When the Pharmaceutical Benefit Manager
Won’t Let You Go On Vacation


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I  leave for vacation in the morning and it was not music to my ears when I heard that the pharmaceutical benefit manager (PBM), the company that reviews your drug use for your health plan or employer, denied an early refill for a maintenance medication. At 4 PM, my local drugstore told me that the pharmaceutical benefit management company for my health plan, would advance me three pills before I leave on vacation –a one day supply.

We discussed how long I would be away. Ten days. The PBM told the druggist to have me pay list price out of pocket for my maintenance medication, fill out a form, and eventually I would be credited for something. I wasn’t thrilled when I was told the out-of-pocket expense would be something on the order of $500. Who can afford that –and just before a vacation?A PBM should know better than to put someone in such a tough situation. I have been warned by my doctor that it is dangerous to abruptly stop taking these medicines.

The drugstore was as fed up as I was. My local drugstore did the decent thing of advancing me for ten days, letting me complete my order when I get back.

I am hoping that drugstores don’t go the way of bookstores. I like a real person in a real drugstore near my home.

It makes me wonder whether a remote PBM really should be in the business of medication therapy management. I have found that their records are out of date. Sometimes they call me to discuss a medication that I haven’t taken for two years or send a print-out based on medicines that I stopped a long time ago, begging me to go mail order so I can get immense savings. They send me charts of drug savings via mail order (which, BTW, seem to be getting less of a savings than they were a few years back). When they started mail order, in some parts of the country you could get three months of medicines for the cost of two. But I don’t think that ever was the case in my neck of the woods (New York City), but then, I don’t live in California or Seattle.

So I think the PBMs have some work to do to get people to think they are up to good. I think you are generally allowed one advance per year for a vacation. It may not be enough in the mobile society that we live in today.

Then there are the disease management calls that people around the country tell me that they get. They know that they are disease management because they are health savvy. And it’s not as if they are against them, but they get no warning, and suddenly a total stranger from a company you never heard of, wants to discuss your chronic illness. It’s uncomfortable. I don’t think the average person out there has a clue what pharmaceutical benefit managers are either.

A friend of mine with rheumatoid arthritis told me that these strangers call her and treat her as if she is on the road to falling off a cliff even though she has never been hospitalized and doesn’t use outpatient services much. Of course, disease modifying drugs for rheumatoid arthritis are costly. Another friend told me that people call, claiming to represent the PBM, to discuss his diabetes, and recommend actions that he could take to improve his outcomes. That is certainly reasonable, but I don’t know many people who take too well to people calling them out of the blue to discuss personal business. Besides, I know what a PBM is, but how many people out there have a clue?

Just a heads-up for the PBM and insurer: it would be nice if you notified us that these calls were going to come in. Sending an email or a snailmail would be nice. The contacts would inspire more confidence if you were working in real time. Otherwise, they sometimes sound like robocalls or like who-knows-who got a hold of your medical records.

The experiences that I mention here seem pretty out of touch and a bit inflexible. How can anyone trust your wisdom if you can’t even let us go on vacation, and go with the medications deemed essential to our good health? What’s your thought? Is there a better way?

(Footnote for readers: I will be posting on this semi-vacation (really change of location). I look forward to conversing with you here and on twitter at lauranewmanny. There is a lot of news even though it is late July–and I will be posting.)

 


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