Medicaid Prescription Battles


By Amy Fox
By Benjy Jeffords

HERRIN -- Many people take prescription pills to deal with various ailments, but it's getting harder to obtain some of those drugs through Medicaid.  Patients have to meet dozens of criteria and get prior approval.

"Every patient is presented with the same problem of 4 drugs per 30 days," said Ben Calcaterra of Logan Primary Pharmacy.

While Medicaid patients are not given a spending limit or dollar amount for those four drugs, for many, the rule has them coming up short.

Calcaterra said, "It's becoming a very common practice for a pharmacist to look at the four most expensive drugs on a Medicaid patient's profile and fill them first, so they can use their spending dollars wisely."

A doctor can authorize additional amounts of medicine needed for the month through Medicaid, but it's a detailed process that takes time.

"It is very frustrating for the average Medicaid patient to try to stay informed and up-to-date with all of the changes, with the four drug limit, with these pre-qualifications and pre-authorizations, certain drugs are not allowed to be used on the medical card any longer," said Calcaterra.

Often, drugs like the new Hepatitis C treatment Sovaldi, are only available by mail order from a specialty pharmacy under Medicaid.

And, since Sovaldi is so expensive, about $1,000 a pill, Illinois Medicaid patients will have to meet more than two dozen criteria to get the drug.

Calcaterra said, "We figure we are presented with a piece of the puzzle when the patient walks in the door and it's up to us to help them navigate through this crazy world of Medicaid and try to figure out what the best outcome is going to be."

If you have questions about your Medicaid benefits, pharmacists are great resources, as well as your doctor.  If they don't have the answer, they can provide you with different resources to help you.


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