The day she was scheduled to receive her treatment--her PBM called to ask for additional authorization due to the medications cost, a detail they failed to mention when the prescription was first filed--causing a three week delay in treatment.
On January 12th, the clinic treating Liane, a cancer patient, submitted a prescription to her PBM’s preferred specialty pharmacy. On January 19th, the day Liane was scheduled to begin treatment, her insurance company notified the clinic that even though they already had prior authorization, they were now requiring a new prior authorization.
Liane was understandably upset by the news; why had the insurance company not contacted them a week ago, when the prescription was first sent? This would now delay her treatment unnecessarily. Later that day, the clinic’s pharmacist ascertained that the additional approval required was related to the medication’s cost, which had been put under a separate review. Over the next five days, the clinic’s authorization specialist, Barbara, was in constant contact with the PBM, who assured her that the medication would be going out at any moment.
All together it took nearly three weeks from the original prescription being submitted to the PBM for the patient to receive it.
A week later, Barbara discovered that this was not true, for when she finally reached a PBM supervisor, Barbara learned that authorization was still pending. She was told that it could take another seven business days or more, before a decision was made.
Barbara’s call must have made a difference however, because later that day the PBM faxed over a form to the clinic, to be filled out and returned to them. The following day approval was granted, albeit for the mail order specialty pharmacy. It took another two days for the specialty pharmacy to receive the prescription, another day to process it, and then the pharmacy contacted the patient to arrange for shipping. All together it took nearly three weeks from the original prescription being submitted to the PBM for the patient to receive it.
“Approval of your medication is pending” may well join the list of phrases that savvy consumers have long-since stopped believing, such as “Your call is important to us” and “The check is in the mail.” Too many patients and physicians have been promised things too many times by PBM and specialty pharmacy reps, only to find those promises unfulfilled or completely contradicted.