Derek, a young husband, was diagnosed with advanced melanoma with brain metastases. Prognosis was grim, yet a ray of light appeared in the form of a new drug prescribed by his doctor. Proven to have the potential of signifi cantly extending life, the drug off ered Derek and his wife real hope. Located in his doctor’s offi ce was the clinic’s pharmacy, where this potentially life-prolonging medication was simply waiting on the pharmacy shelf— but not for Derek. Derek’s PBM mandated that Derek purchase his meds from one of their own mail-order specialty pharmacies. The clinic immediately faxed to the PBM all the necessary information for receiving prior authorization, and for the next ten days, Derek and his wife waited to hear that the prescription had been approved. Upon receiving the go-ahead, they then faxed the prescription to the PBM’s specialty pharmacy, and sat back to wait again.
One week later, the drug still had not appeared; instead, the couple was notified that they fi rst had to remit the drug’s $1,000 co-pay, an amount they were unable to afford. Derek’s wife now began arranging co-pay assistance, but she had to deal with the matter on her own at this point, because Derek had been admitted to the ICU. Several days later, she received approval for co-pay assistance, and forwarded the information to the PBM’s pharmacy, which then overnighted the drug to Derek. The medication finally arrived— only there was no one to take them. By this time, Derek could no longer swallow pills, and sadly, shortly after, he died.
The most common and devastating issue that cancer patients face with PBMs is the fact that they must wait, for weeks or even months, to obtain medication that they could have received within 24 hours, had they been permitted to get it at the point of care from their oncologist. Beyond the stress and aggravation incurred, delays in receiving medication often translate into delayed treatment and worsening of the patient’s condition, and in the most tragic of cases, possibly contributing to the patient’s death.