Specialty Guide

New Start

In order to start or change a biologic therapy, every point should be checked.

If any one of these steps are missed it will halt the process of getting the medication. 

Forms

While the patient is in the office print out the therapies start form for the correct diagnosis, and have the pt. sign if applicable and make sure the patient verifies the information on the form. Notify the patient that the insurance, specialty pharmacy, and patient assistance program may reach out to them. Make sure the patient answers their phone, as they are also responsible for the medication.

Testing

Make sure the required testing (listed under the medication) is done within the last year to be sure the patient is safe to be on therapy, and that insurance will cover the medication. (For some medications like Dupixent, Xolair, and Otezla you do not need a TB test but baseline blood work is recommended.)

Documentation

Have the provider document a relevant scoring method for the disease: (Ex: BSA, PASI, Hurley stage, etc.)

Always document patient’s height and weight, failure to do the above and the insurance may require an addendum to be added to the chart in order to approve the request.

Prior Authorization

Depending on the insurance plan the requested therapy may need a prior authorization. The provider/biologic coordinator, can either send the medication to a specialty pharmacy that assists with coverage determinations, or they can be performed by the office staff. If unsure of how to start the PA call the number on the back of the patients insurance card (use the pharmacy benefit card if available).

Filling

In order for the medication to be filled it will need to be approved and go to the coverage mandated specialty pharmacy(SP). If the patients co-pay is too high they may be eligible for the drug manufacturers co-pay card program or patient assistance program(PAP). If the patients medication is denied, on medicare/medicaid, Uninsured, or is just ineligible for the PAP, they can apply for the drug manufacturers patient assistance foundation (PAF).