CVS Caremark rejected a Delaware patient’s appeal to receive a prescribed drug after the doctor conducting the appeal tried to contact her prescribing physician’s office three times – at the customer service line at Playtex, according to CVS correspondence obtained by Tarbell.

“I can’t defend that and I won’t even try,” said Dr. Donald Liss, vice president of medical affairs for CVS Caremark in a recorded conference call with the patient, Robin Agar, and CVS staff in January. The recording was done with consent from both parties; Agar gave it to Tarbell. You can listen to highlights of her conversation or her whole conversation with CVS Caremark below. Tarbell has also received other correspondence to corroborate the patient’s story, which can be seen here.

Agar’s story highlights many of the systemic problems of the mostly unregulated pharmaceutical benefit management (PBM) sector: rising drug prices, administrative obstacles and waste, a woeful lack of oversight or transparency and potentially dangerous interventions that change the drugs patients are taking for non-medical reasons.


Highlights of Robin Agar’s conversation with CVS Caremark 

On call: Robin Agar, patient; Donald Liss, VP of Medical Affairs 

Concerns over the role of PBMs is increasing as the sector is consolidating. The top three companies account for 85 percent of the market and they are getting bigger. Express Scripts recently merged with CIGNA, while CVS merged with AETNA. The major lobby for these companies, aware of the growing backlash to the role of PBMs, issued a memo encouraging the industry to “build a firewall” on Capitol Hill. Every stakeholder in the American health care system, advocates say, should be aware of this industry’s controversial role and practices.
On April 9 the CEOs for the major PBMs will be at a hearing for the Senate Finance Committee to discuss PBMs’ role in rising drug prices.

Sorry, Wrong Number

Agar, who runs the charitable Delaware Head Huggers, which knits caps for people with cancer, had to triple check the paperwork. Administrative problems are very common in the American health care industry; Agar says CVS Caremark has made several mistakes recently regarding her care. For instance, the company sent her what she describes as a “dangerous dose,” of methotrexate from the company.  The latest gaffe, however, was almost too absurd to be true.

Agar has rheumatoid arthritis and had been going through a frustrating appeals process with her PBM, CVS Caremark. Despite her doctor prescribing Xeljanz, the company gave her a newer (and therefore less tested) medication Kevzara, based on CVS’s 2018 list of approved drugs (called a formulary), which allows for substitutions for certain comparable drugs. It was a catch 22. According to Agar, her doctor didn’t want her to take Kevzara because she previously had a dangerous reaction to a similar drug in the same family of drugs. Her doctor also warned her the vision in her right eye could weaken or go away if she did not medicate appropriately with the Xeljanz she could not get. “My doctor said he didn’t prescribe Kevzara to any of his patients,” she told Tarbell.  “It is too new and less is known about its effects.” Kevzara was released in 2017; Xeljanz in 2012.

Agar said her doctor felt authorization was likely as her medical need to take Xeljanz over Kevzara was evident. CVS Caremark, however, denied her first appeal, and a second expedited appeal was also denied. In correspondence with Agar, Liss said that the second appeal was denied by a board-certified rheumatologist from Nashville, Tenn., Dr. Robert Collins. Liss initially declined to say what state he worked in, emails show.

Robin Agar’s full conversation with producers of Kevzara

On call: Robin Agar, patient; Duane Clark, VP Business Unit Head at Sanofi Genzyme; William Renzo, Sr. Director, Payer Market Access Lead at Sanofi Genzyme; Kerri Ford, Medical Team Lead for Kevzara

Yet, according to CVS letters to Agar, which can be seen here, the phone number Collins called is the number for Playtex, the manufacturer of tampons and undergarments. “Thank you for calling Playtex,” is the recorded greeting a caller receives. Collins, according to a letter to Agar from Liss, called her physician three times but was “unable to reach a live person at the office.”

“You think? No wonder my doctor didn’t answer,”  Agar told Tarbell. “It would be funny if it wasn’t so dangerous and serious.”

If Collins did call the wrong number, perhaps he should have realized it when he heard the Playtex voicemail greeting. His employer told Agar, in a recorded call, that Collins had called the “number CVS Caremark provided.” Agar said her physician’s office has no record – no messages, no voicemails – of any calls from Collins or his staff.  Collins declined to speak to Agar and has not been reached by Tarbell.

“It makes me wonder if [Collins] called anyone,” Agar told Tarbell. “I think anyone could figure that my doctor would not be located at Playtex after one call, not three.”

Making this all the more needless is that CVS Caremark was going to put Xeljanz back on its list in a few weeks. “It is hard to imagine that at no time during this process [CVS] could not figure out something was amiss,” Agar said.

Robin Agar’s full conversation with CVS Caremark

On call: Robin Agar, patient; Donald Liss, VP of Medical Affairs; Lee T. Shackelford, Director, Strategic Accounts; Nathalie A. Krier, Director, Clinical Services; Megan Mann, Account Manager at CVS Health

This was only one of many issues Agar experienced during this appeals process, such as long delays between correspondence, dismissive conversations and little transparency. When told her story, Dr. Ed Weisbart, a former executive at Express Scripts, said in an interview with Tarbell that it is “a good example of the outrageous intervention in patient care that oversteps any reasonable bounds for both physicians and patients.”     

A Moot Point?

Agar was able to appeal to the state, where she and her husband get their benefits. The state of Maryland overruled the denial, an appeal option Agar says many patients don’t have. Once Agar got the Xeljanz she needed, her efforts to hold her PBM accountable did not stop. If anything, they ramped up.

“[CVS Caremark employees] kept saying to me, ‘the matter is resolved,’ or it ‘is a moot point.’ But that is not true at all. There has been no rational explanation how something like this could happen and how to fix it,” Agar said. “I am worried about people who aren’t able to advocate themselves the way I do. How many people are getting the wrong medication because of these problems?”

Questioning the Peer Review Process on PBMs Appeals

After the initial denial from CVS Caremark, the next appeal in the process went to the Medical Review Institute of American (MRIoA), one of many peer review institutions that provide appeal services. CVS employs a contractor to do the appeals, usually in a part-time capacity. These jobs pay up to $500 an hour.

Collins, who handled Agar’s appeal, worked for MRIoA, Agar learned. In a recorded phone call with Dr. Rodney Musselman, chief medical director of the institute, Agar pleaded for explanations about this process but did not get much. 

“We called the number CVS provided,” Musselman said. “The person who does the appeal is ultimately responsible for the content of the appeal,” he added. Musselman agreed to have his conversation with Agar recorded. He declined to comment for this story. Her full conversation with Musselman is below.

ROBIN AGAR’S CONVERSATION WITH Medical Review Institute of America Regarding Dr. Collins

On call: Robin Agar, patient; Rodney Musselman, Chief Medicial Director of MRIoA

“I have you both on tape blaming each other,” Agar in her call with Musselman.

Agar is not your typical “consumer” (i.e., patient) of health care. She and her spouse have both worked in and around the industry. Her depth of knowledge and grasp of its jargon, therefore, make her more literate in medicine and health policy than most patients and maybe some of the staff she tried to get answers from. So she continues to press them for logical explanation to why she was denied the medicine and what they are doing to prevent similar problems in the future. Agar also says she filed a complaint with the Tennessee Board of Physicians against Dr. Collins and warned CVS. Dr. Collins did not respond to Tarbell about this story.

Most of her concerns have been met with awkward silence or deflections, according to Agar. But she has no plans of letting up on the issue any time soon. You can read her documentation (with some personal health information retracted) on her frustrating fight to get the drug her doctor prescribed here.

CVS Caremark has not issued a comment as of press time.