PBM Denies CA Woman’s Cancer Treatment

By Consumers For Quality Care, on August 8, 2019

When Norma Smith found out that she had stage-three multiple myeloma, which had spread extensively and attacked her bone marrow, she wanted to start treatments immediately. Smith and her husband, Rodney, are both retired. The couple considered their $500 a month Anthem policy to be “very expensive” but “the best” coverage, according to the The Fresno Bee.

Smith’s oncologist, Dr. Ravi Rao, started her on chemotherapy. Smith had to stop treatment a few weeks later, when she suffered a life-threatening allergic reaction. Rao wanted to switch Smith to a different chemotherapy drug to continue her treatment. The new drug was denied by Anthem’s Pharmacy Benefit Manager (PBM), CVS Caremark.

“I wanted to shift her to a related drug that does not have that reaction, and the insurance company flatly refused; the PBM refused,” Rao said. “I spoke to someone at the PBM and they faxed me a protocol, basically saying that, ‘You do drug combination A first, you go to drug combination B, and only then will you get drug C,’ and what I was asking for was drug C. And so I told the family, ‘Well, this is their policy, so let’s go with drug combination B.’ “

As Rao tried to tailor his treatment plans to meet the PBM’s requirements and Rodney spent hours on the phone advocating for his wife’s treatment, Smith’s health deteriorated severely. She was nearly bedridden and Rao says that she easily could have died.

After two months, CVS Caremark finally approved the treatment Rao had prescribed. The approval was contingent on pairing it with another drug that wasn’t part of the prescribed treatment. Rao began administering the approved combination while, once again, battling the PBM.

The PBMs’ protocol “was used to override my clinical judgment each time,” Rao said. “Each time they said no, the patient suffered as a result, and it led to the decline in her status by the time that we got to the right treatment.”

Rodney spent hours on the phone with CVS, going as far as contacting the top appeals board supervisor, to get his wife the medication she needed. Smith believes their efforts kept her from dying of cancer earlier this year. She knows that other cancer patients are often not so lucky.

In a statement to The Fresno Bee, CVS Health said that the company uses “utilization management strategies, including prior authorization, which can help ensure that patients access the most clinically appropriate and cost effective medication” to provide consumers better experiences with lower-costs.

The practices are not good enough, in Rao’s opinion. He believes that step therapy is a disservice for patients.

“CVS did, eventually – but belatedly – get these life-saving drugs to my patient,” Rao said. “It is as if a fireman sat around watching a house burn, and then finally by acting at the last minute, put out the fire and then says, ‘See, I did my job.’ ”

He remains frustrated with PBM denials, which he says have become increasingly frequent over the last three or four years. Rao says that PBMs are allowed to deny patients potentially lifesaving treatments but have no responsibility for the outcome.

“Unless I prove to the insurance company that this patient is not going to respond, then I’m out of luck,” Rao said. “Now unfortunately, the only way that we might get proof is if the patient gets much worse clinically. What if Norma’s liver had failed in the meanwhile? I can never talk to the person who made the policy. I don’t have access to someone to say, ‘Hey, can you please change your policy?’ The system is completely opaque. We have no idea who is making the decision.”

Smith’s health has been improving since they were able to get her on a chemotherapy drug that works for her, but the experience has been upsetting, frustrating, and painful.

“I’m a human being. I’m not a used car. I have feelings. I’m a person. I want to live. I want to spend time with my grandchildren. I want to quilt. I want to do things. I want to live.”