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When a kindergarten teacher's insurance changed PBMs, she saw weeks of delays on her proven course of treatment.


Belinda, a kindergarten teacher and mother of two, was fighting thyroid cancer. Her oncologist had her on a particular medication that was approved for off-label use on thyroid cancer; she’d been taking the medication for seven months and was doing well.

In January, Belinda’s insurance carrier moved to a new PBM, which required her to fill her prescriptions at their mandated specialty pharmacy. They assured Belinda that it would be no trouble for them to continue filling her medication. So, that same month, when it came time for Belinda’s refill, her oncologist sent the e-prescription directly to the new pharmacy, and called Belinda to confirm.

When Belinda tried to pick up the prescription, however, the PBM-mandated pharmacy said they were unable to process it “at that time.” She waited an entire month before being contacted by the PBM pharmacy to verify benefits and schedule delivery. After another week went by with no medication, a very frustrated Belinda called her oncologist to see if they could dispense the medication directly to her. Unfortunately, according to Belinda’s insurance policy, they were not allowed to do that.

Another week passed, and, after six weeks of delays, the PBM-mandated pharmacy contacted Belinda. They wanted now to schedule delivery – again. The prescription was then sent to PBM’s Clinical department to verify dose, diagnosis, allergies, and drug interactions.

Had Belinda been authorized to purchase her medicine from the in-house pharmacy at her doctor’s office, the entire process would have taken a single day.

At this stage, someone at the PBM finally noticed that the drug was being prescribed for an off-label usage, and called her oncologist to verify the diagnosis. The oncologist spoke to the PBM pharmacist, explaining that the drug had been approved for nearly a year, with the patient taking it all that time, to very beneficial results. It had always been for off-label usage, and the insurance company had always agreed to it. What was the matter?

The PBM pharmacist had no explanation for the time lag, nor was there any documentation to explain why more than two months had passed. At the end of the conversation, the doctor asked if Belinda could finally expect to receive her medication now. “No,” the pharmacist replied. “Now, we forward the matter to the payment verification center. After that stage, it will be forwarded to the dispensing center. Then we can ship it out.”

Had Belinda been authorized to purchase her medicine from the in-house pharmacy at her doctor’s office, the entire process would have taken a single day.

The larger an organization, the more complex the bureaucratic procedures. This is often done under the guise of ensuring safety. However, how far do things need to go before it can be said that the harm to patients has greatly surpassed any intended good? At what point do the PBMs themselves become accountable to a certain standard of care–even in terms of something as simple as response time?