With no other option, a father of two was dangerously forced to wait for his life-saving medication after the PBM-mandated pharmacy sent the wrong dosage directions.
In 2012, a 45-year-old salesman named Bill was diagnosed with colorectal cancer. Bill had a good job working for a large office supply manufacturer based in the Midwest, a loving wife and two small children, and he decided to fight with everything he had. Following surgery, Bill was treated with IV chemotherapy, but with negligible results. The cancer progressed over the next year, and his doctor changed to a different IV chemotherapy. This time his response was very good, and for the next four years things were fairly quiet.
In 2017, tests showed that Bill’s cancer was back, and this time he was treated with yet a third kind of IV chemotherapy. His response seemed good at first, but by the following year, the cancer had progressed to Stage IV and metastasized to his liver. At this point, Bill’s oncologist ordered an oral medication specially prescribed for relapsed or metastatic colon and rectal cancers.
Bill’s physician at the community oncology practice sent the prescription over to the in-house pharmacy to fill. Unfortunately, according to Bill’s new insurance plan, his prescription could only be filled by a PBM-mandated pharmacy. Despite the facts that Bill’s Stage IV cancer was aggressive, that his doctor wanted to get him started on the medication that very same day, and that the medication was sitting on the shelf of the in-house pharmacy, Bill had to wait. Even the option sometimes given to have a ‘one-time fill’ that would let him get started while waiting for the PBM pharmacy to mail him his medication was denied. Thus, with the drug’s prohibitive list price (over $10,000/month), Bill had no option but to wait.
The doctor sent his prescription on to the new pharmacy, along with Bill’s contact details, so that they could arrange for delivery. Meanwhile, Bill went to his clinic and received detailed in-person counseling on how to take the drug, since it was a somewhat complicated regimen. There were specific directions on how to take the medication, what side effects to expect, and how to ensure the proper dosing. The latter could be confusing, since the drug is taken in multiple tablets twice daily on days 1-5 and 8-12 of a 28-day cycle.
After seven full days of waiting to start his therapy regimen, Bill finally received his medication in the mail. Opening the box, he began to read the label, and found to his great surprise, that it stated: “take once a day.” Picking up the phone, Bill checked in with his oncologist to report the change in instructions. The clinic pharmacist confirmed that the instructions were wrong, and reached out to the PBM pharmacy, which promised to contact Bill about clearing up the matter.
While he waited, his cancer was allowed to progress, unchecked.
Bill received a call from the PBM-mandated pharmacy representative, who apologized for having sent the wrong prescription with the wrong amount of medication. They assured Bill he would receive an additional supply of medication. First, however, they asked Bill to please return the medication he had been sent, so it could be properly labeled. Now Bill, with Stage IV metastatic cancer and his treatment already having been delayed a week, was being asked that rather than take his life-saving medicine, he ship it back to the warehouse for proper labeling and reshipping.
This was not the last time the PBM pharmacy impacted and delayed Bill’s care. Later, when it came time to refill his medication, Bill’s treatment was again delayed. The PBM pharmacy, it seemed, decided that before filling his prescription, it had to first clarify the dosage. It then claimed to have had difficulties in contacting Bill’s community oncology clinic, despite having been provided with all the correct contact details. Ultimately, Bill had to call his local clinic and ask for the in-house pharmacist to call the PBM to confirm dosage, before they would ship it out. And while he waited, his cancer was allowed to progress, unchecked.
One of the most dangerous parts of PBM-mandated pharmacies is the distance between the pharmacy and patient. In this, we are speaking not only of geographical distance, but also of when patients are forced to wait for medicine to be shipped, rather than walk across a hallway to purchase it. More to the point, however, is the situation in which the patient becomes a name or number on a call sheet, rather than an actual human being facing a life- threatening illness; rather than a patient for whom there is care and endearment. That distance is at the core of many PBM mistakes and apathy.
Two weeks and four pharmacies later, a patient was finally able to receive his medication.
Bill was prescribed an oral medication that works to prevent his cancer cells from replicating, thus reducing the growth and spread of the disease. His oncologist faxed the prescription to the specialty pharmacy indicated by Bill’s PBM. Unfortunately, this particular pharmacy does not carry the medication prescribed, and so they forwarded the script to another specialty pharmacy that does carry it.
Five days later, and more than two weeks since the initial prescription was made, Bill receives his medication.
However, that pharmacy does not accept Bill’s insurance. So, the prescription was forwarded again to yet another specialty pharmacy, which is the preferred pharmacy of Bill’s insurance company. However, they don’t carry the medication either.
By this time, ten days have passed since the medication was first prescribed. Bill’s physician, attempting to expedite things, now sends the prescription to a fourth specialty pharmacy that does carry the meds, and personally calls the insurance provider to explain the situation and ask for immediate approval. Five days later, and more than two weeks since the initial prescription was made, Bill receives his medication.
Agreements between insurance carriers and PBMs, which may be part of the same corporation, grant them full authority to determine where patients may or may not purchase their medication. This is carried out regardless of the detrimental effect it often has on patient health and well-being. In such a system, one must wonder whether the objective of curing patients from terminal disease has been usurped by that of achieving financial gain.