“Fail first” insurance mandates not just a problem for U.S. psoriasis patients

“Fail first” policies are one of the mandates imposed by some U.S. health insurers to reduce their costs. They require that people with psoriasis (and other serious diseases) try older and inferior – and often less safe – treatments before they can access the 21st century treatments that work best.

It turns out these policies are not just a feature of the U.S. health care system. In Canada, it is their own government that requires psoriasis patients first try and fail at older therapies.

But like other provinces and territories, biologics are only covered by the Newfoundland and Labrador government with special authorization, after patients exhaust a gauntlet of other treatments.

Patients must have tried Methotrexate, a chemotherapy agent and immune system suppressant, Cyclosporine, an immunosuppressant medication, and UVB phototherapy, without success. They must also have more than 10 per cent of their body’s surface area affected to qualify.

We won’t quarrel (here, anyway) with the UVB and methotrexate mandates. After all, any rationing system will have to . . . ration. You just hope it is based on science and not lobbying. And we’ll assume the Canadian 10% rule has exceptions – surely if “only” your feet are covered, and you can’t walk, the 10% rule is waived?

But cyclosporine? Canada requires people with psoriasis to use cyclosporine, which we would argue has a safety profile making it generally only for those patients in urgent, extreme distress?

That seems extreme. Kidney damage from cyclosporine use is almost a given after two years, and often by the end of year one. It’s a great drug, with many great uses (it saves the lives of transplant patients, for example), and it’s wonderful to have as an option if you are having a full-body psoriasis flare or have certain reasons you are unable to use other therapies, but a general mandate? Given all the other treatment options available, that is hard to defend.

Of course, in America, it all depends on where you sit. If you have good insurance, you get the coverage your doctor recommends. If you have mediocre coverage, you are forced to jump through hoops, as in Canada, though several pharmaceutical companies are now helping American patients in those situations obtain cutting-edge treatments as the patients battle their insurers. And if you are insured through the government, you too can have issues getting access, though in most cases you are entitled to access at least some of the 21st century therapies.

[Have you had problems getting the psoriasis or psoriatic arthritis treatment you need? Please share your story with us so we can focus our energies where they are most needed to improve this system.]

“Fail first” policies are an important reminder why we need people without psoriasis to understand the seriousness of psoriatic disease. When your disease is deemed “cosmetic” or merely a “nuisance,” you are first to get chopped when the bean counters are ordered to cut costs at any cost.

[Last updated 11-7-2019]