California: MediCal Cut in Monthly Prescription Allowances Starting Oct. 1

The 1994 California State budget once again reduced the
prescription allowance for MediCal patients -- starting
October, 1 the limit will be six per month without prior
approval. In 1977 the previous limit of two prescriptions per
month was changed to allow an unlimited number; however, the
1992 California State budget reduced this allowance to ten.
But the limit of ten did not come into force until July 1 of
this year, when an on-line billing system for pharmacies was
set up by MediCal. The new limits could have a serious effect
on people with severe illness, including AIDS.

Prescriptions over the limit can be requested through a
Treatment Authorization Request (TAR), a one-page form which
is otherwise used to allow prescriptions of drugs which are
not on the MediCal formulary. A doctor or pharmacist can
complete a TAR which, if it is granted by the MediCal Field
Office, will allow the patient to acquire the drug in 3-5
days (urgent TARs can be phoned or faxed in and should be
processed within 24 hours). However, many doctors and
pharmacists will not deal with TARs. If their request is
refused by MediCal, it can be resubmitted, but this will take
another 3-5 days.

If you do not obtain approval for the drug in this way, you
can apply to your county AIDS Drug Assistance Program (ADAP).
If the drug is not available on that program, or if you are
refused it, you might ask your physician whether the company
who manufactures it has a patient assistance program; for a
partial list of available programs see AIDS Treatment News
#186, November 5, 1993.

San Francisco is trying to set up a system to automatically
refer rejected MediCal requests to the county ADAP program,
which could reimburse the pharmacy. However, only certain
pharmacies are enrolled in the ADAP program. Also, this San
Francisco proposal has not yet been approved by the state.

The ADAP requires that the supply of a drug to a MediCal
patient be approved on an annual basis, except where the
patient has a higher income than the MediCal limit and is
thus required to pay a share of the cost of prescription
drugs. For these "share of cost" patients, approval must be
applied for on a monthly basis and is based on income. TARs
can be also be approved for up to 12 months and, according to
Len Terra at the MediCal Benefits Branch, this is the usual
case for chronic drugs such as AZT. For other drugs, however,
the patient may have to submit a TAR each month, and ADAP
will never authorize more than a 30-day supply of a drug at
any one time.

Len Terra says the MediCal field offices have already
experienced an increase in TARs as a result of the ten-
prescription limit and they are employing more processors to
handle the further increase they expect after October 1. The
ADAP also expects a large increase in requests but is
confident of being able to handle the paperwork involved.
Money to fund ADAP, though, is provided by each county and
there is concern that there will not be enough funding to
cover what is expected to be a large increase in demand for
medications.

MediCal patients are now faced with a situation which could
endanger their health. Many people with AIDS are taking more
than six drugs, and it is not certain that they will obtain
the necessary TARs to keep up all their treatments. Ed
Miller, at Castro Village Pharmacy in San Francisco, suggests
that if you are prescribed more than six drugs, you could ask
your doctor or pharmacist to apply for TARs for the drugs you
are taking chronically, as these are likely to be approved
for a year and save you the trouble and worry of having to
apply each month.

Also, note that MediCal allows medications (apart from three
or four abusable-type drugs) to be dispensed in amounts up to
100 days' supply; if your doctor thinks you are likely to
need a drug for this length of time, he or she should
prescribe it in this amount. Then you could get another drug
on your allowance of six, for the next two months.

MediCal patients need to make sure their doctors and
pharmacists are aware of the new regulations, and that they
are willing to help them obtain the medications they need.
People we spoke to were still unsure how the regulations
would be imposed, and how difficult it will be for patients
to get TARs approved. As we went to press, however, the
Department of Health Services scheduled a meeting to discuss
the possibility of exemptions for people with AIDS. We will
inform you of the outcome.