Opinion ID: 2784541
Heading Depth: 2
Heading Rank: 2

Heading: Consent Decree 124–30 and CAO 637-8

Text: The 78-page Decree is organized into 308 paragraphs, of which only 7 are involved in this appeal. Paragraphs 124–30 form one subsection of a larger Frew, 540 U.S. at 441 (quoting FED. R. CIV. P. 60(b)(5)). 5 Id. 6 7 502 U.S. 367 (1992). 8 Frew, 540 U.S. at 442. 9 See Frazar v. Hawkins, 376 F.3d 444, 447 (5th Cir. 2004). 10 See Frew v. Hawkins, 401 F. Supp. 2d 619, 631 (E.D. Tex. 2005). 11 See Frazar v. Ladd, 457 F.3d 432, 434 (5th Cir. 2006). 12 In 2009, the case was transferred by Judge William Wayne Justice, who had overseen the case from its inception, to Judge Richard Schell. 3 Case: 14-40048 Document: 00512959210 Page: 4 Date Filed: 03/05/2015 No. 14-40048 section that calls for a variety of training initiatives for healthcare providers. Of these 7 paragraphs, 2 mandate that Defendants perform specific actions: 129. By January 31, 1996, Defendants will implement an initiative to effectively inform pharmacists about EPSDT, and in particular about EPSDT’s coverage of items found in pharmacies. The effort will include presentations at meetings of the Texas Pharmaceutical Association and other appropriate organizations, if possible, articles in the TPA newsletter, if possible, and at least one mail out to all pharmacists who participate in the Medicaid program. The mail out will be designed to attract pharmacists’ attention, explain EPSDT coverage clearly and encourage pharmacists to provide the full gamut of covered pharmaceutical products to recipients as needed. 130. By July 31, 1996, Defendants will conduct a professional and valid evaluation of pharmacists’ knowledge of EPSDT coverage of items commonly found in pharmacies. They will report the results of the evaluation to Plaintiffs by September 1, 1996. If the parties agree that pharmacists’ understanding of the program is acceptable, Defendants will continue the initiative described above to inform pharmacists about EPSDT. If the parties do not agree, or if pharmacists’ understanding is unacceptable, Defendants will conduct an initiative to orally inform pharmacists about EPSDT’s coverage. Plaintiffs will not unreasonably disagree about whether pharmacists’ understanding is acceptable. 13 Plaintiffs contend that three other paragraphs of the Decree are relevant: ¶ 3, which declares that “[r]ecipients are also entitled to all needed follow up health care services that are permitted by federal Medicaid law”; ¶ 6, which describes the purpose of the Decree as “[t]o address the parties’ concerns, 13 Paragraph 124 describes the critical role that pharmacies play in the Program. Paragraph 125 introduces Plaintiffs’ complaints: Pharmacists do not understand EPSDT’s requirements, such as the fact that over-the-counter medications are covered if prescribed by a doctor. Paragraph 126 states that EPSDT also covers medically necessary infant formula, diapers, and other supplies and equipment “commonly sold in pharmacies.” Paragraph 127 continues Plaintiffs’ complaints: Pharmacies that do not understand EPSDT require Medicaid recipients to pay in cash; recipients often do not have cash or end up erroneously paying for covered items. Paragraph 128 states Defendants’ disagreement with these facts. 4 Case: 14-40048 Document: 00512959210 Page: 5 Date Filed: 03/05/2015 No. 14-40048 to enhance recipients’ access to health care, and to foster the improved use of health care services by Texas EPSDT recipients”; and ¶ 190, which states that “EPSDT recipients served by managed care organizations are entitled to timely receipt of the full range of EPSDT services, including but not limited to medical and dental check ups.” 14
This corrective action order begins by referencing ¶¶ 3, 129, and 130 of the Decree. It then describes Plaintiffs’ main complaint with pharmacists’ understanding of EPSDT’s prescription drug program: When EPSDT recipients seek to fill prescriptions for drugs that are not listed on the Program’s Preferred Drug List (“PDL”), pharmacists may fill them only if they have “prior authorization” from the prescribing physicians. If a prescribing physician does not provide the authorization or could not be reached, the pharmacist must dispense a 72-hour emergency supply so that the class member is not deprived of needed medication. Many pharmacists, however, did not know that the stopgap measure was available or treated it as optional and improperly withheld class members’ prescriptions. To remedy the pharmacists’ misunderstanding, CAO 637-8 established a detailed series of action items, elaborating on and expanding the requirements found in ¶¶ 124–30 of the Decree. CAO 637-8 is divided into 12 bullet points, of which 9 require specific actions by Defendants. Particularly contested in this appeal are their obligations in bullet points 6 and 10. 15 14 In March 2012, the EPSDT prescription drug program was transferred from direct state control to the control of managed care organizations. All Texas EPSDT recipients are now served by managed care organizations. 15 CAO 637-8 also requires Defendants to (1) change the Program’s electronic prescription processing system so that it reminds pharmacists of the 72-hour emergency policy; (2) “work with the Texas Pharmacy Association to explain” the policy; (3) make available a PDL database service that doctors may use online or download to a handheld device for reference while providing care; (4) “begin encouraging all Medicaid-enrolled 5 Case: 14-40048 Document: 00512959210 Page: 6 Date Filed: 03/05/2015 No. 14-40048 Bullet point 6 required Defendants to “provide intensive, targeted educational efforts to those pharmacies for which the data suggests a lack of knowledge of the 72-hour emergency prescriptions policy.” 16 In addition to these “intensive, targeted” efforts for particular noncompliant pharmacies, Defendants were also to “continue . . . educational efforts with respect to all Medicaid pharmacies.” Bullet point 10 required Defendants to train staff at their ombudsman’s office “about the emergency prescription standards,” including “what steps to take to immediately address class members’ problems when pharmacies do not provide emergency medicines.”