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

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

#31

Post by yumraj »

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…

But won't that cause a delay, even if you ignore the cost, since I'm sure they won't give the subsequent medications unless the time period in which you are supposed to do the previous treatments had passed?

That delay is what can be the difference between life and death for some.

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

#33

Post by rosser »

qrbLPHiKpiux wrote: post #21
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.

I was once dating a woman who had vertically contracted Hepatitis C during her birth. We had an accident before I had completed my normal vaccination course. The first-line treatment in those cases is a dose of immunoglobulin containing the relevant antibodies.

My insurance gave two choices: pay $800 out of pocket for the drug at any pharmacy that carries it (zero coverage offered, no recourse), take it to my doctor's office by hand, and get it injected there; or go to the ER and have it done one-stop there (at a cost of $300 to me and at least $3000 to them).

Fine, guys. It's your money...

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

#34

Post by techsupporter »

refurb wrote: post #24

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…

This absolutely is new, or at least the use of PBMs in this way has greatly expanded.

When I was in the insurance business, formularies were very common, as I imagine they still are based on my experience as a customer of an insurance plan. Whether or not a drug was on the formulary list was both knowable in advance and negotiable. If your doctor wanted to prescribe something to you that wasn't on your plan's list and had a good reason and felt like having his or her staff spend an hour on the phone once a quarter, your insurance company would often permit it. Funny enough, Anthem--discussed in the article--was one of the better ones in the past about having flexible formulary rules. Even if your doctor wanted to go off-label with an unlisted drug, the majority of insurers would cover it in some way.

This use of PBMs, where drugs are on the formulary list but the doctor is told "nope, you can't prescribe that right now or in this way or in this quantity" and being overruled by a pharmacist at the insurer, is relatively new and scary.

(Incidentally, this is why the rhetoric of "death panels" during the debate around the Affordable Care Act was bullshit. We've always rationed care in this country and, in the private insurance market, how it is rationed is almost always completely opaque.)

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

#35

Post by maxerickson »

lotsofpulp wrote: post #18
dylz wrote: post #12

Earlier quoted context omitted.

For almost everyone in the US, is it not true that "claim for medicine is covered under the plan rules" being denied is effectively "you are not getting this medication"?

I guess, but the nuance is that the PBM is only doing what the payer wants it to do. If a state tells the PBM to only approve payment for certain medications under certain circumstances, I don't see the purpose of blaming the PBM for this. Similary, if an employer chooses a formulary that results in a denial of payment, it's the employer who chose to not cover payment for the medicine. The state or the employer can c…

And the payer can state that the PBM only offers a limited set of options, each hand washing the other.

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

#36

Post by tasty_freeze »

One entirely maddening thing is that the ACA was labeled as having "death panels" that would decide who lives and dies. That phrase was powerfully effective in making large group of Americans strongly oppose the ACA. Even if they knew nothing else about the ACA, they knew they didn't want death panels.

But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them.

It makes me despondent that we can ever get to a place where our politicians can make rational, informed decisions about complex issues requiring multiple trade-offs. Cheap political rhetoric is not only easy to sell, stoking fear and tribalism is a winning strategy to getting reelected. 30 years ago most voters didn't bother to read a paper and were simply uninformed; now most voters are actively misinformed.

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

#37

Post by sorokod »

DanBC wrote: post #16
sorokod wrote: post #3

Can't wait for the US health system to make it to the UK.

Something similar used to happen here with NICE guidance not recommending use of the meds, which is why the cancer drugs fund was set up. After spending a billion or so on meds we found out that they mostly don't increase length of life and also cause nasty side effects. https://www.bmj.com/content/357/bmj.j2097

Can you explain in a bit more detail how NICE guidelines are similar to what is described in the article?

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

#39

Post by darkerside »

refurb wrote: post #24

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…

What's new is the application of step therapy to cancer care. Per the article, this was introduced into Medicare by HHS under the Trump administration.
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