Hawai'i's state and county workers who regularly order the same prescription drug are being required to get their refills from a Florida pharmacy, prompting complaints from workers and some of the pharmacies they previously used.

The change to a mail-order pharmacy for so-called maintenance drugs came last month as the Hawai'i Employer-Union Health Benefits Trust Fund searched for ways to avoid a nearly 30 percent increase in health care premiums for the workers.

By switching to a mandatory mail-order program and making other changes, the EUTF trustees were able to cut the premium increase to 23.7 percent. Mandatory mail order will save $10.6 million that otherwise would have been factored into the premiums.

"Those are pretty big numbers," said James Williams, the EUTF administrator. "We looked at how can we achieve savings without cutting benefits, and that's exactly what the mandatory mail order does."

Previously workers, their dependents and retirees up to age 65 enrolled in EUTF's preferred provider plans were able to go to a pharmacy of their choice for their prescriptions.

But among the changes made July 1 to their drug plans is mandatory use of InformedMail Service Pharmacy in Miramar, Fla., for maintenance drugs — prescriptions taken on a regular basis for chronic conditions such as arthritis, diabetes and high blood pressure.

The program is being phased in, with people being able to get up to three one-month prescriptions or one 90-day prescription filled at their current drug stores before having to switch to the Florida pharmacy.

But the change already has resulted in more than 100 complaint letters to the EUTF office. The University of Hawai'i Professional Assembly has asked EUTF trustees to reconsider the ramification of the change.

The state's small independent pharmacies also are worried they'll have to lay off people as customers transition to mail order.

SEEING CUTBACKS

State Sen. Josh Green, D-3rd (Kohala, Kona, Ka'u), a Big Island emergency room physician, said he understands that the EUTF had the best intentions for its members but that the program may have unintended consequences.

He said that was proven last weekend when a patient with a history of strokes came into a Kohala emergency room asking for high blood pressure medicine. A mail-order prescription hadn't arrived on time and the local pharmacy was closed on a Saturday afternoon.

So Green gave the man three days of the drug to tide him over. Green said the mail-order prescription probably saved a few dollars, but the cost of an ER visit probably was around $500.

"I'm really concerned that patients aren't going to get their medicines on time, and two, there's a culture of small pharmacies in Hawai'i that's very valuable to us," Green said.

At Molokai Drugs, president Kimberly Svetin estimates a pending 5 percent to 10 percent loss in business. She has looked at cutting back employee benefits and when a worker recently left, the responsibilities were divided up among remaining employees.

"It's already affected us," Svetin said.

The same may happen at Maui Clinic Pharmacy, where owner Les Krenk said he may have to let go one or two people. He said that so far this year there have been nearly 7,000 prescriptions entered at his pharmacies for EUTF members; perhaps as many as 5,000 of those fall into the maintenance drug category, he said.

Moreover, people who come in on a regular basis also buy merchandise from what's known as the front end of the store.

"My patients are screaming about this," Krenk said. "The patients are saying how do we stop this, we don't want this."

At Kaua'i's Lihue Pharmacy, owner Kevin Glick said many of his EUTF customers aren't aware that the program is mandatory and believe they can opt not to use the mail system.

He said the use of a Florida pharmacy will cut into employment here and further affect tax revenue at a time when the state is complaining about not having enough tax revenue.

"So if you export taxable revenue to another state, that's a one-way trip," he said. "It not only affects the local pharmacy."'

It's also a bit disappointing to the pharmacies that not only will InformedMail be taking away business from them, but that their stores will be relied on to provide emergency prescriptions when drugs don't arrive on time or to fill initial orders when a doctor switches a patient to a new drug.

Moreover, there are questions about the loss of face-to-face consultations provided by local pharmacists when patients come in to pick up medicine, said Stu McElhaney of the Pillbox Pharmacy in Kaimuki.

He said ordinarily people use the same pharmacy for all their prescriptions and that pharmacists may spot when there's a possible reaction between a maintenance drug and one prescribed for a non-recurring condition.

With prescriptions split between Florida and the local pharmacy here, that checking of medications against each other might not occur, McElhaney said.

SAVING ON PREMIUMS

Williams said EUTF's 10 trustees had looked into issues related to use of mail-order pharmacies and considered such questions, including whether medicines will arrive on time. Requirements that insulin and other medicines be refrigerated have been taken into account, he said.

"Mail order is not new," Williams said. "All of these things have been done for quite a while by InformedRX and other companies."

He said it was understandable that local pharmacies are concerned, since they will be losing the maintenance drug business. "But I don't think that's a high enough number to put them out of business," he said.

No estimates exist for how much business will be sent out of state. Williams' rough projection is that it may be in the neighborhood of $25 million out of the more than $500 million the EUTF spends on health care annually.

He said that the savings for the 87,000 members and dependents who may be affected by the change is tangible.

Without the drug savings sought by EUTF trustees, an HMSA preferred provider plan would cost $11 more a month for a single subscriber, while a family would be paying around $34 more.

"I don't think our board is insensitive to the pharmacies, but our first responsibility is to our people and the employers who pay the bill," Williams said.

"If we could get equivalent pricing at the local pharmacy, then there wouldn't be any need to do this."

Green said that while he understands the EUTF's position, he remains concerned.

"I think they may have to consider reversing some of this plan over the next year unless they can provide a way to include the small pharmacies."