Due to clerical error and the absence of anyone to take responsibility, the patient had already gone 10 days off of her regimen, something which never should have happened.
Paula was a very intelligent company executive battling breast cancer. Her oncologist prescribed a particular medication and she faced no issues in having it filled or refilled the first time. When it came time for the second refill, however, she met a PBM roadblock. Despite several calls to the PBM, and speaking with several different people, all the patient could get them to explain was that there were insurmountable “insurance issues.” Not knowing what else to do, she came into the oncologist’s office so they could call the PBM together to resolve the matter.
The patient had already gone 10 days off of her regimen, something which never should have happened.
After a long wait on hold, the doctor and his patient finally reached a representative who informed them that they were unable to fill the prescription because it could have a negative interaction with another medicine she was currently taking. The doctor and the woman looked at each other for a moment, before asking the rep, “What medicine?” The patient was not taking any other medication. This was, however, not what the PBM had in their records. It took quite a bit of additional convincing by the patient and her doctor before the PBM would believe them, and agree to provide authorization.
By this point, due to clerical error and the absence of anyone to take responsibility, the patient had already gone 10 days off of her regimen, something which never should have happened.
Practices report that they spend an absolutely ‘ridiculous’ amount of time trying to obtain prior authorizations from PBMs – well beyond any reasonable expectancy. Even getting to the point where there is another human being on the other end of the phone to talk to is an achievement in and of itself. This, of course, is only the beginning of the PBM process that is fraught with errors and poor record keeping, all of which can add up to dozens of hours of staff time wasted dealing with bureaucracy, and drag on over days, weeks, even months. In the meantime, patients with cancer are left waiting without the treatment that they need.