Over the past several decades pharmacy benefit managers (PBMs) have acquired substantial power and influence in our health care system, to the point that they often make decisions that affect prescription drug costs and patient access to these drugs. One unfortunate trend in recent years is when PBMs deny patients access to medicines, even if those patients fulfill the requirements and are covered by insurance. In a new article, the Fresno Bee looks at a patient who is being denied chemotherapy treatments by her PBM, even though her doctor has prescribed them.
The patient, Norma Smith, is a retired special education teacher in Fresno, and she and her husband have very expensive but high quality health insurance. Norma has a blood cancer, multiple myeloma. Her insurnace requires her to use CVS Specialty Pharmacy. Dr. Ravi Rao prescribed multiple drugs for her, including chemotherapy infusions and injections, along with pills she got via mail.
But CVS denied the drugs because they didn’t follow the standard protocol sequence of medications that CVS required in their guidelines. Several times over the past several months, CVS denied Norma the drugs she needed. This caused her health to deteriorate and caused her extreme pain. Dr. Rao was appalled, describing PBMs as "one more layer of bureaucracy to go through before we can give the patient the drug...Especially over the last three to four years this whole PBM issue has become a huge issue, and when I talked about this to my colleagues, everyone has similar horror stories. And when I speak to my colleagues in other states, it appears that this is a problem all over the country."
CVS was of little help when they reached out and tried to figure out what was going on. Norma described how her husband is often on the phone for hours asking for help, and trying to get the medicines so she can stay alive. CVS repeatedly said no, overriding the doctor's judgment and hurting her health. Dr. Rao did some digging around, and discovered that other doctors were having similar problems-PBMs were denying them drugs for their patients with kidney cancer.
This is an unacceptable state of affairs. Everyone should have access to affordable prescription drugs. And decisions about prescription drugs should be based on whether they will heal patients, and should be made between patients and doctors. But right now PBMs are denying medicine to patients just because it will save them money and help them turn greater profits, or requiring patients to try less expensive drugs before moving on to more expensive ones, a practice known as step therapy. And since PBMs and insurance companies are increasingly merging, the problem is getting worse.
Legislators should take action to ensure that PBMs cannot deny patients access to prescription drugs that will help them and that their doctors have approved.