Pharmacy benefit managers practices cause delay in prescriptions
Getting the drug, Aimovig, turned into its own headache as the 54-year-old
He is among a growing number of patients facing similar issues, health care experts say, because pharmacy benefit managers, or PBMs, administering prescription benefits for health care plans increasingly mandate certain medications come from mail-order specialty pharmacies, which PBMs often own.
The issues are part of larger concerns over PBM practices that prompted state officials and health care professionals nationwide to call for reforms. While legislators focused on reforms to address fees charged to taxpayer-funded Medicaid and Medicare programs, critics say more must be done to address how PBM practices affect patient care.
In a recent report, the
"PBMs have erected roadblocks that keep patients from receiving medications their physicians prescribed," Dr.
The issue is especially critical for cancer patients, who too often face unnecessary delays in receiving potentially life-saving medications, said
"Instead of giving the patient what they need right there and have a nurse explain what to do, it has to go the PBM, which is rife for delays and denials," Okon said.
The AMA is particularly critical of mandates that require patients get prior authorization for a medication or engage in "step therapy," in which patients must try other medications first and prove they do not work before the PBM approves the medication their doctors prescribed.
Doctors are not infallible and can sometimes make mistakes that result in patients receiving incorrect or ineffective treatment, she said. Health insurers act as a second layer of review.
"Just like doctors use scientific evidence to determine the safest, most-effective treatments, health insurance providers rely on data and evidence to understand what tools, treatments and technologies best improve patient health," Donaldson said in an email. "Insurance providers partner with doctors and nurses to identify alternative approaches that have better results and improve outcomes."
While Venosh's medication is not life-saving, he said the delay in getting Aimovig has caused him to suffer needlessly.
"I was really excited to get it because the success rate is 70% or 80% that it reduces the number of monthly headaches," he said.
He expected to fill his prescription at his local pharmacy the same day but PBM Express Scripts rejected it and mandated he use a mail-order pharmacy. It was initially denied because of an issue with how his doctor wrote the prescription. After that was resolved, he resubmitted it but was denied again because he needed preauthorization.
Donaldson said the industry understands the preauthorization process can be frustrating.
"When patients do better, we all do better, for healthier individuals, a healthier community, a healthier nation," she said. "Let's work together to improve patient health, patient safety and affordability for everyone."
The AMA is pressing for additional reforms. In an 2019 report, the organization argues that each state's insurance department should regulate the industry.
"PBMs have assumed the role of insurers but without having to face similar oversight," Dr.
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