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Pharmacists predict chaos as TennCare changes kick in

Confusion over coverage loss, prescription limits may lead to waits for all





 

Pharmacists are bracing for major changes in TennCare drug policies that will directly affect about 700,000 people across the state beginning Monday.

Some will lose TennCare drug coverage entirely, while others will face new limits on the number and types of prescriptions they can fill.

Already, pharmacists say they are being swamped with calls and visits from TennCare enrollees — many of them confused — asking which drugs they need most or how to get drugs elsewhere. The pharmacists predict "utter chaos" at state pharmacies when they open for business Monday morning, and warn that all customers — including those not on TennCare — may face extra drugstore waits for weeks to come.

TennCare pharmacy director David Beshara says state officials have worked to make sure everything that can go smoothly will.

"There's definitely a little bit of a learning curve with all the changes," Beshara said. "But we've been working very hard with all the pharmacists in the state to make the transition as easy as possible."

The prescription drug changes are a major piece of Gov. Phil Bredesen's plans to overhaul the financially troubled public insurance plan for the poor, elderly and disabled.

The governor has cited the high cost and high usage rates of prescription drugs in TennCare as the program's biggest problem.

As things stand now, the changes taking place Monday will include:

• TennCare will stop paying for prescriptions for about 290,000 people.

About 190,000 of these will have access to "safety net" drugs being offered by the state through drug discounts and free generics.

However, about 97,000 of those deemed "medically needy" — and described by Bredesen as the "sickest" on TennCare — will lose drug coverage altogether on Monday. They will not have access to the discount and generic drug plans being offered to others cut from TennCare, according to Lola Potter, spokeswoman for the Department of Finance and Administration, which oversees TennCare.

She said the state hoped to get concessions in a federal court lawsuit that would prevent this from happening.

• Another 400,000 people will face a cap on their monthly drug benefit. They will be entitled to no more than five prescriptions per month. Of those, no more than two can be brand-name drugs and the rest must be generic. Additionally, there is a so-called "short list" of drugs exempted from this rule that are used to treat such things as hepatitis C, kidney failure and hemophilia.

Other changes that will begin Monday include an end to prescriptions for over-the-counter drugs for most people and the elimination of methadone services, adult dental care, some at-home nursing care and convalescent care in nursing homes for those leaving hospitals.

Pharmacists such as Ferrell Haile of Perkins Drugs in Gallatinarepredicting that the drug changes will create chaos and confusion.

"I think it's going to be utter chaos," he said. "I don't mean to be funny. I think it's going to be total chaos. It's not just going to be a day or two. It's going to be a month or six weeks of total chaos."

Pharmacists are going to have to spend so much time working with TennCare enrollees to straighten out their drug regimen, and to find additional drugs, that normal business operations will be thrown off, he said.

Haile has already seen the effects of the impending changes in his small Gallatin pharmacy. About a third of the patients he sees are TennCare enrollees. In recent days, the pharmacy hasbeen getting up to 50 inquiries a day from people facing TennCare drug changes and wondering what to do next.

Yesterday, Haile's partner, Sam Rickman, talked through the changes with a longtime customer at the pharmacy's drive-through window. Rickman offered to give the man a computer printout of the prescriptions he regularly fills to take to his doctor, so the doctor could determine which could be substituted with generic drugs and which were least expensive and could be paid for out-of-pocket.

"We can do all this work, looking at their drug regimen and contacting their physicians, but all of that takes time and energy," Haile said. "On top of that is the lack of understanding about what's taking place, and why someone has to switch from one pill to another one. When you have to have six to seven pills to survive, there's going to be panic."

Pharmacists also are concerned about changes to computer systems operated by a TennCare contractor, said Baeteena Black, executive director of the Tennessee Pharmacy Association. The computers are critical, she said, to helping pharmacists determine whether someone can still get drugs under TennCare, or whether that customer has reached the five-prescription limit.

"What's happening August 1 is going to require significant systems changes and we do not know, and will not know, how smoothly things are going to happen" until the system goes into place midnight Monday, she said.

Beshara said that the system had been well-tested and that he expected no problems.

But even if things run smoothly, Black said, pharmacists probably will be overwhelmed by the needs of people affected by the drug changes. "My real concern is just the fact that, as willing as pharmacists are going to be on August 1, there's no way they're going to be able to solve all these problems. And it's going to affect all their customers."

The state has plans to provide additional drug assistance.

For about 190,000 people losing coverage, the state is providing a $57 million "safety net" drug program. Discount drug cards have been mailed to everyone being cut from TennCare, and access to a mail-order program that gives away free generic drugs from a list of 55 is also available. Already, about 2,000 orders have been placed for the generic drugs, averaging a request of three apiece, Potter said yesterday.

The state is still trying to find a solution for the 97,000 "medically needy" TennCare enrollees, Potter said. These are people with medical bills so high that they would be impoverished without assistance.

The governor has said he hopes to keep them on TennCare if he can win approval of cost-saving measures in federal court. They would then have the same capped drug benefit as other adults on TennCare.

Enrollees' lawyers are trying to stop the limits from going into place altogether.

Final arguments in a federal court case involving drug and other benefit limits are to take place today.

State officials say the prescription drug cap has been approved by the federal government and will not require a change in current legal agreements.

 

http://tennessean.com/apps/pbcs.dll/article?AID=/20050728/NEWS0204/507280390/1009/NEWS