New Insurance, New Hurdles to Access Treatment

Psoriasis and psoriatic arthritis run in our family. My son and I were diagnosed with both just a few years apart. Psoriatic disease has consumed our lives for more than 20 years. You’d think by now, we’d know all the loopholes and be experts on getting our medications. Not even close.

A push to get his own insurance

In fall 2022, my son had a great job at a small audiology clinic. The only problem was that he could not receive health benefits through his employer. He was 24 years old, and in less than two years, he would be kicked off my insurance. He needed to start looking for his own.

He found a great job at a hospital’s audiology clinic. He started his new job in January 2023. And while we’re thankful for the clinic offers health benefits, things got tricky. He only had a few days to decide if he wanted this new insurance to start right away. When you have a chronic diseases like psoriasis and psoriatic arthritis, there is a lot to consider.

Knowing that none of his doctors were in network with his new plan, he decided it was best to wait until the next open enrollment to switch. He could stay on my insurance for another year, which would give him time to fully investigate the new plan’s benefits.

Open enrollment for 2024

We worked together on his health care strategy because he was new(ish) navigating health insurance, lived farther away from his current doctors, and making private calls during office hours was difficult while working. We had great intentions of doing a serious deep dive into my son’s offered health plan. I wouldn’t say we procrastinated, but we did drop the ball. Next thing we know, it’s November 2023, and it’s open enrollment. The only thing we did know is that none of his current doctors are in-network with the new plan.

Still, he knew either he could switch in January or in June when he turned 26. Either way, a change was coming. He decided to jump into the adult world of his own insurance sooner, rather than later.

Making the switch

We quickly realized there were many tasks to complete to have continuity of care and treatment:

• Find new doctors and make appointments to see them. With his new insurance, basically he will need to see only doctors associated with the hospital where he works to stay in-network and avoid high copays and fees. The problem is getting an appointment with a dermatologist will take a few months. He gets the earliest appointment possible and is put on a wait list in case of cancellations.
• Get records transferred to the new doctors. This was actually not too difficult because his current dermatologist and office staff are amazing. It helped that the doctors could share my son’s electronic health records via the same system.
• Don’t forget the medication. This is where we begin to panic because we ran into a lot of problems.

Getting his biologic

My son has been on many biologics over the years. The latest one has worked well to manage both diseases, and he was due for his next injection in mid-January. Getting this medication is crucial to managing his psoriatic disease.

Unfortunately, his new insurance wasn’t sympathetic to the timing and required a prior authorization, which he can’t get because his current doctor is out of network. Strike one. My son called his new dermatologist for help, but he can’t do anything without seeing my son first. His appointment is in March. Strike two.

Maybe his rheumatologist can help, since the biologic treats both psoriasis and psoriatic arthritis? His rheumatologist can’t prescribe the medication because somehow, my son hasn’t been to the clinic in two years. Oh, and the rheumatologist is out of network, too. Strike three.

Down, but not out yet

He calls back his current dermatologist who says he can try to help with a sample to get him by until he can see his new doctor. Thankfully, a few days later, they secure a sample for him. I stop by the office with “thank you” cookies and a “You’re the BEST!” speech that I give loudly for all of the patients in the waiting room to hear, because honestly, they deserve that and so much more.

Our take-aways on switching insurance

• Start early. Find doctors in network and make appointments as soon as possible. With chronic diseases and specialty doctors, it might take some months to be seen. Unfortunately, many times we aren’t given many months to research and schedule before a switch in insurance takes effect. If that happens, do the best you can.
• Work with both doctors. Avoid a lapse in treatment and get your current doctor and your new doctor to work together so you can get the medication. Ask if they have any suggestions to stay current with treatment. Ask them if you can get a sample to bide the time gap in seeing your new doctor. It’s not always possible, but it never hurts to ask.
• Contact the National Psoriasis Foundation’s Patient Navigation Center. This is a free, personalized service. In my son’s case, our patient navigator recommended he apply for a Bridge Program, a type of assistant program that helps patients get their medication in situations such as insurance denials and treatment transitions. Our patient navigator was able to send us the exact information needed to apply, based on his biologic and new insurance. The Patient Navigation Center is a also great resource for psoriasis and psoriatic arthritis education, finding doctors, and getting access to treatment.

As I’ve told my son often, adulting is hard. Insurance is harder. He agrees.