It was Friday, and oncologist Coral Olazagasti, MD, faced a ticking clock.
Her patient had taken his last prescription anti-nausea pill. Without a refill of ondansetron, he faced a long, painful weekend.
The patient — a man with HPV-related oropharyngeal cancer — was experiencing severe side effects from standard chemoradiation with weekly cisplatin. Intense nausea and grade 3 mucositis, in particular, left him struggling to swallow or take in any food or fluids.
He was on 8 mg of ondansetron (Zofran) every 8 hours, as needed, to keep the nausea at bay. The pills along with a feeding tube helped, but his symptoms were so intense, neither was quite enough.
"He still needed to be hospitalized twice for dehydration," said Olazagasti, who specializes in head and neck medical cancer at Sylvester Comprehensive Cancer Center in Miami, Florida.
But when it came time to renew his ondansetron prescription, his insurance company denied it.
The reasoning: "The company had only approved 30 tablets a month and, for them, it was unjustifiable to approve anything above that amount," Olazagasti explained.
After Olazagasti called the insurance company to resolve the issue, a company representative told her to fill out a prior authorization form.
But it was already after 7:30 pm ET on Friday.
At that point, finding the prior authorization documents, filling them out, and submitting them would take more time — and the paperwork couldn't be filed until Monday.
"My patient was at home with zero tablets left and horrible symptoms. He couldn't keep anything down," Olazagasti said.
On Monday, the oncology team sent the prior authorization request, and her patient received his medication a few days later.
"My patient had to wait about 5 days to get the nausea meds he needed," she said. In the meantime, he was in pain. "Having a refill of this simple supportive care medication rejected was infuriating."
An Alternative Option
When Olazagasti vented her frustrations on Twitter, several people chimed in, suggesting purchasing the drug at a discount through GoodRx or Cost Plus instead of going through the insurance company.
At Cost Plus, for instance, thirty 8-mg pills would cost $6.30, but ordering from the online pharmacy would mean waiting several days for delivery.
Discounts through GoodRx may provide a potentially faster solution in a pinch, but the pharmacy matters. In Miami, thirty 8-mg pills would cost $19.99 at Costco with a GoodRx coupon, but $233.56 at CVS and $253.60 at Walgreens.
Although potentially useful, these options may not be the obvious choice for oncologists and patients, especially when a drug has already been approved and covered by the insurer. In this case, the denial was also a surprise, which left Olazagasti and her patient scrambling right before the weekend.
In addition, companies providing discounted generic drugs may only have a limited number of oncology-related medications. Cost Plus, for instance, now sells more than 1000 generic prescription drugs at a fraction of what insurance companies charge, but only about seven are cancer drugs.
On a broader level, Olazagasti noted, "insurance companies have a responsibility to cover these drugs. If we all get so fed up that we start relying on alternate routes to get patients their treatments, then insurance companies are let off the hook."
However, using an alternative option like GoodRx or CostPlus could mean bypassing insurance company obstacles in certain cases.
"The hurdles someone may have to go through to get a generic drug approved are very frustrating," said Stacie B. Dusetzina, PhD, professor of health policy and a professor of cancer research at Vanderbilt University School of Medicine in Nashville, Tennessee.
In a weekend emergency situation, if the drug is discounted through GoodRx, "it can be a good backup strategy to send the prescription to the pharmacy" and more generally "worth it for patients to check if they can get a better deal on generic drugs through these companies."
This is part of our Gatekeepers of Care series on issues oncologists and people with cancer face navigating health insurance company requirements. Read more about the series here.
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Cite this: 'Infuriating' Rx Denial Leaves Patient Without Antiemetics - Medscape - Feb 16, 2023.