How pharmacy benefit managers dictate care | Column

Tampa Bay Times

by: Dr. Michael Diaz

December 26, 2019

When patients are battling a life-threatening disease like cancer, they want a skilled and qualified physician advising them about treatment plans and the best way to beat this insidious disease. But that’s not always what they get. Sometimes, predatory middlemen called pharmacy benefit managers insert themselves into the decision-making process between the doctor and patient.

As just one example, our team was working with a patient who had metastatic kidney cancer. Both the medical oncologist and urologic surgeon determined that the patient was not a candidate for surgery because of the patient’s other health conditions and the extremely low probability of a cure or any benefit. His doctors instead recommended a specific standard medication approved by the Food and Drug Administration for this condition. However, when the prescription was submitted, the PBM – who is not a physician – denied the request for the specialty medicine and insisted on surgery. The PBM made a medical decision. The appeals process in such a case can take weeks or months, and that’s simply too much time for many cancer patients to wait.

As a medical oncologist, I’ve treated thousands of patients. Unfortunately, I see these situations happen all too frequently. PBMs routinely may delay, deny and obstruct care. This needs to stop.

In another heart-wrenching case, a patient was diagnosed with a rare form of cancer. The physician prescribed an oral chemotherapy medication, a treatment that has been used successfully for several years. However, the PBM would only approve the use of one specialty pharmacy, then deny the claim and insist that the prescription be sent to a different specialty pharmacy. After weeks of going back and forth and dealing with paperwork, and submitting the claim to three different pharmacies, the prescription was finally approved. By then the disease had progressed to the point where he was no longer a candidate for chemotherapy.  Continue Reading

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