For those who’ve been rejected…

I honestly don’t know where to start.  I just saw a headline about Aetna Insurance.  Basically, a former medical director, who was also a doctor, admitted under oath that he never read a patient’s chart before denying or approving coverage of treatments.  Instead, he followed what he stated was “Aetna training” in which nurses would read the charts then make recommendations to the doctor.  Don’t get me wrong….I love me some nurses, but I would expect a doctor to make the final review and decision.  A doctor who is informed about the condition and the corresponding treatments.  This doctor admitted he knew very little about the condition and nothing about the treatment that he denied.  This is frightening.  At the end of the day, if the doctor signs his name on the document, it’s his butt on the line, not the nurses.  I’m glad he is being investigated now.  To read the article click here:  Former Aetna Medical Director Admits to Never Reading Patient File


I’ve written many blogs in the past about insurance.  I’ve always felt so blessed to have good insurance.  Just two years ago, my employer switched us from an insurance company I had been with for 23 years to Aetna.  I was scared.  I grew up with Aetna, but change in healthcare when you have a chronic illnesses is scary.  I tried to be proactive to ensure that my Cosentyx (the biologic I was taking at the time) would be covered.  I was assured that it would be.  I was told there would be no problem.  When it came time to refill my prescription, I was denied by Aetna.  I called again and spoke to a customer service representative who tried to tell me the reason for the denial was because their doctors wanted to make sure I was taking the “safest drug possible”.  As if my previous insurance and current rheumatologist allowed me to take a dangerous drug??!!! UGH!   I responded with my knowledge of step therapy, prescription benefit managers, and rebates and that I would not be bullied into going on a less expensive medication OR a biosimilar drug when the drug I had been taking was working for me.  When I finished, the rep was silent.  I had to ask if he was still there.  He replied, “Wow. You know a lot about this.”  I fought for what I needed, got my doctor’s office involved, and still got my drug two weeks late.  Two painful weeks later.  These insurance companies hope that people don’t know a lot about their procedures and policies.  Years ago, I was ignorant regarding step therapy and PBMs and thought that science was the reason that I had to trial and fail certain drugs before being allowed to try a drug on a higher tier.  Uh, nope!  Let me explain how it really works.

Pharmaceutical companies and insurance companies can’t talk to each other.  So an industry called Prescription Benefits Managers  (PBM) came into existence.  PBM’s are the middlemen who go between the insurance companies and the pharmacy companies to negotiate better prices for consumers.  Sounds good, right?  Wrong.  PBMs manufacture nothing, but make a ton of money off of drugs through rebates.  There used to be a lot of PBMs but most have consolidated into larger companies.  The three most popular are CVS Caremark, Express scripts, and OptumRX and they control most of the market.  This is how they do it.

A drug company has a drug that they want to sell for $100.  The PBM will say the price is too high and they won’t put the drug on their formulary unless they drop the price to $80.  That sounds good for the consumer, right?  But wait….The PBM may still reject the price, so the pharma company will then offer a discounted price of $80 and then offer the PBM a rebate of $20.  Suddenly, the PBM will add this to their drug formulary  and the drug can be prescribed by doctors and covered by insurance.  Ironically, the patient still pays the $80 price, even though the PBM is technically getting it for $60.  So the total cost savings is kept from the patient.  The problem with all of this is that there is a lack of transparency over this negotiation process.  For example.  The drug I used to take, Cosentyx is listed at $18,000.  According to step therapy, I needed to fail on Enbrel and Humira and 4 other biologic drugs which are the preferred brand name drugs prior to starting Cosentyx.  These drugs cost less and offer large rebates to PBMs to ensure a higher ranking than Cosentyx.  So the drug that helped control my pain and swelling cost is $18,000/month.  My insurance was billed $12,000/month and my copay was a percentage of that cost.  Does the drug really cost that much??  No one really knows.  Cosentyx is not a preferred drug so to get on a formulary, it has to raise the cost of the drug to pay the PBM a bigger rebate.  So in reality the drug might not actually cost $18,000 but since the PBMs require a large rebate to get a drug on their formulary, pharma companies jack the prices of prescription drugs to make money while paying off the middleman.  There is no transparency.  It’s pretty shady.

So now I’m hearing that in addition to PBMs raising the costs of drugs while claiming to lower them, insurance companies are denying coverage for patients without having a doctor review medical records.  It’s all so sketchy and disheartening.  Our politicians claim we have the “best health care in the world”.   I know we are luckier than most countries but the health care companies that are supposed to be transparent according to the law are simply bilking sick people while lining their pockets.

I went to Capitol Hill with the American College of Rheumatology in September, 2017 to speak to representatives about the lack of transparency of PBMs and the high cost of drugs.  One legislative aide said, ‘a company has the right to make money’ and then  ‘it’s hard to say that step therapy with biologic drugs isn’t right because patients don’t often respond to them the same way”.  I agree in the USA a company has the right to make money, but at what cost??  Is it more “right” to expect patients to live in pain and suffer, like I did for 7 years, until I finally found a drug that finally helped me??  All the while the PBMs are causing drug costs to rise while making millions for doing basically nothing but demanding rebates.

Denying patients with deadly or chronic illnesses the right to try new drugs on the market is so unfair and cruel.  It’s even worse when it’s confirmed  that insurance company doctors are following company protocol when making decisions instead of researching the best outcome & treatments for the patient.  That is even more cruel. So the sick get sicker and the rich get richer. Hmmmmm….Maybe we should start running drug companies the way they run schools.  Schools don’t get full funding unless all their students score proficient on standardized tests.  Maybe drug companies, insurance companies, and PBMs don’t get all their money until they cure all of their patients!!  Wouldn’t that be interesting….


5 thoughts on “For those who’ve been rejected…

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  1. Never read the files? Ha I knew it.

    Hey I want insurance companies to make money, I want pharma to make money and I do not even mind PBM’s making money. What I do dislike is writing one thing in their policies and doing something else. Like for instance we will have a doctor carefully review your request and then signing off per company policy. Or a PBM pretending to save money and actually costing more and keeping the difference. Grrrr.

    Liked by 1 person

  2. Thankyou for this wonderful articulate explanation, Kelly!
    My husband has AS and waited four very painful months to get approved for Embrel after failing 3 other biologics. I thought I was fighting the insurance company. Now I understand a little more of the layers of evil, I mean complexity. Arggh. Keep on keeping on. Hugs to Georgia.

    Liked by 1 person

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