The PBM specialty pharmacy could in no way help her situation, nor could they refer her anywhere for more information; they were completely useless.

Janine, a 22-year-old woman with Hodgkin’s lymphoma, was prescribed a specific medication for fertility preservation. Her clinic’s representative contacted the PBM specialty pharmacy to determine if prior authorization was required for the drug, and what Janine’s co-pay would be.

The PBM pharmacy representative rudely responded that Janine’s doctor needed to follow the proper procedures: send in the prescription and wait the necessary two days before obtaining the benefits information. The clinic representative explained that they only wanted the benefit information in order to make a treatment decision; that without knowing the co-pay they didn’t know if Janine could afford the medication, and therefore didn’t know whether or not to prescribe it.

The response was that the PBM specialty pharmacy could in no way help in this situation, nor could they refer them anywhere for more information.

The response was that the PBM specialty pharmacy could in no way help in this situation, nor could they refer them anywhere for more information. As a result, the clinic’s hands were tied; they had no idea if the insurance company would authorize the medication, and if not, if Janine would be able to afford them on her own.

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PBM specialty pharmacies have a long list of complex bureaucratic protocols, but shouldn’t they be able to help patients and practices make cost saving decisions? Unfortunately, PBM bureaucratic protocols are often harmful to the very patients they are meant to help.