Medicare’s $2,000 Hurdle to Advanced Dermatology Care

A $2,000 out-of-pocket hurdle can still block Medicare patients from advanced dermatology therapy after they exhaust insurer-required topicals, according to Louis Margulis, PA-C, an Atlanta physician assistant.

In a Dermatology Times’ NP/PA Connect interview at the 2026 Horizons in Advanced Practice meeting in Atlanta, Georgia, Margulis used psoriasis and atopic dermatitis to show why access matters. The account was a clinician interview, not a trial result.

Margulis said many Medicare patients have already tried and failed topical treatment and other standard options that insurers require before approving advanced therapy. Many are veterans who have contributed substantially to the country. For many beneficiaries on fixed incomes, clearing those clinical hurdles does not solve access.

The remaining barrier is cash. Margulis said patients still face a substantial out-of-pocket threshold before Medicare coverage fully applies, and he put the immediate problem this way: “Even with that Medicare, like, all you have to spend is $2,000, and then you get it,” he told NP/PA Connect. “It’s like, they don’t have $2,000. It really breaks my heart.”

The access gap after prior authorization

For clinicians, the practical change is straightforward: selecting the right medicine is not the same as getting the patient access to it. Margulis called obtaining that medicine one of the largest challenges in his practice.

Patients may satisfy every insurer requirement and still be unable to cross the $2,000 cost threshold. In his view, affordability belongs in the treatment discussion from the outset, especially for a veteran or fixed-income patient. Prescribing without addressing that gap can leave the most appropriate advanced therapy out of reach.

Treatment goals are moving higher

The access gap carries more weight because clinicians now have a growing range of options and patients expect more from them. In psoriasis, Margulis said, the goal used to be roughly half clear; now he aims for 100% clear.

He put the change plainly: “Before, like psoriasis, if you were like half clear, that was considered like the goal, and now the goal is like 100% clear,” he said. “So that’s very exciting.”

His statement sets a clinical goal; it is not a reported trial endpoint. The practical implication is that a stronger target makes the route to treatment more important: when complete clearance is the aim, an unaffordable prescription is not an adequate plan.

Atopic dermatitis requires layered care

For atopic dermatitis, Margulis described a layered approach. Clinicians first address the patient’s immediate symptoms, then focus on keeping the skin barrier protected and healed, and sustain that protection over the long term.

The sequence combines immediate relief with ongoing barrier care. It also makes long-term protection an explicit part of the treatment plan, rather than treating improvement in a flare as the finish line.

Making short visits count

Limited appointment time can complicate both treatment selection and access, but Margulis offered a simple opening sequence:

• Introduce yourself.
• Look the patient in the eye.
• Ask which concern they would most like help with first.
• Start there.

He said this sequence sets a useful framework for the rest of the visit. He also recommends being candid that the time is shared: the clinician has work to do, the patient has tasks, and other patients are waiting. Setting that expectation at the outset helps everyone get what they need.

For Medicare patients, that focus is not cosmetic scheduling. A clear first priority helps the clinician and patient decide what must be addressed now, while leaving enough structure for practical barriers—especially cost—to enter the visit rather than emerge after treatment selection.

What does this change for dermatology practices?

It changes what access means at the point of care. Prior authorization remains one gate; the $2,000 threshold is another. The treatment goal may require complete psoriasis clearance; atopic dermatitis care may require sustained barrier protection. And the first visit must turn limited time into a clear priority.

In practice, affordability cannot wait until after a medicine is chosen. Nor can a strong clinical target compensate for a patient who cannot obtain the treatment. Margulis’s point was direct: Medicare coverage does not remove the financial barrier, and good access depends on both an affordable treatment and a visit structured around the patient’s immediate need.

As advanced options continue to expand, Medicare access will hinge on closing those cost gaps without squeezing the short clinical visits that turn treatment selection into a workable plan.