I’ve probably been doing this too long, but I suppose it is human nature to compare personal events to hypothetical situations within your professional life. Many years ago, in “another life”, as they say, I worked extensively in the food service and hospitality industry. My parents bought a motel, restaurant and lounge when I was 10 years old, and I went to work that year bussing tables. Over the next 13 years, I spent most of my working hours bussing tables, preparing food, washing dishes and serving customers; until I graduated from college and went in to management, where I spent much of my time bussing tables, preparing food, washing dishes and serving customers.

For many years after leaving that industry, I could not encounter any significant situation in a restaurant without imagining the ramifications if it had happened in my own operation. This included what we called “crash and burn” poor service scenarios where I was thankful I did not have to do this type of work anymore.

Today, when I encounter a frustrating situation in my own life, instead of the hospitality comparison, I find myself comparing it to the workers’ comp system. I ask myself, how would an employer or injured worker respond if this happened to them? I had one such situation this past week.

Several months back the Pharmacy Benefit Manager (PBM) used by our group health insurer advised me that it would be in my best interest to move my few prescriptions to their mail order service, as it would save me money. The fact that it would save me money because they would punish me with increased co-pays for not doing so was not lost on me at the time. I thought we had set up my prescriptions for auto-renewal, but when my asthma medication ran out several days before Christmas, I found out that was not the case.

This became a lengthy issue that spanned 4 days, numerous challenges (from multiple players) and many phone calls, but I will attempt to relay it as briefly as I can.

As I describe the situation, I ask you to think about this happening to an injured worker whose claim was on your desk.

Day 2 Without Medication:

I phoned the PBM regarding my asthma medication (bear in mind every call I mention involves first navigating a labyrinth of menus and information within their automated system before you get to a human). They arranged to ship a refill, which, due to the holidays, might not arrive until December 30th. I wasn’t concerned, as they said they would authorize a one-time refill at a local pharmacy.

When I called my local pharmacy, a CVS near my home, they could not comply as my current prescriptions had been transferred to the PBM. I had to call my doctor’s office to request a new prescription. This was on Thursday.

Day 3 Without Medication:

Friday, a second call to the doctor was needed as no prescription had been forthcoming. When it arrived in the afternoon, I received an automated message from my CVS pharmacy that my prescription was on backorder, and they would fill it as soon as possible. I called the pharmacy and (after a 29 minute hold for the pharmacist now well documented on Twitter) learned that they would not be able to fill it until Tuesday, the day after Christmas. A search of their system found no CVS pharmacies in the area with any of this medication in stock. I phoned a Walgreens near me, and while they did not have it in stock, they located 3 pharmacies that did. I called the one closest to me and arranged to have the prescription transferred.

Friday night I received an automated call from Walgreens telling me there was a problem with my insurance, and the prescription was on hold.

Day 4 Without Medication:

This was a Saturday with peak frustration, as I was audibly wheezing, had to use an emergency inhaler for the first time in years, and spent almost 4 hours trying to get this resolved. I phoned Walgreens, assuming they had old insurance information. They did not. The refill had simply been declined by my PBM.

I called my PBM. They told me they issued an override approval, and I should call the pharmacy back.

The pharmacy attempted to run it, and the prescription approval was declined.

I called my PBM. They put me on hold while they conferred with their help desk. They then advised me they were putting through an approval override.

The prescription was again denied at the pharmacy.

Once more a call went out to the PBM. Then another to the pharmacy. This time they were told by the PBM that my doctor needed to approve the override.

Fat chance of that on a Saturday before Christmas.

At one point during one of these many calls, I had to call the pharmacist while the PBM rep was on another phone, and they tried to have a conversation through me. That was efficient.

Yet another call to the PBM; and this time I was told the pharmacist had to call the pharmacy assistance line and request the approval by phone. I was assured that this would do the trick. I called my pharmacist, advised them of this, and waited for the confirmation.

Thirty minutes later, he called me to tell me they would not approve the prescription until January 23rd.

We tried once more, and when it was again declined, the pharmacist (I was now on a first name basis with all three on duty) advised me they simply could not get approval. At this point, since I would be out of town when the mailed prescription would likely arrive, I was looking at two weeks without this medication. I asked the cost of purchasing the medication outright, and it was $271. I told him I would probably have no choice, and would call him back to arrange it.

I was now livid, and wanted another shot at my PBM. When I got the first rep on the line for this call and demanded to speak to a supervisor, he instead routed me back to the auto attendant, where I had to start all over again just to get back to a customer service representative. Needless to say, I was apoplectic by the time I got the next rep on the phone. I recounted the sordid details, and demanded to know why it appeared I was continually being lied to. I informed them I wasn’t just a “member” in their parlance; I was the employer that chose to use them for my company. I advised them what my company paid in annual premiums and assured them that this event would influence my next decision regarding future use of their services.

The end result was that this final call and this last representative solved the problem. It took about 30 minutes. We went through the entire saga again, and I was put on hold. Ultimately, she came back and said she had again spoken to the pharmacist, that it had been approved, and my co-pay would be just $10. I called the pharmacy and confirmed that was the case.

Turns out I wouldn’t spend Christmas in the emergency room after all. I picked up my prescription within 30 minutes of that final call. It had been a few days of frustration that I would have preferred to avoid altogether.

If you think this description is both ridiculous and tedious, you should have lived it. Yet, as frustrated as I was, I was so much more fortunate than a hapless injured worker who might find themselves in a similar situation.

For starters, I had the $271. Many injured workers don’t have the resources to just go buy the drugs that are not being provided to them. I certainly was not enjoying the fact that I might have to pay when the service should be forthcoming, but I knew at the end of this, one way or the other, I would have the medication I need. Injured workers often can’t say that.

I also had the benefit of a bit of industry experience, and that likely gave me the tenacity to pursue a resolution, where an injured worker without that benefit may have stopped trying before the issue was corrected.

We also cannot overlook the fact that I possibly had more leverage. I have no idea whether revealing myself as the decision-making employer helped or not, but the fact remains it did not get resolved until I had done so. Injured workers don’t have that leverage, and in fact, are often left feeling powerless in situations like this.

And that final point is the rub; for an injured worker, this type of incident could be a frustrating pain point that makes the critical difference between a smooth recovery and a litigated case. Often overwhelmed by our system, struggling for the medications you are supposed to have is one more sticking point that can cost everyone in the end.

Let’s hope your PBM understands that when dealing with the workers in your care. If they don’t, your workers attorney surely will.


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