Casey Butrus, PharmD: How would you advocate for your patients to a health plan and explain newer drugs are more beneficial potentially than the generic or over-the-counter [drugs]?

Arash Mostaghimi, MD, MPH, FAAD: We can go through these a bit. Of the 3 drugs I talked about, clascoterone is unique in that it has no point of comparison. It’s a topical agent where there’s nothing else in that class, and [it] has an excellent safety and efficacy profile. So while there may be an argument [for] clindamycin, benzoyl peroxide, retinoid, [and that] these things should be used, you’re not really choosing between clascoterone and anything else, particularly in men; there’s nothing else. And women, there may be an argument for spironolactone and things along those lines, but it seems that to force somebody to jump from a topical to a systemic medication for a disease like acne, where you could get it controlled perhaps more safely under this, may not make much sense. I think that there’s actually very little argument that honestly needs to be made for clascoterone. In contrast, for minocycline, again, this comes down to the role of managed care largely from a financial standpoint. There’s a safety standpoint as well as a patient care standpoint. Is antimicrobial stewardship part of the job of managed care? I’m not sure, actually. I’m not sure that’s exactly where that needs to go. So the argument is, could you use an oral or could you use oral doxycycline or minocycline? And should that take the place of beyond the way towards topical minocycline? Maybe, but again, when you’re looking at the patient, the safety and efficacy profile, if you’re picking the right patient, it makes a lot of sense to go to that first and not potentially expose them to the systemic impact that we talked about. For trifarotene, I think this is actually the place where it’s the hardest to make the argument for this drug because there are so many other retinoids that are available, including over-the-counter ones that do work well and are often tolerated. Particularly if you coach [patients] through it the way that Steve was talking about. And although it does have unique data for truncal acne as was mentioned, also it seems to be tolerated by patients who don’t tolerate a lot of other things. That one in particular feels almost like the end point as you’re recycling through a series of retinoids vs something that would be more proximate in the order of treatment.

Casey Butrus, PharmD: And it sounds like it’s more apples to oranges for the topical clascoterone if they’re a candidate for maybe androgen therapy.…

Arash Mostaghimi, MD, MPH, FAAD: It’s apples to nothing. You only have one fruit, and it’s an apple, and you can eat it, if you’d like. If you want to eat an apple, that’s what you can eat. But it really should be thought of differently. And it may be that if the sebum drug that was mentioned comes through, or other medications that come through that are somewhat in the same type of axis of androgen, etc, well, maybe you can think about that. Or maybe future research will show that this drug should either move up or down in the course of treatment, not based solely on cost because this is an expensive drug at present, but maybe based on efficacy. Maybe this type of person responds better to this or that type of [treatment]; forget about the antibiotics first and go directly to this. But we don’t have that information yet. At that point I feel when you don’t have the data, deferring to the clinician at the bedside makes the most sense.

Casey Butrus, PharmD: I think even within the step therapy and the generic space, there could still be high-cost generic. So if you’re pushing patients to one chemical, they can have different dosage forms and different strengths that may vary in price, anywhere from pennies to hundreds of dollars. So I think when I craft my utilization management, I try to think about specifically the lowest net cost option. And are there mechanisms in place to allow for these exceptions for patients who don’t have other mechanisms of action available for them too? [Dr Feldman], what do you think are some appropriate utilization management strategies you would recommend to health plans to make sure that we’re all curbing costs but also promoting these newer therapies in the most appropriate patient population?

Steven Feldman, MD, PhD: To start, I would set any age cutoffs really high. Back in the old days, people had age cutoffs for acne management that said, if you’re over the age of 18 or something, we’re not covering it because acne’s a teenage problem. That’s ridiculous. You mentioned how prior authorizations aren’t free. They’re not free to the insurer either. And if you’ve got 25-, 30-, 35-year-olds, 40-year-olds with acne and you’re going to make them do a prior authorization just because of their age and they’re all going to end up on the drug anyway because they all do have acne, those age cutoffs wouldn’t make sense. So I think age cutoffs for topical retinoids under the age of 40 would probably be a mistake. Certainly, I don’t think we should have requirements that require a trial of something that has already not worked for them. That’s just common sense. And the other thing that I think would be fabulous is if insurers would help me implement strategies that promoted patient adherence to their treatment.

Casey Butrus, PharmD: I think those are all great points. I think there’s also, as you mentioned age, there can be that lower age cutoff where a drug isn’t FDA approved for a pediatric population, but there are also upper age limits too. And I think there’s a misconception that the health plan is always the one implementing that for commercial plans; it could be the employer group that’s the one deciding that benefit is the age cutoff that they want. And a lot of the time the health plan has to go along with the employer group in that scenario. Also sometimes state plans, Medicaid specifically, could be the ones that are imposing those age restrictions. So a lot of the time it is out of the health plans, but I think it’s important to have that conversation just with the managed care organization in general so they know acne is prevalent in adults. Even though they want to curb the cosmetic use that you may see, specifically with retinoids being used for fine lines and wrinkles, and other cosmetic uses. I agree, I think the age limit should be raised, and try to make sure that the appropriate age population still has access to acne treatment when they need it. To your point about not requiring members to try to fail a drug that hasn’t worked, I think that should always be something when we’re asking for a past medical history list or medication list. If they’ve tried a similar active ingredient or even if they’ve tried other products, maybe not the specific strength or the dosage form, they’ve tried an active ingredient and it hasn’t worked, it’s probably not going to work again. So I think from our utilization management pharmacy perspective, we do have clinicians who do review prior authorizations, and I think that’s something any utilization management pharmacist tries to keep in mind, but there can definitely be variability between health plans on how they review those cases. So trying to have a consistent conversation could be important.

Arash Mostaghimi, MD, MPH, FAAD: I think [Dr Feldman’s] point about common sense, basically the vice president of common sense that can look at these things and be like, hey, you don’t need to fail 2 [benzoyl] peroxides, or maybe a drug like erythromycin, we should sunset, because there’s just certain things that don’t make much sense. And I think in that sense, probably a lot of the frustration would diminish and it would be a lot more clear to people why we’re going down a certain path.

Transcript edited for clarity.