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SENIOR BULLETIN: MEDICAID – Non-Institutional
New prescription drug review and authorization system (“TCS”)
begins February 1st for certain Medicaid clients
What is happening?
Beginning February 1, 2002, Medicaid will require a complete drug profile review before certain prescriptions can be filled. Pharmacies maydispense an “emergency” supply while the review takes place. Patientsmay need to return to the pharmacy for a full supply or a substitutemedication after the review is completed. The new system is called “Therapeutic Consultation Service,” or “TCS.” TCS reviews are performed by pharmacists at Affiliated ComputerServices (ACS), a company contracting with DSHS to perform this service.
The reviews require at least one telephone contact from the prescribingprovider to ACS.
The TCS program does not change the prescription drug benefit.
As before, clients will still receive needed prescription drugs. TCS may lead to changes in the brand or type of medicine that is prescribed. If aprescriber pursues the TCS process and believes the prescribed drugshould be provided without any substitution, however, ACS eventuallyapproves the request for a specified period, except in very limitedsituations.1 Because the prescriber’s office rather than the pharmacy mustpursue the authorization, however, some prescribers may be discouragedfrom pursuing the approval even in appropriate situations. The ACSsystem reportedly includes some follow-up by their pharmacist regardingdrug claims that are not filled, although details about this part of theprogram are not yet available.
When is TCS drug review required?
TCS review applies only to fee-for-service (not Healthy Options) Medicaid clients. Nursing home patients will be affected eventually but willnot be subject to TCS at first.
COLUMBIA LEGAL SERVICES, 101 Yesler Way, #300, Seattle, WA 98104
Medicaid – Non-institutional, 02-1, p. 2 The TCS review is required ONLY when such a client: • has four brand-name prescriptions in a calendar month, and is • is prescribed a drug that is “non-preferred” within certain drug What prescriptions does TCS affect?
• Fifth brand-name prescription: Some drug classifications are not
counted when determining whether a client has a fifth brand-nameprescription. These include:• HIV • Non-preferred drugs: As of February 2002, only the following
drug classes are subject to TCS (more drug classes are expectedto be added later): • Proton Pump Inhibitors (such as Prilosec, Prevacid): The preferred drug in this class is Protonix.
• Histamine H2 Blockers (H2RA) such as Zantac: The preferred Why is TCS happening?
• Control of Medicaid Costs. The State of Washington hopes to
reduce Medicaid prescription drug expenses. Drug cost increasescaused large increases in Medicaid expenditures in the past severalyears. Florida implemented a similar system last year. Consultantsreviewing that experience estimate Washington could save $30million annually.
• Management of Drug Treatments. Drug profile reviews may lead
to improved health care for clients by preventing drug conflicts orother adverse side effects. TCS will review all medications beingcovered by Medicaid for these concerns, not just those prescribedby the same provider or dispensed by one pharmacy.
Medicaid – Non-institutional, 02-1, p. 3 What are potential problems with TCS?
• Delays in getting prescriptions filled.
• Need for return trips to fill prescriptions.
• Difficulties in getting emergency supplies.
• Burden on providers to pursue TCS process.
• Substitutions made to avoid the TCS process may not be optimal • TCS review is required again after six months.
What can Medicaid recipients do to prevent problems?
• Seek refills early. Clients with more than four brand-name
prescriptions should seek refills well before supplies are exhausted.
(Refills are not allowed too early, however; at least 75% of theprescription must be gone.) • Discuss alternatives with providers. When a provider prescribes
a new brand-name drug, discuss the medical justification for thisdrug versus alternatives. Determine whether substitution isappropriate or not.
• Get temporary supplies. When a provider prescribes a new
brand-name drug, clients already using four brand-name drugsshould ask the provider for samples if available. If they are not, askthe provider to contact the pharmacy if the client will need atemporary “emergency” supply while TCS occurs. Pharmacies areexpected to be able to dispense such temporary supplies inappropriate situations while the TCS process occurs.
What should clients do about problems?
• Clients with case managers should notify the case manager • has difficulty arranging a return to the pharmacy • is not taking medications correctly due to a delay in the TCS • Clients without case managers can make complaints to the Medicaid – Non-institutional, 02-1, p. 4 medical assistance toll-free number 1-800-562-3022 (TDD/TTYnumber is 1-800-848-5429 for deaf and hard of hearing clients).
• Clients unable to resolve access problems can seek legal advice through CLEAR (1-888-201-1014) or CLEAR*Sr (forclients age 60 or older) (1-888-387-7111). • If a client has trouble getting a medication refilled, requesting a DSHS fair hearing promptly may help maintain coverage whilewaiting for the hearing.
What should case managers and advocates do about problems?
• Case managers/social service providers should notify AASA (or DDD for DD clients) of problems. AASA/DDD staff may refer calls to the implementing person at MAA. • Case managers/social service providers also can contact the local Legal Services program regarding persistent or repeatedissues.
• Legal services advocates are asked to inform Ann Vining by email about specific client problems.
• Case managers and advocates should document client problems and assist clients to the extent possible in addressingthe problem with MAA, the provider, and the pharmacist. • To help us monitor the implementation of this program,
please send documentation of problems to Janet Varon atshort email is fine; send client identifying information only if theclient authorizes this.
1 Limited exceptions occur for drugs not covered by Medicaid at all, before or after thischange, such as those classified as “DESI” (not effective), those manufactured bycompanies without Medicaid contracts, and those for purposes specifically excluded bythe state plan (such as smoking cessation and hair restoring medications).

Source: http://www.washingtonlawhelp.org/resource/new-prescription-drug-review-and-authorizatio/download/392693D3-FD7D-64D1-4B29-F78B4B56E33B.pdf