Prescription for Drug Plan Woes Still Incomplete

Even as the state spends millions of dollars on emergency prescription drug coverage for more than 200,000 elderly, poor and disabled Californians, many of their claims are still being denied, healthcare groups said Tuesday.

Patients’ advocates and others said they continue to get reports from throughout the state that many enrollees in the federal prescription drug program are being told that their medicines are not covered, or are being charged hundreds of dollars instead of the $1 to $5 co-pay they actually owe.

State officials have been scurrying to backstop the Medicare program. Since Thursday, California has paid for 34,000 prescriptions for people whose claims were rejected after they had been enrolled in the federal program Jan. 1.

Gov. Arnold Schwarzenegger and legislative leaders committed Tuesday to spend up to $150 million in state money to continue such coverage for as long as a month. But even seniors who need life-saving drugs are still falling through the cracks, patient advocates said.

The benefit is intended to offer 43 million Medicare beneficiaries nationwide outpatient drug coverage similar to that which most working people have through their employers. Designed by the Bush administration and Congress, the program uses dozens of private drug plans to deliver benefits at an estimated cost of $700 billion over 10 years.

The plan ran into immediate problems. Computerized databases that pharmacies use for billing had inaccurate information on hundreds of thousands of beneficiaries, primarily vulnerable low-income seniors and disabled people.

“Some of the pharmacies seem to know what they are doing, but others don’t,” said David Mandel, supervising attorney at the Senior Legal Hotline, a Sacramento nonprofit set up to help low-income seniors enroll in the Medicare program. “Some of them are just exasperated.”

California is among many states that are spending millions of dollars to cover those being denied medications. Federal officials have said that they would work to ensure that states that step in are reimbursed by the private insurers involved in the Medicare plan.

Calise Munoz, a regional director for the federal Department of Health and Human Services, said “The money needs to go from the plans back to the state.”

Wen Daniels, an Orange County outreach coordinator for California Health Advocates, said several patients told her their pharmacies either had not heard of the emergency system or did not know how to use it.

One patient, she said, could not get anti-rejection medication after a recent heart transplant. Another who needed an oral chemotherapy program was told Friday that her co-payment would be $400, rather than the $1 to $3 that it was under Medicaid. She said she could not afford the drugs.

“We’re still getting pharmacist after pharmacist who hasn’t heard of it, and people still aren’t getting their meds,” Daniels said. “It’s getting to be a crisis situation for some people.”

In San Rafael, near San Francisco, John B. Slack, a 66-year-old retired auto dealership owner, said his Kaiser Permanente pharmacy took 14 days to fill his prescriptions for renal disease and after-care from a kidney transplant. When he went to get them, he was given a week’s supply of only the medicines he needed most and was told that Kaiser could no longer provide his drugs.

Slack was moved to another organization’s insurance plan, and is confused about what happens next.

“I’m lost,” he said. “I’m out in the wilderness. I have no idea where I’m going to get my meds. I have no idea where to turn to.”

Thousands of Californians who are enrolled in the federal program will not be covered by the state’s emergency action, because they were not part of Medi-Cal.

Still, healthcare advocates praised the governor and lawmakers for addressing the Medicare quagmire.

“We understand there are glitches, but we think many people are getting covered,” said Jeanne Finberg, a lawyer for the National Senior Citizens Law Center in Oakland.

Schwarzenegger said at a news conference Tuesday that he would demand that Washington pay the tab for covering Californians as the kinks are worked out of the federal program.

“We will press Washington to reimburse us,” the governor said.

In Washington, the Bush administration’s top health officials said that although they were working out problems as quickly as possible, new glitches could surface.

“After they’ve used their card the first time, it will get much smoother,” said U.S. Health and Human Services Secretary Michael Leavitt.

Munoz said 2,500 operators are on duty at 1-800-MEDICARE, a hotline to help patients.

Medicare Administrator Mark McClellan decried the plight of those who have had to leave the pharmacy without the drugs they need. McClellan, a medical doctor who once practiced in California, said seniors should insist on getting the medicine they are entitled to at the correct price.

“It is unacceptable to me, as a physician, for anyone who had coverage to go without the medicines they need,” McClellan said.

Halper reported from Sacramento and Berthelsen from Orange County. Times staff writers Ricardo Alonso-Zaldivar in Washington and Valerie Reitman in Los Angeles contributed to this report.