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PBM carelessness and incompetence delayed a woman's care by 19 days, landing her in the hospital and hospice.


Rhonda, a 55-year-old wife, mother, grandmother, nurse, world traveler and self-described Disney expert had been diagnosed with Her2-negative breast cancer. She was receiving treatment at a local community oncology center. Her physician prescribed treatment and attempted to fill it on the same day at the in-house pharmacy; however, the co-pay was too high for Rhonda’s limited means.

The clinic’s financial assistance coordinator went to bat and, six days later, had secured a co-pay card from the drug manufacturer. Two days later, however, when the practice tried to fill Rhonda’s script, her PBM rejected the use of the co-pay card at the practice pharmacy. Instead, the PBM required the script to go out to its own specialty pharmacy. Not wanting to delay her treatment, the practice quickly faxed the prescription over.

Rhonda never had the opportunity to take the first pill.
After a lengthy hospital stay she was discharged home to hospice.

Another six days passed before the specialty pharmacy notified the clinic that the prescription must first go through the specialty pharmacy connected with the patient’s PBM, regardless of who would ultimately fill it. The clinic staff filled in all the additional forms and handled all new bureaucratic measures, and then proceeded to wait. Three days later, a clinic RN called the specialty pharmacy to ask for an update. The representative who answered told her that all was well, and that no prior authorization would be needed. She then placed her on hold. Ten minutes later, the representative returned, only to say that actually prior authorization was needed. With the greatest of patience, the nurse filled out all the new forms and faxed all relevant records necessary for the prior authorization, over to the specialty pharmacy.

Later that day, the pharmacy contacted the RN to inform her that the prescription had been denied, based on the patient’s Her-2 positive status. The RN again sent the patient’s records to the pharmacy, highlighting the fact that she was, and had always been, since she was first diagnosed Her-2 negative. Two days later, the medicine finally arrived.

All-together, Rhonda’s therapy was delayed 19 days, which, had she been permitted to fill her prescription in-house, would never have happened. In total, the clinic staff spent five hours dealing with red tape.

Worst of all, Rhonda never had the opportunity to take the first pill. The night before the medication arrived at her home, she was hospitalized for complications of her metastatic disease. After a lengthy hospital stay she was discharged home to hospice.

While the physicians caring for Rhonda were busy trying to “march to the beat of the PBM’s drum”, this sweet, young, vibrant woman’s window of opportunity closed. How many other scenarios involving pointless deterioration, hospitalization, and death from PBM incompetence are there? When reflecting on the life and care of the patients, PBMs should not be part of the conversation.