We have been hearing a lot about the explosion in the cost of specialty Rx that is leaving insurers, health plans, and governmental payors virtually defenseless against their cost (see Sovaldi). One of the mechanisms being deployed to combat the rising price tag is mandatory specialty Rx oversight. What this basically does is cede total control of the distribution and administration of these costly medications to the insurer or PBM. In many instances, these medications are shipped directly to the member’s home. For those plans that have a mandatory mail order provision for medications for chronic illnesses, there is no other option to obtain these drugs locally.
Recently, we got involved in a member dispute with a large national insurer (and the employer) on behalf of a member who is battling HIV. Citing his right to privacy in obtaining his medications from a trusted source, he felt there was no way to fully trust that his privacy would not be compromised with third party involvement. The member was used to picking up his medication directly from his trusted local source. Now, the employer was forcing him to obtain his medication through the mail from a party he did not know and also involved an interaction with a package delivery company.
At first I thought the member was misinformed – certainly the large national insurer’s PBM was taking every possible step to ensure his privacy. But as I thought about it more, I could really see the member’s issue. Could his privacy be 100% guaranteed in this instance? This does add potential for exposure and is an understandable concern, but typically the postal service is reliable and confidential. Perhaps not 100%, but I am not sure there is any reason to assume there will be a breach.