From the Specialty Pharmacy Team: A few months ago Dr. B approached me to help a 12-year-old patient living with severe psoriasis. Under Dr. B’s direction my pharmacy team - financial assistance experts, prior authorization experts, clinical pharmacists and an in-clinic liaison - attempted to get the patient approved for Stelara® or Enbrel®. The patient’s insurance rejected both medications all the way through the prior authorization and appeals processes. Instead, the insurance provider preferred Methotrexate®, which isn’t ideal for a 12-year-old. We again tried to obtain manufacturer financial assistance for Enbrel® but it was rejected.
Making the situation more difficult, the patient’s family was going through a difficult transition. Financial times were tough and his newly-single mother had no resources to help her son. His condition was heartbreaking. He was bullied, in pain and miserable. For months communication with the patient’s mother was sporadic at best.
As a pharmacy team we looked for every possible answer. With a new approach, we again applied for patient assistance with the Johnson & Johnson® Stelara® program. We knew from experience that if the patient was denied Enbrel® assistance, there was an extremely slim chance the patient would gain acceptance into this program. It is significantly harder to get into. But we knew the patient and we knew his mom. Giving up wasn’t an option for us.
After weeks of waiting, we learned that the new approach worked! We received word of the patient’s acceptance into the Stelara program! Luckily we were able to contact the patient’s mother quickly. She was crying when we told her the news. The patient starts Stelara® on 10/1. His mom is overjoyed. When we last spoke with her she said, “God is so good! Our prayers got answered.” The patient is now in a new school and hopefully with this medication, he will be able to be a happy, healthy, care-free 12-year-old.