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Leeway in 7-drug limit

State comes up with a compromise for Medicaid patients

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The state has come up with a compromise, at least for this month, on its new seven-prescription limit for its 225,000 Medicaid members.

The compromise will allow an estimated 5,000 recipients expected to be affected by the prescription limit to keep their current level of monthly medications as long as they show proof they are under a doctor's care and need them all.

Utah Medicaid's new "medical exception policy" will give the state time to come up with a review process to gauge from this over-limit prescription population whether all of the various drugs they take are truly medically necessary, and if more cost-effective prescriptions are available, such as generic brands.

The decision on whether to honor a medical exception will not be based on particular drugs or diseases, but on a case-by-case basis, said Michael Deily, who oversees the state Medicaid program. He pointed out that recipients suffering from chronic illnesses, such a diabetes and heart disease, already are exempt from the cap on prescriptions, as are pregnant women and children.

However, at least initially, the majority of requested waivers in all patient categories are expected to receive approval. "We're going to pretty much for the month of January accept it at face value if someone notifies us in writing of his need for more prescriptions," Deily said. "These medical exceptions will give us a chance to give people a little more time to react to the new prescription limit if necessary and gives us more information on exactly what the problems are out there."

Meanwhile, staff will begin working on a review process that after this month likely will become more restrictive.

The concern is that nobody knows how it's going to work yet and several problems should be anticipated, said Rob Denton, senior attorney for the Disability Law Center.

"The agency legally has the authority to ensure Medicaid is not paying for medications that are unnecessary, duplicative or could be provided more cheaply, but at the same time, legally they have to provide medically necessary services and by virtue of the fact they've already been providing for the prescription medications prior to Jan 1, they've already determined that," he said. "Right now it's all speculation."

The prescription limit and other cost-cutting measures that took effect Jan. 1 are part of the Utah Department of Health's effort to trim $5 million out of its $675 million Medicaid budget, a program funded by federal and state monies in a 3:1 match. The cost cuts were requested by Utah Gov. Mike Leavitt because of an anticipated $200 million shortfall expected this year in the state's general revenue fund.

The cuts also include a new $220 co-payment for each recipient on their first hospital admission of the year and lower reimbursement rates for all prescription drugs.

The announcement of increased costs and benefit cuts prompted a protest at the state Capitol Dec. 29 by public-health advocates and those Medicaid members who will be hardest hit, including nursing home patients, Utahns with disabilities and those who rely on psychotropic drugs to treat their mental illness.

Bruce Bammes of South Salt Lake was among those ranks as his family stood among those to be most severely affected. Bammes' wife Ruth suffers from a litany of health problems and, as a result, takes 26 different medications daily.

He said Wednesday he was glad the state came up with a compromise — "I guess protests really do work, just a matter of getting attention" — but added that the biggest problem he sees is nobody knows specifically how to file for the exemptions. "We haven't gotten anything in the mail yet and we're going to need to start refilling prescriptions in about a week."

That's because the policy is so new, Deily said, and state is still trying to figure out what to require of those needing medical exceptions.


E-mail: nwagner@desnews.com