This PBM tried to steal business and intimidate community pharmacists—despite the patients wishes.
The pharmacist of an in-house clinic at a community oncology practice was going over patient files one day when the phone rang.
The caller politely introduced herself as an employee of a well-known PBM specialty pharmacy, and then abandoned all niceties as she proceeded to ask why the pharmacist was filling a prescription for a patient that by all rights belonged to them. The in-house pharmacist pulled up the file for the patient in question, who was battling advanced stage ovarian cancer. Not seeing any conflict of interest, he requested further details.
“Did the patient’s physician intentionally send the script to you?” she asked, to which the pharmacist replied, “Of course he did. Our pharmacy is located inside of the practice.”
In clipped tones, the caller explained that his filling of this script was “outside of the manufacturer’s contract, and illegal.” Unfazed, the pharmacist responded by saying that there was no law preventing them from filling it. At this point, realizing that her strong-arm tactics were getting her nowhere with the pharmacist, she changed tactics; perhaps the doctor would be an easier target. “Did the patient’s physician intentionally send the script to you?” she asked, to which the pharmacist replied, “Of course he did. Our pharmacy is located inside of the practice.”
With no wiggle room left, the caller said that she would be informing the patient of all this, and abruptly ended the call. The pharmacist was left to marvel at the audacity of trying to intimidate him into handing over a patient – and the corporation that clearly couldn’t care less about what was best for her.
When that corporation’s income is derived from ‘trolling’ the system to collect more profit-generating patients receiving treatment for life-threatening ailments, we realize things have gone way too far. At some point, something must be done to rectify the perverse profit- motives and incentives behind the corporate PBM approach patient care.
After multiple delays and ruined medications, this community oncology clinic began documenting numerous cases of PBM abuses.
A community oncology clinic became so fed up with the problems and delays their patients faced in dealing with a PBM specialty pharmacy that they opened a dedicated file to document each case. Michelle, a patient at a Florida community oncology practice, had arranged for the PBM specialty pharmacy to ship her medication to one of their local branches, for easy pickup. However, when Michelle arrived at the store, she discovered that they had thrown away her prescription. She now had to request a new prescription from her doctor, get a new prior authorization from her insurance carrier, and then have the medication shipped again—all of which resulted in a two-week delay of treatment.
Exposed to the Florida heat and rain, the drugs were ruined and had to be reordered— subjecting him to another round of authorizations, delay of his life-saving treatment, and unnecessary cost for the health care system.
Diane, another patient at the clinic, had her prescription faxed to the same PBM specialty pharmacy. The pharmacy confirmed it had received the prescription. However, 50 days later, the medication had still not arrived. Clinic staff called the pharmacy, who then claimed they had never received the prescription. By the time it was all sorted out, Diane had been left two months behind in treatment.
The following month, another patient of theirs, Juan, came home to find that his medication had been delivered and left in the middle of the road. Exposed to the Florida heat and rain, the drugs were ruined and had to be reordered— subjecting him to another round of authorizations, delay of his life-saving treatment, and unnecessary cost for the health care system.
No system is perfect. But when a PBM specific pharmacy is repeatedly documented making life-threatening mistakes with no accountability, and cancer patients are forced to remain with them, unable to choose another pharmacy, it would seem that something needs to change.
Clearing out their inbox, the PBM was filling prescriptions and sending prior authorization notices for patients who had passed away.
A practice in California began receiving request after request from a particular PBM for prior authorization to initiate a refill—what was unusual was that they were for a variety of expired prescriptions. What was going on? None of the practice’s patients had been prescribed these drugs recently. In fact, some were for drugs that patients had stopped taking months earlier, while others were for patients who had died.
In fact, some were for drugs that patients had stopped taking months earlier, while others were for patients who had died.
The practice was puzzled at first, but then came to the following conclusion: “It seems they [the PBM] are just going through their files, and when a prior authorization expiration date pops up for prescriptions filled through their pharmacy at one time, they are automatically sending out prior auth requests.”
An amusing anecdote on the surface, stories such as this reveal the wholesale approach taken by the PBMs, in which patients are viewed not as individuals in need of medical care, but rather as a potential market of consumers. Spread across the entire health care system with drug benefits managed by PBMs for millions of patients, this scenario also potentially means millions, if not billions, of dollars of wasted costs in cancer medications.
Unauthorized changes to prescriptions by the pharmacy consistently puts patients' care in danger.
A community oncology and hematology clinic in Pennsylvania was being forced to use a specific PBM specialty pharmacy for their patients’ oral chemo prescriptions, despite the practice having its own in-office dispensary. They had actually applied to the PBM two years earlier for the right to dispense drugs; however, approval was still “pending.”
Frank was one of the clinic’s patients battling rectal cancer. His oncologist prescribed an appropriate medication and submitted it to the PBM specialty pharmacy for filling. Soon after, the PBM called the clinic and announced that approval was denied for the submitted diagnosis, however if the oncologist were to change the diagnosis to one of several other cancers, they would then approve it. The clinic responded by noting that this would be a fraudulent change, that they refused to comply with it, and would be reporting it to the State of Pennsylvania. Within ten minutes of that call, Frank’s medication was approved without any changes.
A pharmacy is forbidden to change prescription instructions without the approval of the prescribing physician.
Edward was another of the clinic’s patients, also battling rectal cancer. He had been prescribed the same drug, with a specific dosage, to be taken twice daily, seven days a week, for five weeks. However, when the medicine arrived, the PBM specialty pharmacy had changed the dosage and instructions. This was done despite the fact that a pharmacy is forbidden to change prescription instructions without the approval of the prescribing physician. To make matters even worse, the quantities sent to Edward were incorrect, even for the adjusted regimen.
Chris was another patient at the practice battling with rectal cancer and prescribed the same medication with the same dosage. He too found that his prescription had been changed by the PBM specialty pharmacy—from seven days per week to five days per week. When the PBM specialty pharmacy called Chris to schedule shipment he refused because the instructions were different from those he’d been given at the doctor’s office. At this point, the PBM specialty pharmacy called the patient’s physician, who had to reinstate the original prescription.
Because of the constant, unauthorized changes to the details of prescriptions made by oncologists, this practice worries that patients’ care is in danger. And these changes are not isolated to just this PBM or practice—specialty pharmacies seem to be playing it fast and loose with the oncologists’ directed treatment plans. Details, such as number of dosages and their size, are crucial life-and-death matters, and PBMs and their specialty pharmacies should not be changing them.