An oncologist's expertise was undermined when a PBM insisted they knew which drug was better for a brain cancer patient.
Gordon, a retired FBI agent with a distinguished record of security service on behalf of the United States, was diagnosed with an aggressive form of lung cancer. Proving resistant to the drug regimen his oncologist initially prescribed, the cancer metastasized to his brain, and he was immediately started on radiation therapy. It was at that point that his doctors made an important discovery: Gordon’s cancer had the EGFR mutation, which indicated he would do better with oral medication than infusion chemotherapy. More importantly, there was a new drug that had just been approved by the FDA as the first-line treatment for EGFR-mutated non-small cell lung cancer. This gave Gordon and his cancer care team a window of hope.
Gordon’s oncologist prescribed the new medication, but the PBM denied authorization, providing the name of an alternative drug they wanted him to try first. His doctor argued that his original prescription would be better for the patient; It had been shown to have far higher efficacy for patients whose cancer had metastasized to the brain. The PBM argued back that it had been initially approved for a different EGFR mutation than the one Gordon had. His doctor argued back that this was irrelevant, as it was effective for Gordon’s mutation as well, and was now FDA approved.
After more than 30 days of wasted time, the PBM approved the doctor’s original prescription.
Back and forth, the fight went on for an entire month, with the doctor providing data and rationale to support his clinical decision making. Meanwhile the cancer grew inside Gordon, unchecked. He began to feel increasingly fatigued, and a man who had remained very active throughout his cancer battle began to deteriorate.
Ultimately, after more than 30 days of wasted time, the PBM approved the doctor’s original prescription. Upon beginning the regimen, Gordon’s condition began to slowly improve, but it never should have been allowed to reach such a low state.
Again and again, we see PBMs playing doctor, choosing to authorize one medication and not another, for reasons that have nothing to do with patient care. From pushing the drugs from pharmaceutical companies with which they have made sweetheart deals, to demanding patients be prescribed lower-cost medication, their actions are profit-driven and often in complete contradiction to what the patient actually needs to get well.