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A Seat in the House

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Cuts to Medicaid

I ran into a family friend of ours the other night at graduation and got “chewed out” for the cuts in Medicaid that the legislature approved this last session. Our friend is in her 70’s and, like many in that age group, she is taking medication for some physical problems including arthritis and stomach problems, some of which are caused by the arthritis medicine.  Medicaid has been paying for her prescriptions.

She informed me that because the Legislature approved the Health and Welfare’s requirement that more then four prescriptions had to be approved by Boise before Medicaid would pay, two of her prescriptions had been disapproved.  “I need those drugs!” she told me; “it is the only way I can control the pain and stomach nausea and I can’t afford to pay for them myself. ”  

I told her that I thought there must be a mistake because it was my understanding that Health & Welfare has put the approval requirement for more then four prescriptions on hold because of problems implementing the program, but that I would call the Department and see what was happening. 

I called the Department the next morning and learned that the Department actually has two prescription drug approval programs, one is being implemented, the other one is on hold.  The one on hold is that one requiring Department approval before payment is made for any prescription that exceeds four already being paid for on behalf of the Medicaid patient. Before the Department can implement this program they have to have new computer software developed in order to keep up with the volume of prescriptions.

There is another approval program in effect however, and this is the one that caused the problem for our friend.  This is a new program called “Therapeutic drug prior authorization”.   As many of you are aware there are many generic drugs available on today’s market that provide the same relief as the “name brand” variety, but at substantially less cost.  This new program requires that the doctor prescribe the generic drug rather then the name brand if the generic will provide just as effective relief.  If the doctor can show evidence that the generic has been tried and was not effective then the Department will approve the name brand, otherwise the generic has to be prescribed in order to have Medicaid pay for the prescription. 

In this case our friend’s doctor had prescribed a drug called Vioxx for her arthritis (you see it advertised on TV all the time), and also prescribed a drug identified as Prevacid to help ease the stress on her stomach that many arthritis drugs create.  Under the “Therapeutic drug prior authorization” program, both drugs were initially denied since generics were available.   

As it turns out, however, the Vioxx was approved because there was not a substitute that would provide the same relief as Vioxx in our friend’s situation.  The Prevacid, however, was denied and according to the Department’s Medical Director, Dr. Tom Young, for a very good reason:  “You don’t need or want to prescribe these two drugs together,” he told me. “We okayed the arthritis drug because your friend needs it for the discomfort she experiences in her joints, but there isn’t a need for Prevacid. It really doesn’t help her. It’s duplication."

Vioxx, as Dr. Young explained, is a new type of arthritis medicine that is very easy on the stomach, so in this case you don’t need a second drug to protect the stomach — the Vioxx already does that along with easing the arthritis pain

The Department went on to explain that beyond the therapeutic implications, there is a cost issue. A four-week supply of Vioxx costs more than $70. Over a year that would add up to $910 and that’s okay when the drug is needed and there is not a less expensive substitute, but what is not okay is adding the cost for an unnecessary drug. In this case, the Prevacid would have added another $117 per month to Medicaid’s prescription costs. Over a year, the bill for the unneeded drug would have totaled more than $1,400. 

It was also explained to me that if my friend was still uncomfortable with the decision that she could ask her Doctor to call Dr. Tom Young and he would be glad to discuss the second prescription with her Doctor to determine if it should still be prescribed in her case.

At this point our friend’s problem appears to be solved in that the needed medicine was prescribed.  The prior authorization program began in May as one of several initiatives to slow pharmacy costs in Medicaid.  Pharmacy costs have been increasing at a faster rate than any other Medicaid program and paying for medicine has become one of the agency’s biggest expenses. This program requires use of generics when appropriate and is not unusual in the private insurance world.  I know in the case of my insurance company they require the use of a generic or I have to pay the difference; so this does appear to be a reasonable program to help keep costs under control. 

In any event it appears that our friend is getting the medicine needed and just as important, that this new program will not deny prescriptions for anyone who needs them.  I would suggest however, that if you are a Medicaid recipient that you ask your Doctor to consider prescribing a generic drug when appropriate to avoid unnecessary delays in approval or payment by Medicaid.

I hope this information is helpful for any of you that have questions or concerns relative to the Department of Health and Welfare’s Medicaid prescription drug program, especially the preauthorization requirement.

Again, thanks for reading and as always feel free to contact me anytime.  My home phone is (208) 265-0123 and my mailing address is P.O. Box 112, Dover, 83825.  You can also reach me on “E” mail at [email protected]

Thanks for reading! George

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Rep. George Eskridge Rep. George Eskridge the Republican Representative for District 1 in Idaho’s House, George Eskridge can be reached at 208-265-0123 or write PO Box 112, Dover, ID 83825

Tagged as:

Politics, budget, Idaho Legislature, cuts

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