Go to Bat for Patients in Need

Drug Topics JournalDrug Topics July 2020
Volume 164
Issue 7

“I just hope that pharmacists’ judgment can soon be a contributing factor in pharmacotherapy decisions made by PBMs and insurance companies.”


My elderly patients always remark on my ability to communicate with them. They tell me that I speak loudly and clearly and enunciate, that I never mumble.

My grandpa, a blacksmith, was “stone deaf.” I remember speaking, loudly and clearly, into his Beltone hearing aid that he kept in his shirt pocket, the wires running up to his left ear. I learned that if I wanted Grandpa to understand me, I had to speak and enunciate. I’ve applied this tactic when counseling many of my elderly patients, and it has never failed me—except for 1 patient.

“Dave,” a 75-year-old, longtime patient with type 2 diabetes, is hearing impaired. He came into my pharmacy after his wife, also hearing impaired, called me about issues concerning her husband’s insulin injections. We had recently switched him from the expensive brand-name pen needles to a generic. We discussed the need for such cost savings; she said it was not the needles but the pens. Insulin glargine (Lantus Solostar) pens have been around for years, and I thought I’d misunderstood. Dave and his wife lived a mere 2 blocks from the pharmacy, so I asked whether I could speak with her husband in person.

Dave visited the pharmacy, his box of Lantus Solostar pens in tow. Keeping an 8-ft distance between me and himself, Dave requested that I take off my mask so he’d be able to read my lips. I complied, and he then explained that he was struggling with his new devices and that he wanted the “old” insulin pens he had used previously. After analyzing his file, I found an order for insulin degludec (Tresiba FlexTouch) pens that were formulary last year. Dave’s dexterity issues made the Solostar pens problematic, but he was able to work the Tresiba FlexTouch and get accurate dosing. Mystery solved! I called his physician’s office to explain what Dave needed.

The office sent a new order for Tresiba, which needed a prior authorization from the insurance company. I provided the details and even a script of what to say, and the officesent a prescription for Toujeo (glargine)—the same device. Five days later, I was notified that Dave’s prescription hadn’t been authorized. He has 2 insurance providers for Medicare D, both of which had not given permission to fill insulin. Concerned, I called both providers, and they informed me that the physician’s office hadn’t responded to them. As I left another message with the physician’s office, my patience was wearing thin. “For God’s sake, he needs insulin, not some monoclonal antibody,” I remember muttering.

I called the secondary insurance, PACE, a state prescription assistance program funded by the Pennsylvania Lottery. PACE told me that the primary must pay first. Frustrated and concerned for my patient, I pleaded my case for Dave. The provider gave me the perfunctory apology but no action.

Two days later, I received a call from PACE, asking for Pete. Dave’s wife, who’d just called the PACE representative, instructed her to ask for me. Again, I described Dave’s situation.

“I get it, you have rules. But how can I be the only person here [who cares about their patients]? The primary insurance doesn’t care, the physician’s office doesn’t care, and your organization doesn’t seem to care either,” I told her.

I suggested that a PACE representative visit my pharmacy to witness the desperation felt by our patients when insurance companies and pharmacy benefit managers (PBMs) deny the medications they need. Seemingly convinced, she told me she would consult the next level of PACE management.

About 1 hour later, the PACE rep called and assured me that she’d secured authorization for a 1-year approval of Dave’s insulin. I immediately filled Tresiba for a 90-day supply, barely breaking even, but Dave’s ear-to-ear smile and thumbs-up were compensation enough for me. I just hope that pharmacists’ judgment can soon be a contributing factor in pharmacotherapy decisions made by PBMs and insurance companies. For now, it was just nice to win one.

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