Carl, battling prostate cancer, was prescribed an oral chemotherapy drug to help control his disease. Under his insurance plan, however, the co-pay costs for the medication came to over $4,000 per order. Carl simply could not aff ord to pay such an exorbitant amount. Fortunately, the pharmaceutical company that manufactures the drug has a co-pay program of its own, for eligible patients, making the drug aff ordable. Furthermore, the in-house pharmacy at the clinic where Carl receives his treatment benefits from this arrangement, and is able to acquire these and other cancer drugs for the low patient co-pay of $20. The clinic phoned Carl’s PBM on his behalf, explained the situation and asked them to accept the pharmaceutical company’s co-pay as a ‘secondary insurance.’ Their request was promptly denied, as the PBM explained that their system did not have the capability to add in a secondary insurance. When asked if they could then simply authorize the clinic to fi ll the prescription instead, as they had it right there, this was also refused. Unwilling to believe that his patient was not going to receive this medication because it could not be entered into the PBM’s computer system, Carl’s physician made repeated calls to the PBM, speaking to one supervisor after another. Ultimately, he was forced to admit defeat, and Carl was denied a treatment that might have extended his life.
Patients who receive medication at their treating physician’s in-house pharmacy benefit from the fullest in personal care and attention, and have access to a team that will strongly advocate on their behalf. Patients who are forced to deal with PBMs and specialty pharmacies, on the other hand, are often relegated to numbers and statistics, and if their case requires special attention or extra effort, their needs are likely to go unmet.