PENDLETON, N.Y. (WIVB) – Even though doctors have been prescribing the same crucial medications for Mary Kosmerl’s devastating illnesses for many years-—multiple sclerosis (MS) and myasthenia gravis (MG)–in January, her medical insurer decided every time she needed to get the prescription for MG refilled she would have to get a new authorization from her doctor before they would approve it.
But that new procedure required more than the doctor’s authorization, and it took weeks of phone calls and paperwork to get approved.
Kosmerl has been living with an especially devastating form of MS, which takes its toll on her mobility, since 2006. Not long after she got the MS diagnosis, she learned of the MG, another auto-immune disorder.
Until January, Mary’s doctor prescribed her medications, and her insurance company approved them. That is when the procedure changed to a new way of handling the Pendleton mother’s specialty drugs, Gammagard for the MG, and Avonex for the MS.
Kosmerl’s prescription plan had been turned over to a pharmacy benefit manager (PBM), which has the authority to decide which medicines are necessary, and dispenses them.
Mary was shocked to learn, the benefit manager withdrew its approval for the Gammagard, “Come to find out that they had made the determination that I didn’t need the medicine, that it was not medically necessary.”
Kosmerl appealed the decision, and eventually, the pharmacy benefit manager reversed its position. Then after her three-month prescription ran out, the benefit manager again denied her renewal for the Gammagard prescription, and she had to go through the appeal a second time, the PBM denied the Gammagard a third time.
At that point, Mary contacted Call 4 Action, we advised her the best way to question the Gammagard decision, and no appeal was necessary after the third denial. Mary got her medicine delivered Saturday.
“If it were not for you, and your agreement to help me, I would be on the phone–probably on hold yet again–trying to find out the status of my third appeal.”
News 4 also contacted the Pharmacists Society of the State of New York, to find out why a PBM can cause bring such turmoil to a patient’s life to get their life-saving medicine?
According to a spokesperson for the PSSNY, pharmacy benefit managers are permitted to require new authorizations before approving a prescription every time it is renewed. But the spokesperson also cited an agreement the NY State Attorney General reached with several health insurers to waive those time-consuming procedures, and Mary Kosmerl’s medical insurer was one of them.