It took five calls just to get in touch with a case worker, who ultimately knew nothing about this patient's case.
Lorraine, a multiple myeloma patient, was being denied by her insurance company the medication prescribed by her doctor. A worker at the clinic where she was being treated called Lorraine’s PBM to sort the matter out. She got through to a company representative and began reviewing the situation until, at some point, the call was disconnected. Upon calling back, the worker had to start all over from the beginning with a different customer service representative.
A few days later, she called the PBM a third time, reaching yet another representative, who seemed unable to understand the situation. The clinic worker asked to speak to a supervisor, yet she turned out to be even more abysmal than the prior three representatives, both in terms of her attitude and her inability to understand the situation. The supervisor transferred the matter over to someone in appeals.
She began by emphasizing the urgency of the matter; the longer it took to get Lorraine her medication, the worse her prognosis.
Now, the clinic worker found herself speaking to a fifth employee of the PBM who became even more aggressive, and questioned the worker’s role in the doctor’s office and her right to be making the call. When the worker began to conference the doctor in, so he could participate in the phone call, the PBM representative hung up on them.
As a last resort, the worker tried reaching someone in the PBM investor relations department, and had the call transferred over to the executive escalation team. She began by emphasizing the urgency of the matter; the longer it took to get Lorraine her medication, the worse her prognosis. She added that their office would be contacting both Medicare and the Insurance Commissioner’s office in Maryland, to complain about the unprofessional handling of the matter with a patient’s life on the line. Within twenty-four hours, there was a case worker assigned to Lorraine’s case, yet no knowledge yet of how long it would be before — or even if — Lorraine would receive authorization for the lifesaving treatment she needed.
Dealing with PBM bureaucracy often feels like being trapped on a merry-go-round with no way off. Every issue is handled by a different person or entity, each with its own agenda and protocols. Patients must wait for weeks or even months, to obtain medication that they could have received within twenty-four hours, had they been permitted to get it at the point of care from their oncologist. These delays often translate into delayed treatment and worsening of the patient’s condition, and in the most tragic of cases, possibly contribute to the patient’s death.