A father with two young children missed his chance at a full recovery--all because his PBM-mandated specialty pharmacy couldn't fill his prescription.
Brian, a married social worker with two young children, was in his early 30s in February 2014, when he was diagnosed with a relatively rare form of cancer in his appendix. Brian underwent surgery and chemo at a large hospital system, and for the next few years, his life went back to normal.
Brian’s once promising prognosis has been replaced by one far more dire. In effect, Brian missed his very narrow window and it is likely that he will never get well again.
In late 2017, however, Brian suffered a relapse. He underwent surgery to remove all traces of the cancer, and his oncologist followed up with a round of chemotherapy. Despite the metastasis, Brian’s doctors thought he had a good chance at survival, and recommended that he immediately begin a six-month regimen of oral medication to help keep the cancer at bay. He was young, strong, and had everything to live for; they were optimistic the cancer might never return.
On February 8th, Brian’s oncologist sent a prescription for the pills to the local pharmacy his clinic worked with. They informed him that while they had the medicine in stock, Brian’s insurance and PBM prohibited them from filling the prescription. Instead, they forwarded the prescription to a PBM-mandated specialty pharmacy to receive prior authorization.
The PBM-mandated specialty pharmacy granted the prior authorization, but was also unable to fill the prescription, so it was forwarded to yet another PBM specialty pharmacy. By this point, 11 days had passed. After another few days of silence, the second PBM pharmacy sent a message that they were unable to fill the prescription; it had to be done by the first PBM specialty pharmacy. It seemed that no one really knew who was responsible or able to fill the script.
On February 23rd, the same day that Brian finally received his oral anti-cancer medications, he was rushed to the emergency room for severe pains in his abdomen. There they discovered he had contracted an infection that necessitated surgery to repair his abdominal wall. The pills in his hand were no longer relevant.
Today, Brian must remain on chronic antimicrobial therapy pills to ward away abdominal infection; should he stop, they might easily return. Unfortunately, this precludes any further chemotherapy, and Brian’s once promising prognosis has been replaced by one far direr. In effect, Brian missed his very narrow window and it is likely that he will never get well again.
Oncologists are on the front lines treating patients with cancer who have complex needs–they know the exact state of their patients, and how very precious even a day can be. PBMs and their mandated specialty pharmacies are several times removed from the exam room, and as a result, their lack of urgency and inability to cut through bureaucratic red tape can easily become an indirect–or even direct–cause of patient suffering.