PBM Specialty Pharmacy Requirement Hurting Patients, Specialists Say

— Hassles with prior authorization, delivery make it harder to dispense needed medications

Pharmacy benefit managers (PBMs) are requiring more and more patients to use specialty pharmacies to obtain their drugs — especially for cancer and other chronic illnesses — and medical specialty groups are saying that it’s increasing paperwork and hassle for themselves and their patients without adding any value.

Wayne Woodbury, RPh, pharmacy director at Southern Oncology Specialists in Huntersville, North Carolina, had one patient who regularly received an IV immunoglobulin (IVIG) infusion. “Every year, at the beginning of the plan year when she would renew, [the PBM] would say, ‘This medication you get, an IVIG, you can’t fill that through the provider’s pharmacy; you’ll have to use ours.'”

Patient Pushback Required

The first year that happened, “I pushed back as far as I could; I called the insurance carrier that the PBM owned and told them, ‘This is a therapy that is weight-based and it’s therapeutic-level-based,” Woodbury said in a phone interview. “Every month, the patient comes in, she gets blood work and gets weighed, and based on the lab work and her weight, the dose is determined, so our provider would prefer that we’d be able to dispense that and dose-adjust accordingly, rather than getting the shipment from the preferred pharmacy and [risking] underdosing or overdosing.'” Woodbury said he was told that although he couldn’t make that request, the patient herself could do it, and she was able to get an override for it after several hours on the phone, he said.

That worked for 2 years, but then the patient’s employer switched insurers and a new PBM was involved, Woodbury said. Not only that, but the PBM was using a third-party intermediary to manage the prescription component — “to deal with all of the prior authorizations, deal with the prescription claims coming in and where they were sent,” he continued. “I think they use them for a clearinghouse of sorts, getting the information and ascertaining what level of treatment is this and how can we best get this medication distributed?”

Woodbury’s office tried again to get an exception for this patient “and they were an outright ‘No,'” he said. “Unfortunately we weren’t able to provide the medication for the first time in 3 years… so we had it shipped to [an approved pharmacy] and they ship it to our office every month. If it’s not here in time, we may have to change her appointment.”

The intermediary gave the patient a list of reasons why they wouldn’t allow the in-house pharmacy dispensing, “a long list of what they called negligent acts by us, saying when they initially sent the request for the prescription, we didn’t send it back in a timely manner, didn’t get prior authorizations in a timely manner, and refused to give them clinical information,” Woodbury said, adding that none of that was true. “These are all things we do as part of our process — what it takes them 7 to 10 days to do, we can do in a matter of 2 hours to a day.”

Woodbury said he does see a role for PBMs “when it comes to maintenance therapies for certain disease states, because those are disease states where the therapy is established … You know what therapy you’re going to be on, and the monitoring is not as frequent as acute indications in the oncology/hematology space. There’s a place for them there; they are able to offer medication in bulk, sometimes at a discount.”

“To Us, It’s a Person”

Laurie Dieringer, MBA, office administrator at the Lafayette Cancer Center in Lafayette, Indiana, is having similar experiences at her office’s multispecialty infusion center. One patient in particular had been on a chemotherapy drug for a while, “and he’s been filling it in-office for the last couple of years,” Dieringer said. “I went to process the refill in July and got a rejection — all of a sudden we’re out of network and he has to get it at the specialty pharmacy. There was no [prior] notification to the office or the patient.”

This is further complicated by the fact that “a lot of these patients have copay assistance or foundation assistance,” which Dieringer helps manage. In addition, when there’s a dose reduction, “I know it instantly — I don’t have to wait and send a fax” to the outside pharmacy, which otherwise autofills the refill for the same dosage, she said.

Dieringer informed the patient of the change. He was upset and pointed out that he was still working, and asked, “‘Is it going to get mailed to my house? What if somebody steals it?’ That’s a valid concern,” she said. To the PBM, “it’s just a fill. To us it’s a person, it’s a patient and you must try and do the best for the patient.”

Eventually Dieringer’s office was able to convince the specialty pharmacy to ship the medication to another nearby pharmacy so the patient could pick it up there, she said, adding that sometimes prescriptions are delayed because the specialty pharmacy needs to contact the patient about something and the patient doesn’t recognize the phone number and doesn’t answer. “It can take weeks — and I’ve even had it take months — for the patient to get their medication.” The hassles of having to use the specialty pharmacy — a process called “white-bagging” — are so great that two local hospitals have refused to do it and are now sending all their infusion patients to the center Dieringer works at, she said.

Other Specialties Also Affected

And it’s not just oncologists that are having this problem, according to Madelaine Feldman, MD, president of the Coalition of State Rheumatology Organizations. Rheumatologists have been having the same issue with their infusion drugs, she said in a phone interview. “We’ve been fighting against white-bagging, which has been an issue, over the last 3 years or so.”

Although PBMs say that white-bagging can save money for employer groups, oftentimes that doesn’t seem to be the case, Feldman said, noting that one member of the coalition’s Payer Issue Response Team is the office manager for her husband’s rheumatology practice, and she has found that the price that her office would “buy and bill” for a particular drug is often cheaper than the price that she is quoted by PBM pharmacy technicians or what the human resources person in a self-insured employer’s office says they are getting billed for.

Asked to comment on the issue, the Pharmaceutical Care Management Association — an industry group for PBMs — said in a statement that “Specialty pharmacy dispensing on physician-administered drugs is often much less costly and allows for claims processing to occur in real time through the drug benefit rather than through the medical benefit, where physician ‘buy and bill’ can lead to payment delays and high costs. Specialty and other high-cost medications are often misused and underutilized without PBM and specialty pharmacy management programs, support systems, and monitoring tools in place.”

The association included a comment from a 2019 Massachusetts Health Policy Commission report, which found that “clinician-administered drugs are typically high-cost, and spending for clinician-administered drugs represented almost one-quarter of all commercial drug spending and 4% of total commercial health care spending in Massachusetts in 2015. Spending for these drugs is also growing rapidly; commercial spending for these drugs grew 5.1% in 2015 and 9.5% in 2016.” MedPage Today also sought comment from one of the nation’s largest PBMs, but they were unable to respond by press time.