Cancer patients are being denied drugs, even with prescriptions and insurance • Hacker News Board

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#21

Post by qrbLPHiKpiux » Sat, Aug 03, 2019, 5:34 PM UTC

pacaro wrote: post #5

This happens across the board. I have psoriasis and psoriatic arthritis. The barriers to getting a prescription for an effective (and expensive) biologic medication can be crazy. When I've been forced to use a "specialty pharmacy", they require that the medication be shipped overnight (it has to be refrigerated) which is clearly more expensive than picking it up at a neighborhood pharmacy, that shipment has to be arr…

A patient was on Humira then went on medicare. Medicare would not cover Humira and this patient had to go on Remicade.

The difference? Humira is able to be given by self at home. Remicade requires an infusion by a nurse.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#22

Post by lotsofpulp » Sat, Aug 03, 2019, 5:35 PM UTC

sorokod wrote: post #10

lotsofpulp wrote: post #6

Earlier quoted context omitted.

A pharmacy benefit manager is not a person, it’s an organization. In this organization are usually doctors and pharmacists (who have doctorate degrees also), who review medicinal claims based on the policies set forth by the payer (sometimes an employer, sometimes an insurance company, sometimes the government). They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is co…

>"They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules" Not how it is described in the article. Is the article incorrect in your opinion?

I can't read the article, since it doesn't work on Safari with content blocker enabled, but it's pretty clear that a doctor is free to prescribe whatever they want. The patient is free to obtain the prescription also. The third party payer is also free to object to paying for something it believes should not be paid for under the agreement between the patient and the payer.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#23

Post by wsc981 » Sat, Aug 03, 2019, 5:38 PM UTC

pacaro wrote: post #5

This happens across the board. I have psoriasis and psoriatic arthritis. The barriers to getting a prescription for an effective (and expensive) biologic medication can be crazy. When I've been forced to use a "specialty pharmacy", they require that the medication be shipped overnight (it has to be refrigerated) which is clearly more expensive than picking it up at a neighborhood pharmacy, that shipment has to be arr…

Did you consider treatment at the Dead Sea in Israel? From what I've read it has helped many people that are dealing with psoriasis and perhaps in the long run it might be cheaper than buying medicine?

One example story (but you can find many more I'm sure): http://www.papaa.org/articles/dead-sea-personal-report

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#24

Post by refurb » Sat, Aug 03, 2019, 5:44 PM UTC

This is nothing new and is the process by which insurance companies reduce drug costs.

Insurers come up with formularies that favor less expensive drugs first. If those don’t work, the patient can get the more expensive drugs.

Manufacturers negotiate formulary agreements. They might offer a rebate to move their product to first line use.

In therapeutic areas like psoriasis, the rebates can exceed 50% since it’s such a competitive class with more than a dozen products.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#25

Post by zdragnar » Sat, Aug 03, 2019, 5:44 PM UTC

pacaro wrote: post #5

This happens across the board. I have psoriasis and psoriatic arthritis. The barriers to getting a prescription for an effective (and expensive) biologic medication can be crazy. When I've been forced to use a "specialty pharmacy", they require that the medication be shipped overnight (it has to be refrigerated) which is clearly more expensive than picking it up at a neighborhood pharmacy, that shipment has to be arr…

I'm in the same boat. Currently taking Taltz, but only until their $25 copay program kicks me off in 18 months. After that, my insurance copay goes up to $600 a month (actual cost to them is $5k).

I have no idea what I'll do after that.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#26

Post by jcims » Sat, Aug 03, 2019, 5:46 PM UTC

hondo77 wrote: post #14

Just because they assume their Blue Cross policy is "the best" doesn't make it so. Multiple medical professionals during my current cancer journey (in the Fresno area, as it turns out) actually referred to Blue Cross as "the worst" for the reasons given in this article. My insurer, Cigna, has been great. Also, isn't it possible that the cCare doctor really was not following the right protocol and prescribing things i…

Wife is on a similar journey. Medical Mutual in Ohio has been great as well. Just received two bottles of pills for her next therapy regimen and the cost on the packing list is $16K. $0 to us.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#27

Post by sorokod » Sat, Aug 03, 2019, 5:47 PM UTC

lotsofpulp wrote: post #22

sorokod wrote: post #10

Earlier quoted context omitted.

>"They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules" Not how it is described in the article. Is the article incorrect in your opinion?

I can't read the article, since it doesn't work on Safari with content blocker enabled, but it's pretty clear that a doctor is free to prescribe whatever they want. The patient is free to obtain the prescription also. The third party payer is also free to object to paying for something it believes should not be paid for under the agreement between the patient and the payer.

> a doctor is free to prescribe whatever they want

Presumably not "whatever they want", presumably it's a bit more structured then that.

> The third party payer is also free to object

Aren't the patients payers too?

Read the article, it's nice.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#28

Post by mindslight » Sat, Aug 03, 2019, 5:48 PM UTC

pacaro wrote: post #5

This happens across the board. I have psoriasis and psoriatic arthritis. The barriers to getting a prescription for an effective (and expensive) biologic medication can be crazy. When I've been forced to use a "specialty pharmacy", they require that the medication be shipped overnight (it has to be refrigerated) which is clearly more expensive than picking it up at a neighborhood pharmacy, that shipment has to be arr…

Much of your ongoing annoyances sound like customer service problems. Can you shop around for a different specialty pharmacy? In my (limited) experience with CVS [0], they do offer to ship to a local store for pickup. I've no idea if they'd be setup to do this with refrigerated medicine, although it seems better for them than relying on a commercial carrier that will happily leave a missed-delivery tag and let the package sit over a weekend.

Perhaps you could also get your doctor to write a new prescription a week earlier, so you'd have more of a buffer.

[0] Just to be clear, I'm not trying to sing any praises of CVS. I've only dealt with them because they just bought out another specialty pharmacy which I also had a short experience with. That consolidation is presumably another symptom/cause of the ongoing dumpster fire. I'm just trying to offer pragmatism to perhaps better cope within this broken system.

addendum: I've no idea why I'm being downvoted. Is the only goal of sharing personal situations simply to pile on the outrage party? Obviously OP has been at it for a while, and in that sense should have their own situation figured out the best for themselves. But OP is probably overloaded with stress due to the situation and is just thankful it "works" at all, which results in clinging to local optima.

shrug, I see another comment referencing that CVS is mentioned in the article (my "article" says "Access Denied"), so perhaps pointing out that they do actually do their job some times clashes with that.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#29

Post by alistairSH » Sat, Aug 03, 2019, 5:49 PM UTC

iamleppert wrote: post #15

Instead of fighting them like they did, why not just go along with them and order the medications, throw them out just to get escalated to the right one? When I had to deal with CVS Caremark I frequently had to order things I didn’t need because it was part of their “protocol”. Rather than fight them, I would just go along with them because I knew fighting a company like CVS is pointless. I just threw out the stuff I…

That means a gap in treatment while CVS waits for the stuff you threw away to work. That's not acceptable when the condition ruins QOL.

Re: Cancer patients are being denied drugs, even with prescriptions and insurance

#30

Post by erentz » Sat, Aug 03, 2019, 5:51 PM UTC

lotsofpulp wrote: post #20

erentz wrote: post #11

Earlier quoted context omitted.

> They also don’t “trump” a doctor’s judgment, they simply state whether or not the claim for medicine is covered under the plan rules. I think it’s incorrect to say they don’t trump the prescribing doctors judgement just because they have a company policy they’re following. They also have the ability to override the policy. This means they are making a decision and when they default to what the policy says, if that…

>They also have the ability to override the policy. From my understanding, they do not. At least not outside of a certain margin of error, since the payer (for example a state government or employer) would then blame the PBM for approving payment something it wasn't supposed to approve payment for, and hence seek reimbursement from the PBM or cancel its contract and go with another PBM.

I’ve had specialty medicine approved that very clearly goes against policy at different phases of the review process (including immediately) on different insurance plans. So they do seem to me to have this power.