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Even with a life or death prognosis, his PBM specialty pharmacy chose profit over patient care.


Carl was prescribed regular injections of anticoagulant medication. The initial prescription was sent off to the local branch of a major pharmacy and filled without issue. Three weeks later, however, when Carl tried to refill his medication, the pharmacy charged him a $700 co-pay.

They explained that they could not offer refills; they must go through his PBM-mandated specialty pharmacy. Now there was an emergent situation because Carl needed those syringes immediately.

Carl paid the high price to obtain four syringes, which was all he could afford, while his doctor contacted the insurance company, who said that if the local pharmacy would call them, they could offer an override. The doctor called the pharmacy with the terrific news, only to hear them refuse the request, outright. “We don’t have time for this,” they said. “If the customer wants an override, he needs to make the call himself.”

Three weeks later, however, when Carl tried to refill his medication, the pharmacy charged him a $700 co-pay.

Several hours later, Carl received a call from the local pharmacy, saying that they had spoken with his insurance company, and that the mail-order pharmacy will need a new prescription. No word about the override — they hadn’t even bothered to inquire about it while on the phone with the insurance company. Three hours later, the mail-order pharmacy sent Carl’s doctor a request…only it was for a refill on medication used to prevent side effects caused by chemo and radiation — not for the anticoagulant medication that Carl actually needed.

At this point, Carl was twenty-four hours away from being out of medication. Adding to the absurd irony of the situation, Carl’s doctor actually had an in-house pharmacy that stocked the necessary medicine. However, while the pharmacy was once part of the network of Carl’s insurance company, in 2011 their contract had been cancelled, as they presented competition to the PBM’s specialty pharmacy.

Even when PBM specialty pharmacies are unable to provide a patient with the necessary medicine, and even when the situation is urgent to the point of life and death, they still  will not release that patient so he or she can purchase it where it is available. The greed is so deep that they would rather risk a patient’s life than allow another pharmacy to profit in their stead