Carol was battling metastatic colon cancer. Unable to receive the same chemotherapy Carol had been treated with initially, her oncologist prescribed a medication to help stop the cancer from spreading any further. Her physician sent all documentation necessary to the specialty pharmacy mandated by Carol’s PBM. One week later, when Carol’s oncologist phoned the PBM mandated pharmacy to check on status of the prescription, again, they were told that nothing had been done— they refused to process the prescription without knowing Carol’s current weight. Rather than calling Carol or the doctor to ascertain the necessary information, they had simply done nothing. Another week went by, and the doctor called in again to check on the prescription. This time she was told that there was a form the doctor needed to fi ll out, in order to request Prior Authorization from the PBM. The doctor couldn’t understand why they hadn’t simply sent the form to her— or told her about it a week ago, when she had called. Eventually the doctor received the form, filled it out and submitted it, as Carol continued to wait and her cancer continued its lethal advance. Ultimately Carol received the medication— a full six weeks after it was initially prescribed, the most terrible irony being that had she been allowed to receive the pills at the site of care, she would have had them within a day.
Another serious issue patients and doctors face with PBMs and specialty pharmacies is their passive attitude towards patient care. Time and again, patients and doctors wait for medication that will never arrive. One small detail missing in the documentation is enough to delay its delivery, and the specialty pharmacy staff , who do not see themselves as partners to patient care, also do not see it as their responsibility to take any action to hasten the process.