He kept getting the runaround, being told one thing by a representative, only to have that information contradicted the next moment by someone else.
James, a third-grade teacher in his early 40s, has lived with leukemia for many years, keeping it in remission with a daily oral medication. In November, his insurance provider notified James’doctor that a new prior authorization was required to continue receiving his medication. There was no time to lose; James had just finished his last bottle and needed an immediate refill. The authorization was immediately obtained, and the clinic forwarded it on to the PBM-mandated specialty pharmacy.
Four weeks went by, yet no medication arrived. Brenda, a clinic worker, contacted the specialty pharmacy, and a voice on the other end stated that a new prior authorization was needed. Confused, Brenda again faxed the approval letter to the pharmacy, while continuing to wait on hold. After a considerable wait, the pharmacy worker came back on the line and told Brenda that this letter was already in the patient’s file, but that a new prior authorization was needed.
What on earth for? Brenda wondered to herself, as she hung up the phone. They were in February, so perhaps it was because the previous prior authorization had been sent in 2017? Yet, according to the insurance company, the old prior authorization was still in effect. She called the specialty pharmacy back, and this time a different representative answered. He looked up James’ case and stated that all was well; in fact, the medication should arrive in just a few days.
Four weeks went by, yet no medication arrived.
Brenda hung up and called James to let him know he should expect his medication any day now. Answering the phone, James told Brenda that for the past four weeks, going without medication, he’d been frantically calling the pharmacy on a regular basis, trying to order it. They had told him each time that they’d been unable to contact Brenda, despite many attempts, and that his being without medication was due to the clinic’s negligence.
Meanwhile, during those same four weeks, while James’ blood counts were reaching horrific levels, Brenda was able to fill five prescriptions of the same drug for other patients, whose PBM allowed them to receive their medications in-house.
Dealing with PBM bureaucracy can be frustrating to say the least. Getting the runaround… being told one thing by a representative, only to have that information contradicted the next moment by someone else…having the person on the other end of the phone lie to you…these are the things patients and clinic workers meet time and again. And, as if lying about the status of a drug’s delivery wasn’t bad enough, to add insult to that situation by implying the delay is the fault of the very people treating the patient, is unconscionable.
While the PBM bureaucracy failed to remedy the situation, his cancer went untreated and continued to spread.
James was a patient in his late 50s, suffering from advanced renal cell carcinoma. On May 18th, his oncologist prescribed a particular medication, and they began a two-week wait for his insurance company to approve usage. Upon receiving approval, the doctor’s office sent the prescription over to James’ PBM-mandated pharmacy, with a request that it be handled ASAP, as the patient’s situation was dire.
One week after making the urgent request and having heard nothing, the practice followed up to ascertain the status of his prescription. A few days later, a response came back from the pharmacy that they had attempted to contact James twice, but had not succeeded to reach him. They asked the doctor’s office to have the patient call the pharmacy himself. The office asked the pharmacy if and when they had been planning to contact them, to notify them that there was an issue with delivering James’ medication. The pharmacy responded that their policy is to try phoning the patient three times, and then they either contact the prescribing doctor’s office or simply mail the prescription back to the patient.
James’ cancer continued to spread, untreated, leaving him no closer to receiving his medication than he had been three weeks earlier.
While the PBM bureaucracy failed to try to remedy the situation, James’ cancer continued to spread, untreated, leaving him no closer to receiving his medication than he had been three weeks earlier. As for the PBM pharmacy, they seemed completely unconcerned, despite the fact that the five-year survival rate for advanced renal cell carcinoma goes from 53% down to 8%, if it passes from Stage III to Stage IV.
Time and again, doctors reach out to PBM-mandated specialty pharmacies to enquire about the status of medication— only to discover that the process is stuck, and no one at the pharmacy feels any sense of urgency, despite the fact that the patient in question is being treated for a life-threatening condition in which time is of the absolute essence.
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.