Instead of receiving her prescription within 48 hours, this patient waited nearly two months because of a PBM specialty pharmacy.
Darla had been taking a medication to treat her thyroid cancer since June. Then, in January her insurance provider changed to a new PBM, although they assured Darla that she would be able to continue filling her prescription at her doctor’s in-house pharmacy. However, when it came time for her January refill, the PBM denied the clinic authorization to fill the script, saying it had to be filled at their own specialty pharmacy.
Despite being a federal government-supported plan under Obamacare, which mandated that the PBM consent to any “willing provider,” Darla never received her January refill. By the time the PBM contacted her for benefits verification, an entire month had gone by. Another week passed, and then another, without Darla ever receiving her medication.
Six weeks later, on March 7th, the PBM called Darla to schedule delivery, but there was more to come. Now her case was passed on to the PBM clinical department, where they needed to verify the dose, diagnosis, allergies, and drug interactions, despite the fact that Darla had been on the medication already for nearly ten months.
If Darla had been allowed to purchase her meds from the in-office pharmacy at her oncologists practice, she would have had them within 48 hours at the most.
Once everything was verified, someone at the PBM realized that the medication was being used off-label. They called up Darla’s oncologist, who confirmed that the patient had received prior authorization back in June to use the drug for thyroid cancer. He also asked the PBM specialty pharmacy representative for an explanation as to why it had taken so long to get Darla her medicine, and why there had been so many lags in communication, but the PBM representative had none to offer. As the call came to an end, the physician asked if Darla could now finally get her medicine. “No,” the specialty pharmacy representative said. “Now we forward to the payment verification center. Once complete, it will be forwarded to the dispensing center. Then we can ship it out.”
If Darla had been allowed to purchase her meds from the in-office pharmacy at her oncologists practice, she would have had them within 48 hours at the most. With the PBM specialty pharmacy, it took closer to two months.
Even when PBM specialty pharmacies are unable to provide a patient with the necessary medicine, 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.