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Presentation

Improving Access to Hidradenitis Suppurativa Care Through Prior Authorizations, Specialty Pharmacies, Appeals, and Financial Assistance

Description

The session focused on practical ways to improve access to hidradenitis suppurativa (HS) care, emphasizing that treatment delays often stem from insurance, authorization, dispensing, and affordability barriers rather than biology alone. The speaker described patient experiences with high medication and supply costs, and explained how disease progression can worsen when care is delayed. They outlined the coverage decision process: submit prescriptions through specialty pharmacies, file prior authorizations, and if denied, use peer-to-peer review, written internal appeals, and, when needed, external appeals. Key advice included documenting diagnosis, severity, comorbidities, prior treatments, contraindications, labs, and medical necessity, and using HS Foundation prior authorization templates. The talk also covered plan-specific differences for commercial insurance, Medicaid, Medicare, and uninsured patients, including preferred biologics and biosimilars, and noted that specialty pharmacies can speed approval and dispensing. Additional strategies included appeal timing rules, preparing effective peer-to-peer calls, avoiding cosmetic language in laser hair removal notes, documenting wound care needs carefully, and using financial support resources such as copay cards, patient assistance programs, bridge programs, grants, and tools like NeedyMeds, PAN Foundation, and America’s Medicines. The speaker concluded that clinicians can substantially improve HS access by being systematic, proactive, and well-prepared.

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Conclusions

Patients with hidradenitis suppurativa face major access barriers, and disease worsening often reflects failures in coverage, authorization, dispensing, and affordability rather than biology alone.
Specialty pharmacies can shorten prior authorization and prescription turnaround times, making them an important partner in getting HS therapies to patients faster.
Successful prior authorization depends on thorough documentation of diagnosis, severity, comorbidities, prior treatments, contraindications, labs, medical necessity, and supporting literature.
Appeals are often necessary after denials, and peer-to-peer, written internal appeal, and external review each have distinct roles in overturning coverage decisions.
Expedited review should be requested whenever possible because delays in HS care can quickly worsen pain, scarring, and long-term outcomes.
Insurance plans frequently impose step therapy and preferred-drug requirements, so using the plan’s preferred biologic or biosimilar can save time and increase approval odds.
Patient assistance, copay cards, bridge programs, and grant resources can meaningfully reduce out-of-pocket costs and improve access for uninsured or underinsured patients.
Laser hair removal and wound care supplies can be justified as HS treatments when documentation clearly ties them to disease control and functional improvement.
Inpatient infusion or other workflow adjustments may sometimes bypass outpatient insurance delays for patients needing urgent treatment.
Overall, proactive documentation, specialty-pharmacy collaboration, and knowledge of appeals and assistance programs are key strategies for improving HS therapeutic access.

Hecht et al. Journal of the American Pharmacists Association 2021.