‘Someone Is Gonna Die’: Medi-Cal Sufferers Battle to Fill Prescriptions

SACRAMENTO, Calif. — A month into its debut, California’s new Medicaid prescription drug program is riddled with issues, leaving hundreds of sufferers with out medicines — usually after languishing on maintain for as much as eight hours on name heart cellphone traces.

On Jan. 1, the state handed management of its Medicaid drug program, generally known as Medi-Cal Rx, to Magellan Well being, which is administering prescription drug protection for California’s 14 million Medicaid sufferers, most of whom beforehand bought their medicines from about two dozen managed-care plans.

However Magellan has tripped up implementation. It didn’t anticipate that calls to its assist heart would take so lengthy, and numerous its name heart staff have been sickened through the omicron surge — with 100 of 220 absent through the first two weeks of January, state officers stated. Magellan additionally didn’t get some information it wanted from managed-care plans.

This has left Californians from Redding to Oceanside with out their medicines for days, typically weeks.  

“We’ve had many, many sufferers who’re kind of on this limbo,” stated Dr. James Schultz, chief medical officer of Neighborhood Healthcare, which operates 17 clinics in Riverside and San Diego counties. 

“Someone is gonna die in the event that they haven’t already,” added Schultz, who stated a few of his clinics’ sufferers have skilled delays getting life-saving medicines akin to antibiotics or these used to stop seizures and blood clots. “That’s why we’re combating so exhausting.”

Officers from the California Division of Well being Care Providers, which administers Medi-Cal, California’s Medicaid program for low-income folks, referred to as the issues “unacceptable.” The division and Magellan Well being are scrambling to search out lacking affected person information, repair improper declare denials, add name heart staffers, and supply pharmacists with codes to override prescription denials. 

Handing over Medi-Cal’s drug program to a single pharmacy profit supervisor is one in all Gov. Gavin Newsom’s large well being care initiatives. His administration estimates it would save the state $414 million within the 2022-23 finances yr alone, partly by getting larger reductions on medicine than the managed-care insurance coverage did.

However the huge switch has been rocky for a lot of suppliers, pharmacists, and sufferers, particularly sufferers who use medicines their docs take into account medically needed however require prior authorizations from Medi-Cal Rx and are typically not on the state’s authorized drug checklist. Magellan has obtained greater than 95,000 prior authorization requests because it took over, state officers stated. 

Within the months main as much as the swap, sufferers and docs have been informed all their medicines could be grandfathered into the brand new system for 180 days, however that hasn’t at all times been the case.  

Marilyn Bloomer of Oceanside had gone practically every week with out a specialty histamine prescription that she takes to manage an overactive allergic response in her physique, a situation generally known as mast cell activation syndrome, as a result of her pharmacist and Magellan stated it was now not lined. When she lastly reached somebody on the Magellan name heart final week — six hours after she positioned the decision — a supervisor gave her a code the pharmacist might use to override the denial. 

However the pharmacy wouldn’t settle for it. 

On Monday, Bloomer’s well being plan secured an emergency five-day provide for her, however she doesn’t know what is going to occur when it runs out. With out the remedy, referred to as ketotifen, Bloomer will get vivid purple, patchy hives throughout her face. 

“I’m getting the runaround, and I’m getting confused,” stated Bloomer, 57, who stated her face had been starting to swell. “It’s past irritating.”

State officers stated Magellan representatives had answered greater than 81,000 calls on the 24-hour, 7-day-a-week name heart as of Feb. 1 and paid 11 million prescription claims totaling roughly $1.3 billion as of Feb. 4.

“As we sit right here, clearly 5 weeks into operations, Magellan, our contractor, has actually struggled with some service operations,” Jacey Cooper, the state’s Medicaid director, informed lawmakers at an Meeting finances subcommittee listening to Monday.

She stated that the Division of Well being Care Providers is holding each day conferences with Magellan to debate its administration of this system and that the state has supplied staffers to assist reply calls on the Medi-Cal Rx name heart. The rapid objective, Cooper added, is to make sure medicines that require prior authorization are authorized inside 24 hours. Within the meantime, she stated, the state has given pharmacies the go-ahead to fill emergency prescriptions for as much as two weeks. It additionally has eliminated prior authorization necessities for some medicines.

Magellan referred media inquiries to the Division of Well being Care Providers.

After the listening to, Meeting member Joaquin Arambula (D-Fresno), who chairs the Meeting finances subcommittee that oversees Medi-Cal, stated he’s glad with the administration’s plan. “I consider there’s an actual path ahead to implementing the system efficiently,” he informed KHN.

Sharon Ng, pharmacy director on the Venice Household Clinic, isn’t as optimistic. Despite the fact that state officers say they’ve given pharmacies authorization to make use of override codes and fill non permanent emergency prescriptions, prescriptions proceed to be denied. 

“It’s simply chaos,” Ng stated. “We simply stored getting rejections. It’s been so irritating as a result of the rejection doesn’t inform you what’s fallacious. After which in the event you lastly undergo their traces, they don’t enable you both. They’re simply guessing.”

What Magellan wants, she added, is a devoted hotline for pharmacists — just like the managed-care plans had — in order that they don’t need to compete with Medi-Cal sufferers.

Sufferers and authorized advocates say they’re confounded by the chaos as a result of each the state and Magellan had loads of time to organize for the rollout, because the program was delayed by practically a yr after the well being care firm Centene introduced plans to accumulate Magellan.

Medi-Cal Rx lastly launched Jan. 1 after state officers dominated in December that Magellan might independently administer the Medi-Cal drug profit with none battle of curiosity with its new proprietor. 

“Magellan ought to have come into this understanding totally what the amount and the wants have been going to be,” stated Jack Dailey, an legal professional with the Authorized Assist Society of San Diego, which is representing some Medi-Cal enrollees unable to get their remedy. “I didn’t suppose that is the place we might be a month into this course of.”

Shah’ada, a mom in Redding, has spent the previous two weeks desperately attempting to get her 16-year-old son’s contraception remedy authorized. He’s transgender and hadn’t had a interval in 5 years till final week, she stated. With out the contraception, he bled for 11 days. 

“Issues in our family have began dissolving,” stated Shah’ada, who requested that her final title not be revealed to guard her son’s privateness. “He’s been depressed, unable to go to high school for a number of days, actually excessive nervousness. It’s simply very emotional and irritating.”

When Shah’ada tried to fill the prescription, the pharmacist informed her that it was denied due to her son’s gender. 

She dialed the prescription name heart each probability she bought. Her managed-care plan steered there was a glitch within the system however didn’t know learn how to assist because it now not controls pharmaceuticals for its members. Her son’s physician tried to submit extra paperwork to no avail, and she or he submitted a grievance to Medi-Cal Rx. 

Over the weekend, she lastly bought approval for her son’s contraception, however she’s fearful about refilling the prescription in three months.

Schultz, the San Diego County doctor, stated his employees can be directed to the decision heart to ask questions when sufferers are denied medicines. However the enchantment type they’re requested to fill out is incomplete, he stated, missing a piece for the earlier medicines a affected person has tried, as an example, info Medi-Cal Rx requires for approval.

“We’ve bought folks out with covid. We actually don’t have time to take a seat on maintain for eight hours. We have now dozens of sufferers in the identical boat,” Schultz stated. “Theoretically, all of our employees might be tied up on maintain with Magellan. We will’t do it.”

This story was produced by KHN, which publishes California Healthline, an editorially unbiased service of the California Well being Care Basis.

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