What We’re Reading: Insurer Denies Gene Therapy, Evolution of the PBM, United Healthcare Sued

More Insurance Company Denials

One Michigan insurance company made the decision to deny a life-saving CAR-T treatment because gene therapies aren’t drugs, despite a state law requiring coverage for cancer therapies. A ProPublica story looks at one case in which an insurer denied covering Kymriah. The patient died at the age of 50 from an aggressive form of lymphoma.

History of the PBM Industry

A recent article in JAMA Health Forum provides an overview of how the role of pharmacy benefit manager has evolved. In this paper, Ge Bai, Ph.D., of the Johns Hopkins Carey Business School, David A. Hyman, M.D., of Georgetown University and T. Joseph Mattingly II, Pharm.D., indicate that PBMs may adapt their business models to minimize the impact of any legislative or regulatory approaches of reform.

Class Action Suit is Filed Against United Healthcare

A California-based law firm has a class-action suit against United Health Group, alleging that United Healthcare Medicare Advantage illegally used an algorithm to deny rehabilitation for people with Medicare, according to a StatNews article. Previously, StatNews had reported about the use of the algorithm.