Prescription for Disaster: Changes to Tennessee's Medicaid Program

I had selected several psychiatrists near my home but I was informed by the Premier representative that only three psychiatrists were currently accepting new TennCare patients. Since none of the three had practices within Davidson County, I made an appointment with a psychiatrist in Gallatin, Tennessee - quite a distance from my home in Bellevue.

At my initial appointment on May 20, the psychiatrist prescribed an anti-depressant (SSRI) for major depression and anxiety. The initial prescription was written for 50 mg. and I was instructed to increase the dosage by 50 mg. weekly. The physician was increasing my dosage gradually because I had experienced severe side effects in the past with a similar anti-depressant. Once he felt confident that I could tolerate the 200 mg. daily, he wrote my next prescription for 100 mg. tablets.

When I took the prescription to the pharmacy on June 3, 1999, the pharmacy informed that I could not have my prescription since it needed to be pre-authorized. I called the doctor's office the next day and they faxed in a request for pre-authorization immediately. I called the TennCare Advocacy Line and they told me it would take 3-5 days to receive authorization. I called the pharmacy the following Monday, and every day thereafter to inquire about the status of my pre-authorization request.

In the midst of a major personal crisis, I went to the pharmacy on June 12, 1999, and told the pharmacist on duty that I needed a 3-day emergency supply of medication as per Grier[2].The local pharmacy (Walgreens ion Highway 70 South in Bellevue) never informed me that I was entitled to a 3-day emergency supply, but I am fortunate enough to be aware of the TennCare policies on BHO medications.

I scheduled my next appointment with my physician on June 14, 1999, and was given a copy of the pre-authorization form that they had received from TennCare on June 11, 1999. Despite having the signed pre-authorization form in hand (with the necessary approvals) when I returned to the pharmacy, I was told that I could not get the 100-mg. tablets that were prescribed by my physician. I spent almost 2 hours at the pharmacy while they negotiated with TennCare about the authorization status of my medication. Ultimately, I was given 120 50-mg. tablets instead of the 100-mg. tablets that were specified on the pre-authorization form.

Throughout this experience, I made several calls to the TennCare Bureau and First Health. I asked the pharmacy to call and request an early refill since the daily dosage had changed from the original prescription. The request for early refill was denied. I was informed by Premier that a prescription had been pre-authorized on June 1, 1999, however, after speaking with my physician it became obvious that pre-authorization had neither been required nor requested until June 3, 1999.

The customer representative at First Health refused to give me any information about the status of my prescription. She also refused to give me her name or an employee identification number so I could log the call properly.

I hope this statement will give you all a better understanding of what TennCare beneficiaries have been going through since our pharmacy benefits were changed. It is very frustrating to be a patient in distress and not be able to communicate with any knowledgeable person about your health care benefits. Of the little information we are given, it is often inconsistent and incorrect. Furthermore, since it took constant effort to get my prescription filled 11 days after it was dropped off at the pharmacy, a 3-day emergency supply policy is clearly inadequate.

"So, in closing, Mr. Lapps, although your statement reports only one formal complaint on file from "Patient X" resulting from the sudden changes to the TennCare program over Memorial Day weekend, let me personally assure you that now you have two."

Sincerely yours,

Elyssa Durant

TennCare Recipient[3]

Signed June 12, 1999[4]

[1]Premier was the state's answer to climbing health care costs and fee for service plans and was the behavioral health component (BHO) for TennCare-- Tennessee's version of Medicaid; modeled after Oregon's Medicaid managed care program; implemented in the state of Tennessee by way of a federal waiver in 1994.

[2]Grier was still considered the standard of care at the time, but was ultimately eliminated by Governor Bredesen due to sweeping cuts and changes to the TennCare program in 2005.

[3](and Doctoral Student & Graduate Assistant in Public Policy)

[4]Footnotes and signature on file added on June 8, 2008 for Historical Reference

Resources

1. www.tnjustice.org
2. www.thcc2.org
3. www.familiesusa.org