Utah Medicaid Beneficiaries with More than Seven Prescriptions Per Month Must Demonstrate Need Under New Policy

Under a compromise reached on Jan. 1, certain Utah Medicaid beneficiaries who need more than seven prescription drugs a month will have to "show proof they are under a doctor's care and need them all," the Deseret News reports. The original plan -- one of several cost-cutting measures implemented by the state Department of Health to reduce the state's $675 million Medicaid budget by $5 million -- called for an inflexible, seven-drug limit for all Medicaid beneficiaries except pregnant women, children and individuals with chronic illnesses. But facing a public backlash from advocates and beneficiaries, state officials instead decided to implement the new "medical exception policy," which will allow the 5,000 people estimated to be affected by the limit to continue with their current level of medications, at least through January, provided they can show need. According to state Medicaid Director Michael Deily, determining who qualifies for the exception will be examined on a "case-by-case basis," but the majority of beneficiaries who request the waiver will be approved. "We're going to pretty much for the month of January accept [a request] at face value if someone notifies us in writing of his need for more prescriptions," Deily said. However, the News reports that state officials plan to design a prescription review process in the meantime that "likely will become more restrictive." The News reports that Medicaid beneficiaries in nursing homes and those with disabilities or mental illness will be most affected by the seven-drug limit (Wagner, Deseret News, 1/2). Utah currently has a $200 million budget shortfall (Santini, Salt Lake Tribune, 12/30/01).

Contradictory Policy?
According to Rob Denton, senior attorney for the Utah-based Disability Law Center, even with the compromise, "several problems" with the prescription limit "should be anticipated." He said, "The agency legally has the authority to ensure Medicaid is not paying for medications that are unnecessary, duplicative or could be provided more cheaply, but at the same time, legally they have to provide medically necessary services, and by virtue of the fact they've already been providing for the prescription medications prior to Jan. 1, they've already determined that. Right now it's all speculation" (Deseret News, 1/2).