For most Americans, picking up a prescription is a routine ordeal. Though costs and co-pays can vary greatly, most Americans can pick up a medication prescribed by their doctors at their neighborhood pharmacy when it’s convenient for them.
But, many patients are forced to wait for their insurer and its associated Pharmacy Benefit Manger (PBM) to authorize and ship their medication from a specialty or mail-order pharmacy.
Pharmacy Benefit Managers are the unseen middlemen and cost drivers of the prescription drug supply chain. Because of this, the Trump Administration has rightly targeted PBM abuses. In 2018, President Trump signed legislation which banned “gag clauses” from PBM-pharmacy contracts for Medicare plans. Gag clauses are imposed by PBMs onto pharmacies, preventing a pharmacist from helping patients to find the best price of their medication. Similarly, the Trump Administration recently proposed forcing PBMs to pass rebate savings on directly to patients at point of sale, sending cost savings from the manufacturer to their intended target instead of letting the PBM pocket them.
While mailing a prescription may sound routine, most patients forced to wait for these services are those with complex or life-threatening conditions such as cancer. Delaying these treatments can have serious repercussions for these patients’ health and potentially lessens their outlook.
Insurers and PBMs claim that these delays are rare and that these programs are instituted to help manage costs and assist patients in managing their medications.
But, unsurprisingly, this isn’t the case – patients are routinely denied coverage or find their treatments significantly delayed.
One example in Ohio found that cancer patients could have to wait up to a month to receive their oncology medications after their insurance and PBM have received the prescription.
The reason, the PBM and insurer requires that the medication be sent from a specialty pharmacy.
A report from The Columbus Dispatch in 2018 highlighted the problem, finding patients like Elvin Weir who not only had to wait for his prescription to be sent to him, but he was also sent the incorrect medication twice.
PBMs and insurers claim that specialty pharmacies help to manage care and costs, but in Mr. Weir’s case, their “care” led to a delay in his treatment and the waste of $20,000 worth of treatments.
Importantly, this isn’t an isolated incident. Another 2018 report from The Times-Picayune in New Orleans highlighted how numerous cancer patients are forced to wait or are outright denied the medication their doctor has prescribed them, forcing them to wait for an appeal.
In the instance highlighted, the patient, Connie Raborn, had to wait almost three months before she was able to take her medication.
For cancer patients, these kinds of the delays are quite literally the difference between life and death. Unfortunately, cancer treatments are often the medications which insurers and PBMs restrict via specialty pharmacies.
These delays aren’t the only problems facing patients forced to use a specialty or mail-order pharmacy by their insurance and PBM. Patients have reported receiving medications which were shipped at unsafe temperatures, rendering them ineffective or even dangerous.
Problems with mail-order, specialty pharmacies affect patients struggling with complex or life-threatening conditions, ranging from cancer to HIV. It’s why states have passed “Anti-Mandatory Mail Order” laws to stop insurers and PBMs from forcing patients to bear the brunt and extra costs associated with these pharmacy policies.
As PBMs continue to drive up costs and reduce choice for patients, we need patient-first reforms which increase transparency in the opaque drug-pipeline system, creating real accountability for middlemen and insurance companies. We hope that leaders in Washington take a hard look at mandatory mail-order pharmacies and the burdens they create, as well.
