It was early June and spontaneous combustion had already become a legitimate health concern in Phoenix. Following the diaspora north, my wife and I decided to visit the mountains of Colorado. It was all going splendidly until she realized that she had not brought enough of her Flovent (fluticasone) inhaler.
As a former practicing pharmacist and thirty-year academic who has researched, published and taught extensively in the area of pharmacy benefit management, my immediate reaction was “No problem, you have several refills remaining so just have your pharmacy in Phoenix transfer the prescription to one here in Colorado. It happens all the time.”
A few minutes later she returned. “No go. The prescription transfer went fine but the pharmacist in Gunnison says that our pharmacy benefit manager (PBM) won’t authorize the refill because it’s too soon.”
“Yes, yes,” I said patiently, “but there are override codes for circumstances like this. The last thing your physician wants is to interrupt effective asthma therapy and risk the consequences.”
It was agreed that I, the expert, would call our PBM and explain the situation.
Moments later I was speaking with a customer service representative for OptumRx, one of the big three PBMs that collectively control approximately 90% of the prescription benefit management market in the US. “Sorry” she said, “but your plan has no provisions for granting a refill when we calculate it’s too soon.”
So now I am beginning to get irritated, “Wait a minute, are you telling me there are no provisions for extenuating circumstances? Vacations? Emergencies? Lost, stolen or damaged medications?”
“That is correct,” she replied.
“Fine” I said, “let me speak to your supervisor.”
A few moments later I was speaking to her supervisor, a Nicole C. (good luck getting a full name from anyone). Ms. C reiterated that, short of paying for the prescription completely out of pocket (over $300 for a Flonase inhaler, really?), there was absolutely nothing that could be done . . . unless I happened to be a customer of their own mail order pharmacy, in which case there magically was an override code that might be available.
Recognizing we were at an impasse, I decided to go over the head of the PBM and directly to our major medical insurer, Blue Cross Blue Shield of Arizona, who had contracted them. While the PBM operates in a silo of minimizing prescription drug costs, I reasoned that the major medical carrier would recognize the potentially disastrous consequences of interrupting therapy, if not in consideration of my wife’s well-being then to avoid the possible emergency department visit and/or subsequent hospitalization costs they would incur.
It was Friday afternoon and I reached a representative in their Tucson office named Jennifer. I explained the situation and was told that the information provided by the PBM was correct, there were no provisions for an early refill.
“But this is not oxycodone we’re talking about here. It’s a medication for asthma, for goodness sakes! Think about it, keeping her out of the hospital is in your best interests, too.”
Jennifer was sympathetic but firm; there was nothing she could do.
“No offense,” I said, “but you are not a health care provider, are you?”
“No,” she replied.
“Okay, please let me speak to someone who does have medical training. I’m sure they will understand the point I’m making.”
“I’m sorry, but those people have already left for the weekend.” Looking at my watch it was approximately 3:15 pm in Tucson . . . sigh.
“Okay, please get back to me as soon as possible.”
‘As soon as possible’ turned out to be mid-morning the following Monday and I saved the voice mail message I received:
“Hello Mr. Rupp, this is Jennifer at Blue Cross Blue Shield calling you back about your wife’s medication. I just got a response back from our internal pharmacy department and they advised that they do not do any kind of overrides for any situation. So, I do apologize. I wish we had some other answers on that, but that is the management’s rule on it. If you have any further questions feel free to give us a call at 800-232-2345. Thank you.”
No, thank YOU, Jennifer!
In the weeks that followed, my deep sense of humility for the naive perspective I had on my own industry was replaced by outrage. How can this occur? How can such a clearly inappropriate PBM policy be acceptable to a major medical insurance carrier that will ultimately bear the cost of an asthma exacerbation? How could such a flawed plan be acceptable to my employer, or to any employer, for that matter? What if it had been a medication for DVT or diabetes or cancer? What if it had been you or a member of your family?
At a more fundamental level, when is a health care benefit not really a benefit at all, and when is health care insurance not synonymous with reasonable health care assurance?