A cancer patient's life was put at risk when unnecessary bureaucracy delayed oral chemotherapy.
Donald, an electrical engineer, husband and father of two college students, had been diagnosed with colorectal cancer and was scheduled for radiation treatments. His doctor prescribed an oral chemotherapy to be taken alongside the radiation and faxed the prescription off to Donald’s PBM-mandated specialty pharmacy. Three days later, the pharmacy contacted Doreen at the clinic treating Donald, to clarify his prescription. Doreen handled the matter without delay, and then, four days later, called to ask when the medicine had shipped…only to discover that due to ‘issues’ it had not yet gone out.
Doreen had plenty of the medication Donald needed – right there in the in – house pharmacy, and could easily have filled Donald’s prescription herself, had the PBM allowed her to do so.
The pharmacy transferred Doreen to the Medicare department, and after a lengthy wait, a representative came on, to whom Doreen explained that Donald was in fact not a Medicare patient. After another lengthy wait, the silence was broken only by the occasional interjection of “One moment,” the representative explained that regardless of the patient’s coverage, this particular medication ordered for him needed to be ‘released’ from the Medicare Part B department.
The representative informed Doreen that the next step was for her to call Donald and ask him to call them – the pharmacy – to schedule delivery, as the pharmacy was not able to make outbound calls. However, she said, another option was for Doreen to bring Donald in on a third-party call and then wait on the line while the pharmacy verified the entire shipping process with him.
A very frustrated Doreen hung up and called Donald to explain the situation. By now it was Friday afternoon, and Donald was scheduled to begin radiation treatments on Monday, accompanied by the oral medication. It was looking more and more unlikely that Donald would have his medication in time. Adding to the absurdity of the situation was the fact that Doreen had plenty of the medication Donald needed – right there in the in- house pharmacy, and could easily have filled Donald’s prescription herself, had the PBM allowed her to do so.
Countless times, bureaucratic PBM delays mean that patients must postpone treatment–or begin, but without the right combination of medicine–that will give them their best chance at battling this devastating disease.Yet, even when the situation has become a matter of life and death, patients have no recourse other than to wait it out, as the bureaucratic machinery of the PBM is not programmed to make any kind of exception.