Even with his care team's support, this patient still experienced weeks of delays due to a lack of communication by a PBM-mandated pharmacy.
Dylan had been on a specific medication for several years to manage his chronic cancer. Each time, he would simply fax the refill script to his pharmacy and the prescription would be filled with no glitches. Dylan’s new insurance policy, however, required him to now fill his prescriptions at a specific PBM specialty pharmacy.
As usual, the clinic treating him faxed his refill prescription over to the new pharmacy in mid-May and Dylan waited for his medication to arrive. He waited and waited. In fact, over the next few weeks, Dylan’s wife began calling the pharmacy on a daily basis, asking them when the medication would arrive. Each time, she was told there was some issue delaying delivery, but that it would be resolved in just a day or two, not to worry. Every few days, she would call back to say it had still not arrived, only to have the same conversation with a different person.
After over a month of waiting, Dylan’s wife asked his oncology clinic to intervene and one call from them determined the actual problem.
Finally, after over a month of waiting, Dylan’s wife asked his oncology clinic to intervene and one call from them determined the actual problem. Apparently, the prior authorization for the medication had expired, something no one at the specialty pharmacy had bothered to inform Dylan, and no one his wife had spoken to had bothered to check what the real issue was holding up delivery. The clinic handled the situation, arranging for authorization and for the medicine to finally be shipped.
Patients and practices often find their efforts to be futile in trying to overcome the massive bureaucracy morass they face with PBM-mandated specialty pharmacies. This creates a costly burden on the physician offices throughout the country, who must now take up the task of contacting pharmacies, resubmitting medication approval, locating missing prescriptions, questioning holdups, and more. But what of the thousands of patients out there with no one in their corner, who are forced to fight these battles on their own?