Treatment Delayed Due to Pharmacy Restrictions

Bill was prescribed an oral medication that works to prevent his cancer cells from replicating, thus reducing the growth and spread of the disease. His oncologist faxed the prescription to the specialty pharmacy indicated by Bill’s PBM. Unfortunately, this particular pharmacy does not carry the medication prescribed, and so they forwarded the script to another specialty pharmacy that does carry it. However, that pharmacy does not accept Bill’s insurance.

So, the prescription was forwarded again to yet another specialty pharmacy, which is the preferred pharmacy of Bill’s insurance company. However, they don’t carry the medication either. By this time, ten days have passed since the medication was fi rst prescribed. Bill’s physician, attempting to expedite things, now sends the prescription to a fourth specialty pharmacy that does carry the meds, and personally calls the insurance provider to explain the situation and ask for immediate approval. Five days later, and more than two weeks since the initial prescription was made, Bill receives his medication.

Agreements between insurance carriers and PBMs, which may be part of the same corporation, grant them full authority to determine where patients may or may not purchase their medication. This is carried out regardless of the detrimental eff ect it often has on patient health and wellbeing. In such a system, one must wonder whether the objective of curing patients from terminal disease has been usurped by that of achieving financial gain.