22. AKs turn into squamous cell carcinomas (SCCs). $4,366-$7822 is the cost of treating one SCC, per The Journal of American Academy of Dermatology.

What about more complex autoimmune diseases? Previous treatments immunosuppressed, risking cancer and infections. Now biological medicines target one immune factor with minimal risk. For 28-year-old Tracy’s psoriasis, insurance wouldn’t cover her Humira unless she fails cyclosporine, methotrexate, azathioprine, and tacrolimus. These medicines are contraindicated in women of childbearing age, two aren’t approved for psoriasis, and one isn’t approved for long-term use.

For 31-year-old Brad’s eczema, his insurance denied Dupixent, a medicine with no bloodwork requirements or serious risk, and is requiring Rinvoq, which requires frequent blood work and has a risk of stroke.

The story is more frustrating for the 30 million Americans with rare diseases without FDA-approved treatments, such as pemphigoid, a disabling blistering disease. “Denied as not FDA-approved for this disease.” Yet the FDA explains, “Once the FDA approves a drug, health care providers may prescribe the drug for an unapproved use.” Insurance implies it is protecting, but these same insurance companies require non-approved, cheaper steps for common diseases like Tracy’s psoriasis.

What happens when a physician personally receives a denial? In January 2020, Dr. N recommended the human papillomavirus (HPV) vaccine to me since dermatologists are at risk for HPV-induced cancer due to the virus in laser/cautery plumes. Approved to age 45, it was off-label for me at 54. Insurance initially paid, but two years later, a revised statement showed denial based on age and $1,300 due. I had paid premiums for 28 years with only well-care claims; this vaccine was additional preventative well-care.

I began to fight now as a patient. After months of transfers/holds, an agent gave me their denial: “We can’t go above the FDA.” Educating her on this nonexistent rule, I asked what qualifications my insurance has to overrule my internist. Through my portal, I demanded my reviewers’ names/degrees and received this revealing answer: “The review has been reprocessed. A payment will be issued.”

My insurance doesn’t have the qualifications to make medical decisions … and knows it. I must educate others and fight, even 33 times per week.

Sheryl Hoyer is a dermatologist.