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A Joint Project of the Maine
Association of Interdependent Neighborhoods |
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Volume 9 No. 2 |
August 2005 |
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MAIN
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A Joint Project of the Maine
Association of Interdependent Neighborhoods |
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Volume 9 No. 2 |
August 2005 |
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MaineCare Prior Authorization for Prescription Drugs
Some Needed Improvements on the Way!For several years, Maine’s Department of Health and Human Services (DHHS) has had a “preferred drug list” in the MaineCare Program. Under this system, health care providers are given a list of “preferred drugs.” A preferred drug is just what it sounds like—a drug that DHHS prefers providers to prescribe for a condition. If providers want to prescribe a drug that is not on the preferred drug list for a MaineCare member, they must request “prior authorization,” or permission from DHHS.
DHHS had two goals for establishing the prior authorization process and the preferred drug list. The first was to save money—typically they pay less for drugs on the preferred drug list. They also claimed that the system would result in more appropriate prescribing practices and thus better care for MaineCare members. Whatever the goals, from the beginning MaineCare members and providers have experienced difficulty with the prior authorization system.
Testifying this spring in front of the Legislature’s Health and Human Services, Alice, a MAIN member from Auburn, described her frustration when her doctor tried to prescribe a drug for her that was not on the preferred drug list. He wanted to prescribe a drug that was not as strong as the one that DHHS would approve. Alice explained that “pain is an indication of something else that is going on in your body…if I take something stronger I forget that I have the pain and do activities that can cause additional damage to my body.” But her doctor couldn’t persuade DHHS and Alice ended up paying for the drug out of pocket, which she could ill afford. The system has also burdened providers with much additional paperwork. Alice described the difficulty that MaineCare members already have particularly in finding specialists in some parts of the State and argued that prior authorization “is just one more reason that doctors decide not to accept MaineCare and cause persons with disabilities to drive longer distances to get the services we need.”
Blanche from Waterville is in her early sixties and is no longer able to work as a nurse’s aid because of a workplace injury. She has multiple health problems and needs medication for pain, a muscle relaxant and help sleeping. Coverage for two of the drugs her doctor prescribed was denied by DHHS. She too spoke up about the need for change: “It doesn’t seem right that I was made to suffer through those months of pain and stress when my doctor who knows and understands my health problems well, knew and prescribed the proper medication for me. But because of the over burdensome prior authorization process it took months before I was allowed the relief that I desperately needed.”
In the spring of 2004, as a result of many concerns like these, the legislature asked the MaineCare Advisory Committee to explore ways to improve the prior authorization system. A subcommittee representing both MaineCare consumers and providers went to work with DHHS to look at the problems and find solutions. Now, a year later, several improvements have been made or are in the works. Here are some of the most important changes:
►A 4-day supply of drugs will be available without prior authorization in certain situations. While pharmacists have been able to give a 4-day supply of drugs without prior approval for some time, there has been a lot of confusion about this policy. DHHS has now made clear that a pharmacist can give a MaineCare member a four day supply of a non-preferred drug without prior authorization when:1. No one from the Department is available to respond to a completed prior authorization request within 24 hours. This usually applies when a drug is prescribed over a weekend or holiday.
2. A provider has not submitted a completed prior authorization form for a drug requiring prior authorization. In this case the pharmacy must call DHHS to get special permission to fill the prescription. At the end of the first four days if the provider still has not submitted a completed form, the pharmacy may ask DHHS for approval to dispense an additional refill.►Information will be made available immediately at the pharmacy to MaineCare members when DHHS denies a request for prior approval of a drug so that they will know what options they have to get needed medication. This information sheet will include the DHHS Pharmacy Help Desk number (toll-free 1-866-796-2463; or TTY 207-287-1828) for the member to call for help.
►DHHS will work to reduce the amount of paperwork that providers must submit in support of a request for permission to prescribe a non-preferred drug. MaineCare members have often complained about delays in getting needed drugs because of the burdensome paperwork required of their provider by DHHS. This change will help both consumers and providers.
►Hearing decisions will be made more quickly when a member appeals DHHS’s decision to deny coverage for a non-preferred drug. Both because of the work of the subcommittee and because of a lawsuit brought by MEJP, DHHS has agreed to make sure that prior authorization fair hearing decisions will now be made within 90 days of when the appeal is requested. If you have requested a fair hearing, and you have been waiting for more than 90 days to get a decision, please let us know. (Call Crystal at MEJP, 1-866-626-7059, ext. 205)
►An independent research firm will study the impact of the prior authorization process on MaineCare members and its cost to the system. This study will investigate whether MaineCare members are suffering any adverse health consequences in the prior authorization process and, if so, the human and financial costs of those unintended consequences.
These are all important changes that MAIN hopes will prevent many of the problems that MaineCare members have had in the past. However, with thousands of drugs prescribed each day for nearly 300,000 MaineCare members, this system must still be carefully monitored. In addition, in this recent legislative session DHHS was required to secure more savings through the use of a more aggressive prior authorization process for some drugs. This same legislation established some important consumer protections. This new system will not go into effect until at least January 2006. The next issue of MAIN Update will update members with any new information about this.
Website information about Prior Authorization and the Preferred Drug List (PDL) has been revised to be more “user-friendly.”
