Carl was prescribed regular injections of anticoagulant medication. The initial prescription was sent off to the local branch of a major pharmacy and filled without issue. Three weeks later, however, when Carl tried to refill his medication, the pharmacy charged him a $700 co-pay.

They explained that they could not offer refills; they must go through his PBM-mandated specialty pharmacy. Now there was an emergent situation because Carl needed those syringes immediately.

Carl paid the high price to obtain four syringes, which was all he could afford, while his doctor contacted the insurance company, who said that if the local pharmacy would call them, they could offer an override. The doctor called the pharmacy with the terrific news, only to hear them refuse the request, outright. “We don’t have time for this,” they said. “If the customer wants an override, he needs to make the call himself.”

Three weeks later, however, when Carl tried to refill his medication, the pharmacy charged him a $700 co-pay.

Several hours later, Carl received a call from the local pharmacy, saying that they had spoken with his insurance company, and that the mail-order pharmacy will need a new prescription. No word about the override — they hadn’t even bothered to inquire about it while on the phone with the insurance company. Three hours later, the mail-order pharmacy sent Carl’s doctor a request…only it was for a refill on medication used to prevent side effects caused by chemo and radiation — not for the anticoagulant medication that Carl actually needed.

At this point, Carl was twenty-four hours away from being out of medication. Adding to the absurd irony of the situation, Carl’s doctor actually had an in-house pharmacy that stocked the necessary medicine. However, while the pharmacy was once part of the network of Carl’s insurance company, in 2011 their contract had been cancelled, as they presented competition to the PBM’s specialty pharmacy.

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Even when PBM specialty pharmacies are unable to provide a patient with the necessary medicine, and even when the situation is urgent to the point of life and death, they still  will not release that patient so he or she can purchase it where it is available. The greed is so deep that they would rather risk a patient’s life than allow another pharmacy to profit in their stead

Carl, battling prostate cancer, was prescribed an oral chemotherapy drug to help control his disease. Under his insurance plan, however, the co-pay costs for the medication came to over $4,000 per order. Carl simply could not afford to pay such an exorbitant amount.

Fortunately, the pharmaceutical company that manufactures the drug has a co-pay program of its own, for eligible patients, making the drug affordable. Furthermore, the in-house pharmacy at the clinic where Carl receives his treatment benefits from this arrangement, and is able to acquire these and other cancer drugs for the low patient co-pay of $20.

He was forced to admit defeat, and Carl was denied a treatment that might have extended his life.

The clinic phoned Carl’s PBM on his behalf, explained the situation and asked them to accept the pharmaceutical company’s co-pay as a “secondary insurance.” Their request was promptly denied, as the PBM explained that their system did not have the capability to add in a secondary insurance. When asked if they could then simply authorize the clinic to fill the prescription instead, as they had it right there, this was also refused.

Unwilling to believe that his patient was not going to receive this medication because it could not be entered into the PBM’s computer system, Carl’s physician made repeated calls to the PBM, speaking to one supervisor after another. Ultimately, he was forced to admit defeat, and Carl was denied a treatment that might have extended his life.

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Patients who receive medication at their treating physician’s in-house pharmacy benefit from the fullest in personal care and attention, and have access to a team that will strongly advocate on their behalf. Patients who are forced to deal with PBMs and specialty pharmacies, on the other hand, are often relegated to numbers and statistics, and if their case requires special attention or extra effort, their needs are likely to go unmet.