She watched her health deteriorate for almost two months while PBMs consistently denied her doctor's request for a new life-saving medication.
In the Fall of 2012, Trisha, a medical software instructor in her early 60s, suffered renal failure and was rushed to the hospital. Diagnosed with Multiple Myeloma, she underwent dialysis and was referred, by her community oncologist, to a Myeloma specialist at the nearby hospital system. The specialist recommended a particular regimen of chemotherapy to keep the disease in check, and Trisha was released.
A few months later, tests revealed that the cancer was progressing. Her chemo was clearly not working; a new medication had to be tried. This would not be simple, for following Trisha’s renal failure, her kidneys had never returned to normal. This meant her doctors had to be extremely careful about what drugs they prescribed, as certain medications for Myeloma are known to take a heavy toll on the kidneys.
Ultimately, after more than two months of delay, the correct medicine was finally approved by the PBM.
Trisha’s oncologist, in consultation with the hospital specialist, decided to prescribe a particular drug that could slow the progression of her disease, without having any adverse effects on her already stressed kidneys. Her oncologist sent in the prescription to the PBM mandated specialty pharmacy, which promptly sent back a notice denying the request.
At first, the pharmacy said that prior authorization was needed. Her doctor said, “No problem,” and instructed the in-house clinic to fill out all the necessary forms and fax them over. This was followed by a second denial, which stated that the patient did not meet “the proper requirements” to receive the requested drug. What were those requirements? Trisha had to first have tried two other drugs, one after the other, and to prove that either her body had been unable to tolerate them, or that they had failed to slow the cancer’s advancement.
Of those two drugs that the PBM demanded Trisha try – and fail – first, one was the very same drug she had been prescribed the previous year that had already failed to slow the cancer’s progression. The second was a medication that, had she taken it, would have seriously damaged her kidneys and likely put her back into renal failure.
Over the next two months, Trisha’s oncologist appealed the PBM’s decision, and a long series of communications ensued between the oncologist, the Multiple Myeloma specialist, and the PBM specialty pharmacy. Trisha, meanwhile, watched with increasing anxiety as her myeloma protein markers quadrupled, indicating that the cancer was gaining ground. The appeal turned into a letter of medical necessity, and ultimately, after more than two months of delay, the correct medicine was finally approved by the PBM.
PBMs have been given enormous amounts of control over what doctors may and may not prescribe. They try to strong-arm doctors into prescribing the medicine that the PBMs choose, even though they have never met the patient, and often have no medical background to support the decisions they are making.