Groups representing low-income Medicaid enrollees in Connecticut are sounding the alarm about the state’s planned rollout of new prior authorization requirements for a slew of prescription drugs, warning that thousands of vulnerable people across the state could lose access to their medications. The concerns are centered on the chance that some enrollees will be unaware of the change in policy and their doctors will not seek prior authorization before the April 1 deadline. They also say the rollout will break state law by allowing authorizations to be denied if clinical criteria is not met. Last week, leaders of Disability Rights Connecticut, the Disability Rights Project at the Center for Children’s Advocacy, the Connecticut Legal Rights Project, Connecticut Legal Services, and Greater Hartford Legal Aid wrote to Department of Social Services Commissioner Andrea Barton Reeves and other state officials to express their concern in what they call “deficiencies” and “violations of law” in the department’s proposed rollout of the rule change, which will affect people taking 11 classes of prescription drugs that include over 200 medications. The medications that will require prior authorization — the process by which doctors must obtain approval from insurance companies before prescribing certain medication — are used by people with severe disabilities, the groups say, including Multiple Sclerosis, traumatic brain injury, seizure disorders, arthritis and diabetes. Advocates say the impact is significant because these are commonly used drugs, meaning that that tens of thousands of people across the state will be impacted by the new rules. In a Dec. 1 bulletin to health care providers, DSS explained the new requirements for prior authorization, announcing that they go into effect on January 1 for new prescriptions and on April 1 for existing prescriptions. That means people on Medicaid who have an existing prescription for a drug like the GLP-1 Mounjaro, the anti-seizure medication lamictal, or the plaque psoriasis treament taclonex, and who have not completed the prior authorization process before April 1, will find their medication supply is abruptly cut off until authorization is completed. The advocacy groups also argue that the plan violates state and federal law in several ways. The proposed rollout does not include a plan to send people individualized written notices if their prescription is being terminated due to a lack of prior authorization, according to Sheldon Toubman, litigation attorney for Disability Rights Connecticut. Such a notice would inform those people of their rights, including the right to appeal. Advocates also say that the rollout violates state law by permitting the use of drug-specific “clinical criteria” as a basis for denying prior authorization. In other words, Medicaid would be able to deny authorization if a patient’s condition doesn’t meet the clinical criteria for taking the medication, even if a physician considers the medication beneficial or necessary. In response to an inquiry from the Connecticut Mirror about the allegations, a spokesperson for DSS said in a statement that the agency is reviewing the letter but believes its policy complies with state and federal law. DSS also said the new policy brings Connecticut into alignment with national standards when it comes to non-standard drugs. “Nationwide, it is standard, best practice for Medicaid programs as well as Medicare and commercial plans to implement such prior authorization clinical policies without any compromise to patient safety,” the statement said. “Alignment to best practices through use of clinical criteria provides stronger clinical oversight and adherence to appropriate prescribing guidelines. This aims to improve clinical outcomes by following evidence-based clinical criteria to ensure the right care, at the right time, and at the right cost.” Toubman said that while he doesn’t contest the state’s right to require prior authorization, he believes the plan violates a state statute which prohibits a drug from being denied on the basis of clinical criteria. That statute reads, in part, “…clinical criteria or any other generally accepted clinical practice guidelines used to assist in evaluating the medical necessity of a requested health service shall be used solely as guidelines and shall not be the basis for a final determination of medical necessity.” Toubman said the plan is, “just plain illegal. It violates the state law and there is a reason the state law is there.” Toubman also criticized the state’s decision not to send out a general notice to all Medicaid recipients to inform them of the rule change. Kristen Whitney Daniels, a member of the diabetes advocacy group Connecticut #insulin4all, said that the plan is especially dangerous for people with diabetes who are taking GLP-1’s such as Mounjaro, which now requires prior authorization, because even a brief interruption of treatment can have a catastrophic impact. “Anytime you’re messing with a diabetic’s prescription or what medication they’re able to take, that can have a drastic impact on people’s blood sugars,” she said, explaining that someone with diabetes who has been managing their condition with a GLP-1 could be left in the lurch if they don’t have prior authorization completed by April 1. Then, they could need insulin instead — right away. “If they don’t have the prescription for insulin, that could be an emergency sort of situation.” A full list of the impacted medications can be found here. ...read more read less