PI Original Matthew Blake Friday October 12th, 2012, 4:26pm

Prescription Drug Limit Worries State Medicaid Advocates

The Smart Act that Gov. Pat Quinn signed into law this June contains 62 different ways that the state is supposed to save $1.6 billion each year on Medicaid, the federal-state health care program that cares for the poor, elderly and disabled. Some of these cost-saving items are more difficult to implement than others.

The Smart Act that Gov. Pat Quinn signed into law this June contains 62 different ways that the state is supposed to save $1.6 billion each year on Medicaid, the federal-state health care program that cares for the poor, elderly and disabled.

Ensuring these cuts happen has emerged as an absolutely critical component to balancing a $33.7 billion 2013 fiscal year budget in a state nationally known for its financial troubles. 

“There are definitely going to be implementation problems,” says State Sen. Heather Steans (D-Chicago), the Smart Act’s Senate sponsor. “The folks at HFS [The Illinois Department of Health Care and Family Services] are implementing 62 different projects at once.”

Some of these cost-saving items are more difficult to implement than others. The “most challenging” according to Steans is the new limit on prescription drugs for Medicaid recipients, which caps it at four prescriptions a month.

The Quinn administration expects that it will save $180 million this fiscal year by phasing in the limit. HFS spokesman Mike Claffey argues that the prescription drug cap was included in the larger Medicaid package partly because “too many medications can be counter-productive” and cause unnecessary drug interactions.

Claffey says the state has phased in the limit, starting with at 10 prescription-a-month maximum, and then shifting to the current eight prescription limit. The four prescription limit is set to be enacted in the next few months.

Still, there are approximately 200,000 Medicaid patients in Illinois who take more than four prescriptions a month. While some of these prescriptions may be unnecessary or even counterproductive, thousands of patients may also need more than four, or even more than eight, prescriptions each month.

In response to this issue, the state has set up a system where patients and their physicians must request approval from HFS to be covered for more than four monthly prescriptions.

Medicaid patient advocates are worried about the prior approval process.

“There is some confusion among providers and clients and concern that the process is taking too long,” says Kathy Chan, the director of policy and advocacy at the Illinois Maternal and Child Health Coalition. Chan says prior approval “could be a barrier” to getting needed prescriptions for vulnerable clients.

Sarah Lovinger, the executive director at Physicians for Social Responsibility in Chicago, says that she tried to call the HFS prior approval number and couldn’t get through. Lovinger says that patients with many different kinds of conditions will require approval for more than four monthly prescriptions. Such patients, for example, may include those who suffer from metabolic disorders or certain types of mental illnesses.

Steans says her office has received complaints about HFS implementation of the prescription drug limit. “The prior authorization is taking time,” the state lawmaker says. “It sounds like there are some kinks.”

Claffey counters that the “prior approval process should be handled relatively quickly and should not result in anyone not receiving medication.”

“That’s why we are phasing it in, so that we can make sure we can process the requests,” he added.

Even if the process does function smoothly, it is not clear how accommodating HFS will be to requests. The agency is working with the University of Illinois Chicago’s College of Pharmacy to review doctors' prescriptions and prior approval applications. “We don’t know how stringent the state is going to be,” Lovinger says.

The prescription drug limit is one of the Smart Act components the state is implementing “in a deliberative fashion, which is what they should do,” says Larry Joseph, director of the fiscal policy center at Voices for Illinois Children. Joseph notes that the state is also slowly phasing in a plan that verifies the eligibility of Medicaid recipients.

Other Medicaid cuts were implemented immediately, such as the elimination of Illinois Cares RX, which provided about 180,000 seniors receive prescription drugs through Medicaid.

The passage of the Smart Act was a political triumph for Quinn and lawmakers, such as Steans, who had worked for years to find cuts in a Medicaid system that was pretty lean in the first place. Enacting the cuts without also hurting Medicaid patients, though, may be an even more difficult challenge. “The state has very little wiggle room,” Joseph says. 

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