‘Any individual Is Gonna Die’: Medi-Cal Sufferers Wrestle to Fill Prescriptions

SACRAMENTO, Calif. — A month into its debut, California’s new Medicaid prescription drug program is riddled with issues, leaving 1000’s of sufferers with out medicines — usually after languishing on maintain for as much as eight hours on name middle telephone traces.

On Jan. 1, the state handed management of its Medicaid drug program, referred to 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 middle would take so lengthy, and a lot of its name middle employees have been sickened throughout the omicron surge — with 100 of 220 absent throughout the first two weeks of January, state officers mentioned. 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,” mentioned Dr. James Schultz, chief medical officer of Neighborhood Healthcare, which operates 17 clinics in Riverside and San Diego counties. 

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

Officers from the California Division of Well being Care Companies, which administers Medi-Cal, California’s Medicaid program for low-income folks, known 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 middle 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 can save the state $414 million within the 2022-23 price range yr alone, partly by getting greater 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 medical doctors contemplate medically vital however require prior authorizations from Medi-Cal Rx and are usually not on the state’s authorised drug checklist. Magellan has obtained greater than 95,000 prior authorization requests because it took over, state officers mentioned. 

Within the months main as much as the change, sufferers and medical doctors 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 referred to as mast cell activation syndrome, as a result of her pharmacist and Magellan mentioned it was now not coated. When she lastly reached somebody on the Magellan name middle 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 treatment, known as ketotifen, Bloomer will get shiny pink, patchy hives throughout her face. 

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

State officers mentioned Magellan representatives had answered greater than 81,000 calls on the 24-hour, 7-day-a-week name middle 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 price range subcommittee listening to Monday.

She mentioned that the Division of Well being Care Companies is holding every 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 middle. The quick purpose, Cooper added, is to make sure medicines that require prior authorization are authorised inside 24 hours. Within the meantime, she mentioned, 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 Companies.

After the listening to, Meeting member Joaquin Arambula (D-Fresno), who chairs the Meeting price range subcommittee that oversees Medi-Cal, mentioned he’s happy 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. Although state officers say they’ve given pharmacies authorization to make use of override codes and fill short-term emergency prescriptions, prescriptions proceed to be denied. 

“It’s simply chaos,” Ng mentioned. “We simply stored getting rejections. It’s been so irritating as a result of the rejection doesn’t let you know what’s incorrect. After which if you happen to lastly undergo their traces, they don’t assist you both. They’re simply guessing.”

What Magellan wants, she added, is a devoted hotline for pharmacists — just like the managed-care plans had — so that they don’t must 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 arrange for the rollout, because the program was delayed by practically a yr after the well being care firm Centene introduced plans to amass 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 absolutely what the quantity and the wants have been going to be,” mentioned Jack Dailey, an legal professional with the Authorized Support Society of San Diego, which is representing some Medi-Cal enrollees unable to get their treatment. “I didn’t suppose that is the place we’d be a month into this course of.”

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

“Issues in our family have began dissolving,” mentioned Shah’ada, who requested that her final identify not be revealed to guard her son’s privateness. “He’s been depressed, unable to go to highschool for a number of days, actually excessive anxiousness. 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 middle each probability she bought. Her managed-care plan recommended there was a glitch within the system however didn’t know how one can assist because it now not controls prescribed drugs 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 nervous about refilling the prescription in three months.

Schultz, the San Diego County doctor, mentioned his employees can also be directed to the decision middle to ask questions when sufferers are denied medicines. However the enchantment kind they’re requested to fill out is incomplete, he mentioned, missing a piece for the earlier medicines a affected person has tried, as an illustration, 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 mentioned. “Theoretically, all of our employees could possibly be tied up on maintain with Magellan. We are able to’t do it.”

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

KHN (Kaiser Well being Information) is a nationwide newsroom that produces in-depth journalism about well being points. Along with Coverage Evaluation and Polling, KHN is among the three main working applications at KFF (Kaiser Household Basis). KFF is an endowed nonprofit group offering info on well being points to the nation.


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