Pharmacy benefit managers (PBMs) wield immense power over the prescription drug supply chain and often interfere with decisions that should be between doctors and patients. In many cases, they even deny patients medicines they need because the medicines are not covered, or too inexpensive, or for other, even more arbitrary reasons. A recent report from Tarbell.org, a nonprofit journalism site, found that the PBM CVS Caremark rejected a Delaware woman's appeal to receive a prescribed drug after the doctor making the appeal tried three times to contact her prescribing physician's office.
The patient, Robin Agar, has rheumatoid arthritis and needs medicines to treat it. Her doctor prescribed her Xeljanz, but CVS Caremark instead gave her the newer and less tested drug Kevzara, because it was on CVS's 2018 formulary (its list of approved drugs). PBM formularies allow for certain substitutions of comparable drugs. But in this case, Agar's doctor recommended against her taking Kevzara, because she had had a dangerous reaction to a similar drug. He also told her that if she did not take Xeljanz, the vision in her right eye could be harmed. So Ms. Agar had good reasons to take Xeljanz instead of Kevzara.
But CVS denied her first appeal to take that drug, and denied her second appeal as well. Her second appeal was denied by a rheumatologist from Nashville, and emails show that the number he called was the number for Playtex (a manufacturer of tampons and undergarments) instead of Ms. Agar's doctor, whom he was supposed to speak with. Moreover, during her appeals to CVS Agar encountered numerous problems, including but not limited to long delays between correspondence, a lack of transparency into what was going on, and dismissive conversations with PBM representatives.
Fortunately, Agar was able to appeal to the state of Maryland, which overruled CVS's denial, and so she could get Xeljanz, the drug she needed. But most patients do not have that option. And she is still frustrated and demanding an explanation for why CVS denied her the medicine. She also wants to know how widespread these problems and what CVS will do to end these unjust denials.
Even CVS's Vice President Donald Liss admitted that "I can't defend that and I won't even try." As Tarbell writes, "Agar’s story highlights many of the systemic problems of the mostly unregulated pharmaceutical benefit management (PBM) sector: rising drug prices, administrative obstacles and waste, a woeful lack of oversight or transparency and potentially dangerous interventions that change the drugs patients are taking for non-medical reasons."
This is one of many examples of why PBMs need more state and federal regulation, and more investigations into their business practices. We have written multiple times about how regulators should take the lead and ensure PBMs are helping patients instead of harming them. We hope that the state of Maryland will investigate this denial of medicine and ensure that similar cases do not happen in the future.