California’s new Medicaid prescription program is plagued with problems

SACRAMENTO — A month after its debut, California’s new Medicaid prescription drug program is plagued with problems, leaving thousands of patients without medication — often after waiting on center phone lines for up to eight hours of calls.

On Jan. 1, the state ceded control of its Medicaid drug program, known as the Medi-Cal Rxto Magellan Health, which manages prescription drug coverage for California’s 14 million Medicaid patients, most of whom previously received their drugs from about two dozen managed care plans.

But Magellan tripped up the implementation. It hadn’t anticipated that calls to its help desk would take so long, and many of its call center employees were sick during the omicron surge – with 100 of 220 absent over the past few months. first two weeks of January, state officials said. Magellan also didn’t get some data it needed from managed care plans.

It left Californians from Redding to Oceanside without their medication for days, sometimes weeks.

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

“Someone is going to die if they haven’t already,” added Schultz, who said some of the patients at his clinics have experienced delays in getting life-saving drugs such as antibiotics or those used to prevent seizures and blood clots. “That’s why we fight so hard.”

Officials with the California Department of Health Care Services, which administers Medi-Cal, California’s Medicaid program for low-income people, called the problems “unacceptable.” The department and Magellan Health are working to find missing patient data, correct inappropriate claim denials, add call center staff, and provide pharmacists with codes to override prescription denials.

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Handing over Medi-Cal’s drug program to a single pharmacy benefit manager is one of Governors Gavin Newsom’s Big Health Care Initiatives. His administration estimates it will save the state $414 million in the 2022-23 budget year alone, in part by getting bigger drug discounts than managed care insurance plans.

But the massive shift has been difficult for many providers, pharmacists and patients, especially patients who use drugs their doctors consider medically necessary but require. prior authorizations of Medi-Cal Rx and are generally not listed as state-approved medications. Magellan has received more than 95,000 pre-clearance requests since taking over, state officials said.

In the months leading up to the change, patients and doctors were told that all of their drugs would be grandfathered into the new system for 180 days, but that wasn’t always the case.

Patients endure hours of waiting, repeated refusals

Oceanside’s Marilyn Bloomer had gone almost a week without a prescription for the specialized histamine she takes to regulate an overactive allergic reaction in her body, a condition known as mast cell activation syndrome, because her pharmacist and Magellan said she was no longer covered. When she finally contacted someone at Magellan’s call center last week – six hours after making the call – a supervisor gave her a code the pharmacist could use to override the denial.

But the pharmacy did not accept it.

On Monday, Bloomer’s health plan secured her a five-day emergency supply, but she doesn’t know what will happen when it runs out. Without the drug, called ketotifen, Bloomer has bright red, patchy hives all over his face.

“I’m going around in circles and getting confused,” said Bloomer, 57, who said his face was starting to swell. “It’s beyond frustrating.”

State officials said Magellan representatives answered more than 81,000 calls to the 24/7 call center as of Feb. 1 and paid 11 million prescription claims totaling about $1. .3 billion as of February 4.

“As we sit here, clearly five weeks into operations, Magellan, our contractor, has really struggled with some service operations,” state Medicaid director Jacey Cooper told lawmakers during of a House Budget Subcommittee hearing on Monday.

She said the Department of Health Services holds daily meetings with Magellan to discuss its management of the program and that the state has provided staff to help answer calls to the Medi-Cal Rx call center. The immediate goal, Cooper added, is to ensure that drugs that require prior authorization are approved within 24 hours. In the meantime, she said, the state has given pharmacies the go-ahead to fill emergency prescriptions for up to two weeks. It also removed prior authorization requirements for certain drugs.

Magellan has referred media questions to the Department of Health Services.

After the hearing, Assemblyman Joaquin Arambula (D-Fresno), who chairs the Assembly budget subcommittee that oversees Medi-Cal, said he was happy with the administration’s plan. “I believe there is a real way forward to successfully implement the system,” he told KHN.

Sharon Ng, director of pharmacy at the Venice Family Clinic, is not so optimistic. Even though state officials say they have given pharmacies permission to use override codes and fill temporary emergency prescriptions, prescriptions continue to be declined.

“It’s just chaos,” Ng said. “We continued to receive rejections. It’s so frustrating because rejection doesn’t tell you what’s wrong. And then if you finally go through their lines, they don’t help you either. They are just guessing.

What Magellan needs, she added, is a dedicated helpline for pharmacists — like managed care plans had — so they don’t have to compete. with Medi-Cal patients.

Some seek legal redress as problems stretch into second month

Patients and attorneys say they are baffled by the chaos as the state and Magellan have had ample time to prepare for the rollout as the program was delayed nearly a year after healthcare company Centene announced its intention to acquire Magellan.

Medi-Cal Rx was finally launched on January 1 after state officials ruled in December that Magellan could independently administer the Medi-Cal drug benefit without any conflict of interest with its new owner.

“Magellan should have fully understood what the volume and the needs were going to be,” said Jack Dailey, an attorney with the Legal Aid Society of San Diego, which represents some Medi-Cal enrollees unable to get their medications. “I didn’t think this was where we would be a month into this process.”

Shah’ada, a mother from Redding, has spent the past two weeks desperately trying to get her 16-year-old son’s contraceptive drug approved. He is transgender and had not had a period for five years until last week, she said. Without contraception, he bled for 11 days.

“Things in our house started to dissolve,” said Shah’ada, who asked that his surname not be published to protect his son’s privacy. “He is depressed, unable to go to school for several days, very anxious. It’s just very moving and frustrating.

When Shah’ada tried to fill the prescription, the pharmacist told her that it had been declined because of her son’s gender.

She dialed the prescription call center every chance she got. His managed care plan suggested there was a problem in the system, but didn’t know how to help since he was no longer in control of prescription drugs for his members. Her son’s doctor tried to submit more paperwork to no avail, and she filed a grievance with Medi-Cal Rx.

Over the weekend, she finally got her son’s birth control approved, but she worries about renewing the prescription in three months.

Schultz, the San Diego County physician, said his staff are also directed to the call center to ask questions when patients are denied medication. But the appeal form they are asked to fill out is incomplete, he said, without a section for previous medications a patient has tried, for example, the information Medi-Cal Rx needs to approval.

“We have people with COVID. We really don’t have time to be on hold for eight hours. We have dozens of patients in the same boat,” Schultz said. “Theoretically, all of our staff could be on standby with Magellan. We can’t do that.

This story was produced by KHN, which publishes California Healthline, an independent editorial service of the California Health Care Foundation.

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