New Illinois Medicaid Rules

[BidingMyTime]

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So starting back in July, Illinois public aid rules limit people to 4 prescriptions in any rolling 30 day period. It is slowly going into enforcement. The only exempt drugs are birth control, HIV drugs, antibiotics, & organ rejection drugs. Prior auths will be considered off of a limited list of drugs (the list does include most lifesaving, maintenance meds.)

When I first heard this idea, I thought it was bad. Seeing how people are being affected by it, now that its enforcement is being rolled out, I am even more certain that its bad. Too be fair, I am no fan of socialized medicine/single payer medicine/government managed medicine. However, since the government has agreed to provide a medicaid service, I think it is obligated to provide a reasonable & decent one. I do not think 4 prescriptions per 30 days does that.

Take someone with diabetes, they get testing strips, lancets, lantus, Humalog, Whoops they are now maxed out. Hopefully they didn't really need their lisinopril or syringes. Of course, they maybe even more unlucky in the cycle, in that they picked up their lisinopril, syringes, lancets & testing strips last week....so this week they have to pick between getting their lantus or humalog Yes, most likely their PA for their insulin will be approved, but what happens when they are out on a Friday night of a 3 day weekend? Beg their friends for $100+ to get their insulin? Or will they go without for 3 days, and end up in the hospital emergency room, costing the state far more than if the insulin had been paid for to begin with.

It seems to me the state came up with the rule to stop the people who were emergency room hopping to get 10 Norco RX's each month. I can think of much better ways to control prescription costs than a blanket limit of 4 scripts/30 days (especially if such prescription cost control leads to increased medical costs)

Has this sort of thing been implemented in other states? Anyone in Illinois have thoughts on this.

 

[eagles22]

what happens when they are out on a Friday night of a 3 day weekend? Beg their friends for $100+ to get their insulin? Or will they go without for 3 days, and end up in the hospital emergency room, costing the state far more than if the insulin had been paid for to begin with.
.

Plan ahead? This requires patients who are on several medications to be responsible. They know the plan. They know when their medicines run out.

 

[Sparda29]

This **** doesn't make any sense at all. I have plenty of patients that I know who take 10+ prescriptions/month. For example, I know a guy with DM, HTN, HL, COPD, and peripheral neuropathy.

Every month he gets Metformin, Lantus, Humalog, Pen Needles, Alcohol Pads, Test Strips, Lancets, Norvasc, Lisinopril/HCTZ, Aspirin, Gabapentin, Advair, Ventolin, and Crestor. What the **** am I supposed to tell him?

 

[group_theory]

I had to prior auth a patient for Advair and Singulair since a patient was already on 6 other prescription meds (all medically necessary too)

yay for spending 15 minutes filling out a form describing why I think Advair/Singulair was necessary, printing out a copy of my office note, printing out a copy of the patient's latest PFT, and a copy of the CXR report ... and waiting 3 weeks to receive noticed that "my request to override the prescription limitation was approved" that is valid for 1 year (at which point I can repeat the above process)

15 minutes may not seem like much, but think of how many patients will need prior auth (on an annual basis). All uncompensated work.


I'm sure it is just as fun on your end (pharmacy) when the patient doesn't come in to pick up the meds that you spent time processing and filling (and I spent with paperwork)

Fun times.

*I'm not in Illinois but many states are trying to save money by restricting the number of meds. I understand the rationale for this but the implementation hasn't been well thought out (also Illinois is notorious for waiting months to pay claims submitted under medicaid)

 

[VA Hopeful Dr]

This **** doesn't make any sense at all. I have plenty of patients that I know who take 10+ prescriptions/month. For example, I know a guy with DM, HTN, HL, COPD, and peripheral neuropathy.

Every month he gets Metformin ($4 wal mart), Lantus, Humalog, Pen Needles, Alcohol Pads dirt cheap OTC, $2 for 200 at wal greens, Test Strips, Lancets, Norvasc $4 at local grocery store, have wal mart price match, Lisinopril/HCTZ ($4 wal mart), Aspirin dirt cheap OTC, 108 tabs for $5 at walgreens, Gabapentin ($4 at local grocery, have wal mart price match), Advair, Ventolin, and Crestor get on pravachol/zocor $4 wal mart. What the **** am I supposed to tell him?

My bolded comments are where you start.

 

[npage148]

This **** doesn't make any sense at all. I have plenty of patients that I know who take 10+ prescriptions/month. For example, I know a guy with DM, HTN, HL, COPD, and peripheral neuropathy.

Every month he gets Metformin, Lantus, Humalog, Pen Needles, Alcohol Pads, Test Strips, Lancets, Norvasc, Lisinopril/HCTZ, Aspirin, Gabapentin, Advair, Ventolin, and Crestor. What the **** am I supposed to tell him?

Just pre-bill everything. Set it to auto fill 4/day so the last one is done the day he needs them. YOu should have some semi-legal work around cooked-up

My bigger issue is why is he getting the ventolin every month? Sounds like his asthma is not appropriately managed /ruleof2'd

 

[Wheresmyaricept]

My bolded comments are where you start.

So my pharmacy is supposed to suffer because we aren't a retail juggernaut like walmart that can afford to give away drugs dirt cheap? What if, in the rare instance, there isn't a Walmart around? Or if their pharmacy is already closed? Why is it the patient's fault for just coming out of the ER at 9 pm?

Have you ever tried to get in touch with a doctor's office that accepts Medicaid? 9/10 times, faxes for drug changes and prior auths are ignored, phone calls are never returned, and the office staff are usually pretty nasty.

Also some people on Medicaid are on it for a reason, believe it or not. They might not be able to afford all those 4 dollar copays and OTC prices every month. In my state, they can lose their coverage if they are found buying prescriptions without their coverage because the state assumes the patient now has the means to pay for it.

Your response is just plain stupid, bro.

 

[All4MyDaughter]

My bolded comments are where you start.

The LAST thing we want to encourage is someone on multiple meds getting them at different pharmacies. It's a recipe for disaster and bad patient care. Plus, these points too:

So my pharmacy is supposed to suffer because we aren't a retail juggernaut like walmart that can afford to give away drugs dirt cheap? What if, in the rare instance, there isn't a Walmart around? Or if their pharmacy is already closed? Why is it the patient's fault for just coming out of the ER at 9 pm?
...
Also some people on Medicaid are on it for a reason, believe it or not. They might not be able to afford all those 4 dollar copays and OTC prices every month. In my state, they can lose their coverage if they are found buying prescriptions without their coverage because the state assumes the patient now has the means to pay for it.

 

[BidingMyTime]

Just pre-bill everything. Set it to auto fill 4/day so the last one is done the day he needs them. YOu should have some semi-legal work around cooked-up
My bigger issue is why is he getting the ventolin every month? Sounds like his asthma is not appropriately managed /ruleof2'd

It's a total of 4 prescriptions every rolling 30 day period, not 4/day. If a patient needs more than 4 prescriptions/30 day period, there is no way (short of the doctor filling out the PA form) to get around it.

 

[BidingMyTime]

Plan ahead? This requires patients who are on several medications to be responsible. They know the plan. They know when their medicines run out.

Easy to say, but we know many people don't plan ahead, and it is me & the other taxpapers who will be paying for these people emergency room care, because the state has refused to pay for their maintenance medicine due to an arbitrary rule.

Edited to add, from what I understand the PA for the over 4 RX/month rule will only last 3 months for each drug. I can see how this can quickly become complex as a pt's PA for each of their drugs expires at different 3 month periods. Honestly, if I were on 20 different drugs, this would be hard for me to keep track of.

 

[npage148]

It's a total of 4 prescriptions every rolling 30 day period, not 4/day. If a patient needs more than 4 prescriptions/30 day period, there is no way (short of the doctor filling out the PA form) to get around it.

ah, i caught the typo in your first line and ran with it. Yeah. 4/30 days is BS. You could lock it down and say no more than 3-4 controlled drugs filled/month. That would catch most of the issue with ER hopping

BUT: Get rid of the the monthly ventolin

 

[npage148]

The LAST thing we want to encourage is someone on multiple meds getting them at different pharmacies. It's a recipe for disaster and bad patient care. Plus, these points too:

Based on his handle, he's at the VA. He has little idea how it works once you get away from the VA bubble hence the amazingly bad advice. I'm surprised he also didn't mention transfer coupons to help the patient out

 

[type b pharmD]

My bolded comments are where you start.

Lol . I hope you aren't treating a lot of Medicaid patients. Out of all my friends who are on medicaid, not one of them really has this kind of money to spare on prescriptions. $25 per month is like a Medicaid patient's gas money and food money. Only upside to this new change is it will probably crash the emergency healthcare system in Illinois and maybe lead to better underserved care after people wake the **** up . There's no economic wiggle room when you're on medicaid , when you're poor or disabled, that's the reason you're on it! Illinois politicians can't be expected to do anything but the stupidest, most corrupt thing though when confronted with any problem. I guess we'll see how their paying constituents enjoy not having ED access for a while before they change it.

What a disaster. I feel for all Illinois pharmacists having to deal with this ****. I guess we can hope this will wake people up and move us toward universal coverage?

🙁

 

[Sparda29]

My bolded comments are where you start.

Nope, guy's on the highest dose of Crestor, that other **** isn't gonna work.

 

[All4MyDaughter]

4 Rxs per month is dumb. I definitely get tired of filling junk scripts for patients on Medicaid (like the IBU script one dropped off the other night from the ER from July), but this rule is overly strict.

 

[npage148]

He actually suggested zocor with norvasc! Good call attending!

 

[All4MyDaughter]

Not to mention that the owner of the independent pharmacy where I work probably doesn't want us sending people to Walmart and Walgreens...

 

[spacecowgirl]

This is ridiculous. What bozo thought this would save money?

 

[BidingMyTime]

This is ridiculous. What bozo thought this would save money?

Good question, of course Illinois is the state where our last 2 governors are currently in prison, and I think something like 4 of the last 8 have done prison terms, and a 5th governor was charged with felonies but managed to get acquitted.

 

[eagles22]

Easy to say, but we know many people don't plan ahead, and it is me & the other taxpapers who will be paying for these people emergency room care, because the state has refused to pay for their maintenance medicine due to an arbitrary rule.

Edited to add, from what I understand the PA for the over 4 RX/month rule will only last 3 months for each drug. I can see how this can quickly become complex as a pt's PA for each of their drugs expires at different 3 month periods. Honestly, if I were on 20 different drugs, this would be hard for me to keep track of.

Yea it may be difficult to plan ahead, but you get what you pay for. People will learn to plan ahead once it does negatively affects them.

I'd be interested to see if the savings from the 4/month balances out trips to the ED for these possible lack of drugs issues. The data could solve this whole debate.

 

[rph3664]

And one of those imprisoned governors (George Ryan) used to be a pharmacist.

TennCare did a similar thing, and may still, also with disastrous results. 😡

I found out a while back that Illinois Medicaid pays NINE DOLLARS for an optometry exam! To give you some perspective, Medicare pays $55 and they barely break even on that. In addition, if you've ever dealt with Illinois Public Aid, you know this already, but they are often a year or more behind in paying their bills, so many independent pharmacies and other entities do not take it for this reason.

 

[Sparda29]

Just pre-bill everything. Set it to auto fill 4/day so the last one is done the day he needs them. YOu should have some semi-legal work around cooked-up

My bigger issue is why is he getting the ventolin every month? Sounds like his asthma is not appropriately managed /ruleof2'd

He doesn't get it every month, at least every other month though. It's COPD, not asthma.

 

[genesis09]

I went to school in Illinois, and the state is in a lot of financial trouble. The last I heard, for medications, the average time to reimbursement was over 100 days. The closest thing we have to this in Wisconsin, is that WI Medicaid will only pay for 5 controlled rx plus tramadol minus suboxone per month.
To be limited to only 4 prescriptions per month can be a true hardship for some people. Someone with diabetes will easily max it out. Someone with multiple disease states, i.e. someone with htn, hyperlipidemia, and asthma will do the same. If they want to decrease cost, decrease the number of covered brands to the bare minimum. This is such an arbitrary thing to do.

 

[Momus]

This is one of the many reasons poor people tend to die sooner than rich people. There is a direct correlation between life expectancy and money. You will live longer if you have a lot of money because you can at least afford health care!

 

[BidingMyTime]

Yea it may be difficult to plan ahead, but you get what you pay for. People will learn to plan ahead once it does negatively affects them.

Um, I doubt it. Many of these people on multiple medications are not capable of complex planning. I don't even work in an impoverished area, yet I know several of my patients are illterate. They have enough trouble even figuring out how to take their medication, much less trying to keep track of when their 3 month PA is up.

The other problem will be, if doctors refuse to do the PA every 3 months. As has been pointed out, Medicaid reimbursements already are extremely low & very late. A couple of family doctors in my area told our pharmacy that they will not be doing PA's for their medicaid patients--too much hassle, and I suspect they wouldn't mind if their medicaid patients left their practice. But finding a new doctor for a medicaid patient isn't easy either, most doctors in my area will only take a certain percentage of medicaid pt's, the ones that don't have a limit are maxed out and not taking new patients at all.

I'd be interested to see if the savings from the 4/month balances out trips to the ED for these possible lack of drugs issues. The data could solve this whole debate.

Yes, eventually that data will be forthcoming, and I suspect it there will be changes to the system. In the meantime, patients are the ones who will suffer, and pharmacies & prescribers will be spending a lot of time dealing with the headaches. Then again, by then maybe the whole state will go bankrupt and they won't be covering any prescriptions.

 

[Digsbe]

In my state Medicaid patients are limited to 5 prescriptions per month and has been in effect for quit a while. It hurts patient compliance due to some patients not taking more expensive medications until the next month rolls around if they have exceeded their 5 fills.

 

[VA Hopeful Dr]

Mercy, so many responses. Perhaps I should have prefaced my response with "This situation obviously sucks, a rx drug limit that low is going to cause problems for mant patients. That said, if we're trying to get a patient the best care we can given the current circumstances, then here is what I suggest..."

That said, I'll wade into this.

So my pharmacy is supposed to suffer because we aren't a retail juggernaut like walmart that can afford to give away drugs dirt cheap? What if, in the rare instance, there isn't a Walmart around? Or if their pharmacy is already closed? Why is it the patient's fault for just coming out of the ER at 9 pm?

Have you ever tried to get in touch with a doctor's office that accepts Medicaid? 9/10 times, faxes for drug changes and prior auths are ignored, phone calls are never returned, and the office staff are usually pretty nasty.

Also some people on Medicaid are on it for a reason, believe it or not. They might not be able to afford all those 4 dollar copays and OTC prices every month. In my state, they can lose their coverage if they are found buying prescriptions without their coverage because the state assumes the patient now has the means to pay for it.

Your response is just plain stupid, bro.

I see mostly medicaid (50% of the practice, though I am a resident). If a pharmacy calls, my nurses leave me a note on the EMR and I always call the pharmacy back myself. Always. It only ever takes more than about 4 hours if I'm post-call, and I don't have a solution for that. Likewise, I check my inbox once daily and do every form I have in there. I'm sorry your experience with MDs has been less good.

You mean your medicaid patients don't smoke or drink? Where is this Nirvana in which you live? I assume mine can do $4/month because they all smoke at least 1ppd ($3/day here, and my state has some of the cheapest cig prices).

Lastly, your bottom line matters as little to me as mine does to you I expect.

The LAST thing we want to encourage is someone on multiple meds getting them at different pharmacies. It's a recipe for disaster and bad patient care. Plus, these points too:

Obviously its not ideal, but it beats not getting the drugs. See my disclaimer.

Based on his handle, he's at the VA. He has little idea how it works once you get away from the VA bubble hence the amazingly bad advice. I'm surprised he also didn't mention transfer coupons to help the patient out

Nope, when I made this user name I was an undergrad (hopeful dr) in Virginia (VA).

Lol . I hope you aren't treating a lot of Medicaid patients. Out of all my friends who are on medicaid, not one of them really has this kind of money to spare on prescriptions. $25 per month is like a Medicaid patient's gas money and food money. Only upside to this new change is it will probably crash the emergency healthcare system in Illinois and maybe lead to better underserved care after people wake the **** up . There's no economic wiggle room when you're on medicaid , when you're poor or disabled, that's the reason you're on it! Illinois politicians can't be expected to do anything but the stupidest, most corrupt thing though when confronted with any problem. I guess we'll see how their paying constituents enjoy not having ED access for a while before they change it.

What a disaster. I feel for all Illinois pharmacists having to deal with this ****. I guess we can hope this will wake people up and move us toward universal coverage?

🙁

Once again, your medicaid population must be very different compared to mine.

He actually suggested zocor with norvasc! Good call attending!

Nope, just a resident and I haven't written for any zocor in 2 years (for that exact reason, I love me some norvasc) but as many people still like it, just throwing it out there.

Besides, I thought if you staying to 20mg the norvasc interaction wasn't too bad? Am I mistaken?

 

[VA Hopeful Dr]

Nope, guy's on the highest dose of Crestor, that other **** isn't gonna work.

Better some statin than none (see disclaimer from other post).

 

[rph3664]

Most Medicaid recipients are children and younger adults, but most of the dollars are spent on the elderly, and while I'll grant that a huge percentage of that is used for people in nursing homes, that isn't always the case. My grandmother was one of those people for a couple years before she did indeed have to go to one, and while she was in relatively good health almost to the end (she died at 91), I know she was on more than 4 medications. The ones I can think of off the top of my head were Nexium (for which she got a prior auth) and nitro patches. She was on Iowa Medicaid, which has always been very good about making payments and is also not as strict as many other states.

 

[xiphoid2010]

Based on his handle, he's at the VA. He has little idea how it works once you get away from the VA bubble hence the amazingly bad advice. I'm surprised he also didn't mention transfer coupons to help the patient out

Having been a VA resident, maybe I'm a little biased. But the VA model is actually very good at cost containment. A formulary defended by a well staffed number of empowered clinical pharmacists keep the cost down quite nicely. If a state could adopt an all EMR system for medicaid patients, with all RX reviewed by clinical pharmacists empowered with limited prescribing rights, it might indeed keep the cost down without the Draconian system Illinois is adopting.

 

[Carboxide]

Most Medicaid recipients are children and younger adults, but most of the dollars are spent on the elderly, and while I'll grant that a huge percentage of that is used for people in nursing homes, that isn't always the case. My grandmother was one of those people for a couple years before she did indeed have to go to one, and while she was in relatively good health almost to the end (she died at 91), I know she was on more than 4 medications. The ones I can think of off the top of my head were Nexium (for which she got a prior auth) and nitro patches. She was on Iowa Medicaid, which has always been very good about making payments and is also not as strict as many other states.

First thought here - if you don't have a tube, don't use Nexium. It just racemizes to omeprazole in the stomach anyways.

As for Sparda's patient:

I'd agree that getting the $4 generics is better than nothing for the patient. If this is really about the PATIENT, then all this complaining about your bottom line should stop. But pharmacy hopping isn't safe (see: that patient's Norvasc + Zocor). On top of that, 5 of that patient's Rxs were OTC....why can't he buy the aspirin himself? I don't think Caid should cover OTCs anyways...

 

[npage148]

Having been a VA resident, maybe I'm a little biased. But the VA model is actually very good at cost containment. A formulary defended by a well staffed number of empowered clinical pharmacists keep the cost down quite nicely. If a state could adopt an all EMR system for medicaid patients, with all RX reviewed by clinical pharmacists empowered with limited prescribing rights, it might indeed keep the cost down without the Draconian system Illinois is adopting.

I know he VA system is a great model when working within itself but in my expirence, va people have a relatively tenuous understanding of the functioning on the medical system outside of the VA.

 

[owlegrad]

First thought here - if you don't have a tube, don't use Nexium. It just racemizes to omeprazole in the stomach anyways.

As for Sparda's patient:

I'd agree that getting the $4 generics is better than nothing for the patient. If this is really about the PATIENT, then all this complaining about your bottom line should stop. But pharmacy hopping isn't safe (see: that patient's Norvasc + Zocor). On top of that, 5 of that patient's Rxs were OTC....why can't he buy the aspirin himself? I don't think Caid should cover OTCs anyways...

Great, so patient's get more expensive RXs for things that could be managed by cheaper OTCs. 😉

 

[rxlea]

Medicaid babies
bringing baggies of cocaine
Ride in Escalades

 

[npage148]

Nope, when I made this user name I was an undergrad (hopeful dr) in Virginia

Sorry bout the misclassification

 

[Carboxide]

Great, so patient's get more expensive RXs for things that could be managed by cheaper OTCs. 😉

If MDs are prescribing clopidogrel instead of baby aspirin, they need a good hit on the head. The number of Rxs we fill for Colace and regular strength acetaminophen daily is through the roof. JUST BUY IT.

 

[rxlea]

Isn't the point that they don't pay for things like colace? I mean, all that OTC adds up....especially for someone making minimum wage or out of work.

 

[rxlea]

So something I saw working in the ghetto: condoms being covered by state medicaid. Can someone explain?

 

[joetrisman]

Great, so patient's get more expensive RXs for things that could be managed by cheaper OTCs. 😉

Déjà vu

 

[KARM12]

So something I saw working in the ghetto: condoms being covered by state medicaid. Can someone explain?

A box of condoms is much cheaper than the state paying for a baby or an STD...

 

[joetrisman]

A box of condoms is much cheaper than the state paying for a baby or an STD...

IUD ftw...(stds aside)

 

[rxlea]

A box of condoms is much cheaper than the state paying for a baby or an STD...

Agreed. I just wonder how someone goes about doing that. There are a number of patients that would benefit from that. Do they say it's for birth control or is there some other criteria?

 

[owlegrad]

Déjà vu

Am I repeating myself?

 

[All4MyDaughter]

So something I saw working in the ghetto: condoms being covered by state medicaid. Can someone explain?

It's a great idea.

We had free condoms at the VA.

 

[owlegrad]

Free condoms?! What's next, clean needles?!!!!! 🙄

 

[rxlea]

Lulz I would hand out free condoms and needles all day if I could!

I'm serious though. I'd love to pass on some info aboutgetting condoms covered to some rural and underserved patients. Guess I'll have to look it up. I haven't seen it anywhere else except the ghetto in phoenix. So I'm wondering if it was because the couple couldn't use another form of BC

 

[npage148]

Free condoms?! What's next, clean needles?!!!!! 🙄

So we're basically promoting sex and IV drug use now?

 

[owlegrad]

So we're basically promoting sex and IV drug use now?

Amen brother! I am not a pharmacy student to help people have sex or use drugs.

 

[Doctor M]

So we're basically promoting sex and IV drug use now?

They r gonna do it no matter what we offer. Condoms or no condoms, they r gonna do it. clean needles or dirty needles, they will shoot up. We sell needles, no questions asked if you r 18 years or older.

 

[All4MyDaughter]

So we're basically promoting sex and IV drug use now?