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After repeating her story from one PBM representative to the next, she finally received her medication just before running out.


After having survived her battle with thymus cancer in 2015, Rachel was surviving with several autoimmune disorders, including myasthenia gravis, a condition in which the body attacks its own neuromuscular connections. After utilizing several immunosuppressants, Rachel has managed to keep the illness in remission for the past two years, by taking a wonder drug that works as an immunosuppressant, maintaining a low volume of antibodies in her system.

An advanced oncology certified nurse at a community oncology clinic, Rachel knows her condition well and how to stay healthy. For two years she has been taking her medication faithfully every day, working to care for her patients, and living life as normally as could be.

Then, at the beginning of 2019, her employer changed insurance carriers. When it came time one Friday for Rachel to refill her meds, she went to the local pharmacy to pick them up, only to be told that there were ‘issues.’ The pharmacist was confused and said he would look into it.

Two hours later, the pharmacist called to say that from now on, Rachel must obtain her medication through the PBM’s specialty pharmacy. She immediately called the new pharmacy’s number, where she waited a long time until she was connected. After trying fruitlessly to locate Rachel in the system, he put her on hold for ten minutes. When someone else finally came back online, Rachel had to tell her entire story from the beginning. This happened several times, with Rachel’s blood pressure rising exponentially. It was Friday afternoon, and she had six pills left – enough for two days.

Rachel hung up the phone; this had been a dead end. Falling back on a trick she had learned after dealing with countless PBM bureaucracies on behalf of patients, Rachel called the member services number on the back of her insurance card. After being passed around from representative to representative, she reached “Brian,” who promised to establish a new member’s account for her. However, as to her refills, he insisted he first needed to call her doctor to get prior auth.

It was Friday afternoon, and she had six pills left – enough for two days.

Rachel began to see red. It was Friday afternoon, and her neurologist’s office was closed. Trying to remain calm, Rachel explained to Brian that she still had several refills left. Brian promised he would contact her pharmacy and have the refills transferred over. “Call me in the morning,” he said. Saturday morning, at 7:30 am, she called the specialty pharmacy, where she was told that no one named Brian had been in touch, and there was nothing in the computer about her issues. However, this new representative was the real deal. She handled everything over the next few hours, and arranged for the meds to arrive by Monday – which they finally did – just as Rachel’s pills had run out.

Infinite patience coupled with buckets of determination and self control seem to be de rigueur when it comes to dealing with PBM Specialty Pharmacy bureaucracies holding one’s life-saving medicine hostage. If it was this difficult for a seasoned, tough-as-nails advanced oncology nurse to get her own meds, what is going to happen to the other 99.9% of the population?