As the doctor waited on hold with the insurance company to figure out why a patient's potentially life-saving medication was denied—the family called to say their loving husband, father, and grandfather had passed away.
James, a 73-year old husband, father and grandfather, had been battling metastatic non–small cell lung cancer (NSCLC) for a while, when his oncologist prescribed a new medication that was FDA approved for cases like James’, in which the cancer was “locally advanced or metastatic.”
They would never get a chance to see if the medicine would have prolonged his life.
On November 13th, James’ doctor submitted a request for prior authorization to the PBM. The first sign that things were not as they should be was when the request was denied—in a way that made absolutely no sense; they were demanding the results of his blood tests for jaundice. His doctor was incensed. How could the PBM deny someone an FDA-approved medication that was indicated for their illness and prescribed by an oncologist? They resubmitted the request, and for the next three weeks, waited in vain for the determination, with the doctor occasionally calling for status, only to be disconnected or told to call back.
On December 4th, as the doctor waited on hold with James’ insurance company, James’ family called to say that James had died. They would never get a chance to see if the medicine would have prolonged his life.
PBMs, by giving decision-making power to administrative workers with no medical background and little to no patient contact, have created a system that often results in treatment delays and, in worst- case scenarios, the patient’s untimely death. In contrast to this, when patients are permitted to purchase their medication from a physician-owned pharmacy, they are spared the crippling bureaucracy of the PBM system.