PBM delays and runarounds caused this patient's cancer to go untreated for nearly two weeks, leaving him vulnerable to a number of infections and diseases.
One serious complication that often results from chemotherapy and radiation treatments is a condition called neutropenia, in which there is a significant reduction of the white blood cells that provide essential first line of defense against infections. Neutropenia can lead to sepsis, organ failure, and death; however, it need not progress this far, if properly treated in time.
Marvin, a cancer patient being treated by a community oncology clinic, had developed neutropenia, and his oncologist prescribed a medication that helps the body to produce more white blood cells. His PBM indicated that, in order for Marvin to receive this particular medication, it had to be mail ordered from a specific PBM specialty pharmacy.
Marvin’s neutropenia continued to go untreated for nearly two weeks, leaving him vulnerable to any number of infections and diseases that his body was unable to fight off on its own.
The clinic where Marvin was being treated faxed the prescription over to the specialty pharmacy on February 27th. Three days later, they called to check on status, and were told that the prescription was in the ‘benefits verification stage,’ in which the PBM pharmacy confirms that the patient’s insurance provider will indeed cover the medication’s costs. The clinic asked if prior authorization was required, but the PBM specialty pharmacy representative was unable to say; she promised to call back with that information. Two days later, having heard nothing, the clinic called again, and a PBM specialty pharmacy representative told them that indeed prior authorization was required. That same day, the clinic arranged for prior authorization, called the PBM specialty pharmacy back, told them the medication had been approved, and requested that they now call the patient and arrange for delivery. The PBM specialty pharmacy representative refused, however, stating that the prescription was still ‘being processed.’
Having had enough, the clinic manager asked to speak with a supervisor, who under pressure, agreed to deliver Marvin’s medication on March 7th. However, the date came and went, without any medicine being delivered; nor did Marvin or his clinic receive any phone calls from the PBM or specialty pharmacy, to let them know about or explain the additional delay. When the clinic called back the next day, the PBM specialty pharmacy representative told her that the medication was out of stock, but they would arrange for delivery on March 9th.
Because of the PBM delays and runaround, Marvin’s neutropenia continued to go untreated for nearly two weeks, leaving him vulnerable to any number of infections and diseases that his body was unable to fight off on its own.
Dealing with PBM bureaucracy often feels like being trapped on a merry-go-round, with no way off. Every issue is handled by a different person or entity, each with its own agenda and protocols, and there is no one person who has a bird’s-eye view of the patient’s situation. Nor is there any accountability or certainty that the promises made will be met.