Most pharmacists have stories of how the PBMs have overstepped their bounds in the arena of patient care. This blog has documented several examples over the last year, and a recent encounter serves as today’s edition of Tales from the Counter.
One of our patients was started on finasteride 5 mg by their urologist. Later the patient saw his primary care provider complaining of light headedness and dizziness. The primary care doctor changed his therapy and started him on tamsulosin 0.4 mg daily. The patient then went to the pharmacy to have his new prescription filled. The pharmacist immediately identified a duplication of therapy between the drugs and consulted with the patient. The patient related their story of adverse events with finasteride and reported that they were to stop the finasteride and start with the new prescription, tamsulosin. The pharmacists was satisfied with the patient’s response and documented the intervention in the patient’s chart.
Upon attempting to adjudicate the claim with the patient’s insurance, the processing pharmacy benefit manager also identified the duplication of therapy and rejected the claim. A rejected claim typically requires either the pharmacy enter appropriate clarification codes, often called DUR codes, documenting the resolution of the problem, or a phone call giving verbal clarification to the PBM. With this information in place, the claim would then adjudicate.
In this case, however, the PBM did not allow the pharmacy to document and receive the override. The PBM would not allow the prescription to process without the PBM directly working with the prescriber. The PBM insisted on faxing paperwork for the physician to sign stating that the finasteride was to be discontinued and to ensure the patient would not receive both medications. Once the paperwork was completed and submitted, it would take will take 3-5 business days to complete before the claim would be allowed to adjudicate.
The patient was anxious to get started on the new medication. The pharmacist attempted to force the issue once again. Why wasn’t the pharmacy’s documentation sufficient? The representative informed our pharmacist that they needed to have written confirmation from a licensed healthcare provider that the finasteride is to be discontinued.
Our pharmacist confused. They politely informed the PBM representative that they were, in fact, a licensed healthcare provider. They offered to complete the documentation to certify that the finasteride was discontinued. The PBM representative chuckled and restated that they needed a signature from a licensed healthcare provider. I am not sure, at this point, how well the representative understood the U.S. healthcare system.
I am certain that the PBM representative was just doing their job and following established company policy. The fault lies with the company’s failure to recognize the pharmacist’s legal and ethical responsibility in the day-to-day care of patients. It seems that the PBM believes that they are the entity responsible for caring for the patient. In this case, however, the PBM crossed the line from useful to obstruction.
In this case, the PBM needs to be reminded that pharmacists can and do take responsibility for the care they provide their patients. They deserve respect from the PBMs. Pharmacists are a part of the healthcare team. It is time that this PBM actually joined the team as well.
Ironically, during the same shift, our pharmacist had another patient switching between these exact same drugs. Their insurance used a different benefit manager, and that company did not create any obstructions to patient care.
