He kept getting the runaround, being told one thing by a representative, only to have that information contradicted the next moment by someone else.
James, a third-grade teacher in his early 40s, has lived with leukemia for many years, keeping it in remission with a daily oral medication. In November, his insurance provider notified James’doctor that a new prior authorization was required to continue receiving his medication. There was no time to lose; James had just finished his last bottle and needed an immediate refill. The authorization was immediately obtained, and the clinic forwarded it on to the PBM-mandated specialty pharmacy.
Four weeks went by, yet no medication arrived. Brenda, a clinic worker, contacted the specialty pharmacy, and a voice on the other end stated that a new prior authorization was needed. Confused, Brenda again faxed the approval letter to the pharmacy, while continuing to wait on hold. After a considerable wait, the pharmacy worker came back on the line and told Brenda that this letter was already in the patient’s file, but that a new prior authorization was needed.
What on earth for? Brenda wondered to herself, as she hung up the phone. They were in February, so perhaps it was because the previous prior authorization had been sent in 2017? Yet, according to the insurance company, the old prior authorization was still in effect. She called the specialty pharmacy back, and this time a different representative answered. He looked up James’ case and stated that all was well; in fact, the medication should arrive in just a few days.
Four weeks went by, yet no medication arrived.
Brenda hung up and called James to let him know he should expect his medication any day now. Answering the phone, James told Brenda that for the past four weeks, going without medication, he’d been frantically calling the pharmacy on a regular basis, trying to order it. They had told him each time that they’d been unable to contact Brenda, despite many attempts, and that his being without medication was due to the clinic’s negligence.
Meanwhile, during those same four weeks, while James’ blood counts were reaching horrific levels, Brenda was able to fill five prescriptions of the same drug for other patients, whose PBM allowed them to receive their medications in-house.
Dealing with PBM bureaucracy can be frustrating to say the least. Getting the runaround… being told one thing by a representative, only to have that information contradicted the next moment by someone else…having the person on the other end of the phone lie to you…these are the things patients and clinic workers meet time and again. And, as if lying about the status of a drug’s delivery wasn’t bad enough, to add insult to that situation by implying the delay is the fault of the very people treating the patient, is unconscionable.