November 13, 2024
A young woman with breast cancer was experiencing such intense hot flashes from her triplet chemotherapy regimen, AC-T, that she begged to stop treatment.
Her oncologist, Ramy Sedhom, MD, suggested she take oxybutynin, an inexpensive drug for overactive bladder that has been shown to help reduce hot flashes. But her insurer refused to pay for the drug, even after Sedhom had several peer-to-peer discussions with the insurer in which he emphasized the effectiveness and low cost of the medication.
Frustrated, Sedhom, a medical oncologist at the University of Pennsylvania Perelman School of Medicine in Philadelphia, suggested the patient buy oxybutynin directly from CostPlus Drug Company. The site sells the medication for $6.50 for 30 pills.
The oxybutynin was a game changer. It curbed the patient’s hot flashes and helped her remain on the chemotherapy regimen.
But the headache the patient experienced was “unfair,” said Sedhom, also medical director of oncology and palliative care at Penn Medicine Princeton Health.
Insurers and pharmacy benefit managers (PBMs) have traditionally used processes to evaluate the necessity of medical treatments and services on an individual patient basis — a practice called utilization management. But utilization management techniques, which include prior authorization, can also delay or flat out deny essential care for patients. Even if treatments are eventually approved, patients still may be on the hook for a large portion, sometimes all, of the cost.
Read more at Medscape Medical News.
