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HMO patients wait -- in pain Glitch in new procedures stalls prescriptions By SUSAN JAY Tracy Long is still waiting for his pain medication -- five days after his doctor called in the prescription. Other Oregon Health Plan members covered by the HMO Family Care are in the same predicament -- unable to fill insulin prescriptions, receive anti-seizure drugs or get the meds needed for their HIV cocktail. Since Family Care, the HMO for thousands of Jackson County residents, implemented new guidelines and restrictions on prescriptions, people such as Long have gone without medication -- calling and waiting and calling and waiting. Pharmacists and doctors have made similar calls. This is not how the new guidelines should be working, said Family Care CEO Jeff Heatherington. The firm implementing them, Med Impact, told him the glitches were nearly worked out. "At this point we need to have a direct review with a pharmacist in their office just to see what problems they're incurring," Heatherington said. "We have the understanding that these problems will be fixed." Heatherington said he would be talking to Family Care staff and sending a nurse case-manager to visit a pharmacist and see what problems existed. He said no patients should be leaving the pharmacist empty-handed, even if their prescriptions require pre-authorization. Family Care started requiring a pre-authorization statewide for all narcotics and muscle relaxants a few weeks ago. In Jackson County, it also started using guidelines requiring pre-authorization on a broader variety of medications. It also has eliminated some drugs from coverage, suggesting others as substitutes. Family Care has been losing about $150,000 a month, and is trying to get a handle on drug costs in Jackson County, along with curbing abuses statewide. Heatherington said pharmacists are supposed to be able to give customers a limited supply of medication while they wait for authorization. "There's an automatic 10-day refill, and they can call Med Impact for approval," Heatherington said. Pharmacists should be seeing the authorization for the limited refill on their computers. Jack Sabin, pharmacist and owner of Ashland Drug, hasn't seen it. Neither has Dale Smith at Evergreen Pharmacy; or Melanie Perry of Christian's Pharmacy in downtown Medford; or other Jackson County pharmacists. "That's what is very misleading," Perry said. "They are telling these people that we should be able to run a 10-day supply until they get an authorization, but that's not true. When we run it in the computer for a 10-day, it still doesn't work." Evergreen Pharmaceutical Inc., which fills prescriptions for institutions like nursing homes and assisted living homes, has about 100 customers covered by Family Care. For those whose medications are not on the approved list, and have serious conditions, Evergreen is filling the prescriptions anyway. "They've narrowed the formulary (drug guidelines) down so tightly that medications in a lot of different classes are not being covered," Smith said. For example, Evergreen filled prescriptions for anti-seizure medication for brain-injured children living in a residential facility, and for a woman who is terminally ill with multiple sclerosis. Heatherington said he thought these medications would be covered, and that patients living in institutions should be automatically covered. Sabin said he didn't receive the new guidelines until Thursday. Like other pharmacists, he has been giving prescriptions on his own, such as Tylenol elixir for a baby who just had surgery for a cleft palate. The prescription was approved, but the dosage was only enough for a day, and Sabin couldn't wait the weekend for the authorization for more. "I know the insurance companies have to protect themselves so they won't go broke," Sabin said, admitting frustration. "But what they neglected to do was tell us what the playing field was going to be or the rules and regulations." Family Care's Heatherington has said the HMO did make a mistake not telling the pharmacists beforehand of the change. In the meantime, people like Long, a mental health patient living in a foster home, are still waiting. Long awaits medications prescribed by his orthopedic surgeon to relieve the pain from his two herniated discs. But, while Long understands Family Care's concern over drug abuse, he said those who are using the medication legitimately shouldn't be punished. "There's got to be a better way to do this," Long said. Mail Tribune Copyright � The Mail Tribune 1999, Medford, Oregon USA