Idaho Medicaid Drug Utilization Review Program · 2015-04-16 · Urine drug screening ... This will routinely include drugs in these four categories: 1) Analgesics 2) Antinauseants

16 April 2015

1

Follow-up to Previous Reviews

Review of any outcome studies for long term narcotic use in chronic non-malignant pain

Hospice

2

Outcome Studies for Long-term Narcotic Use Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al.

The Effectiveness and Risks of Long-term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Preventions Workshop

Annals of Internal Medicine Vol 162 No. 4 17 February 2015

Funded by AHRQ 3

Purpose To evaluate evidence on the effectiveness and harms of

long-term (>3 months) opioid therapy for chronic pain in adults

Evidence was used to facilitate a National Institutes of Health Pathways to Prevention Workshop

Co-sponsored by

NIH Office of Disease Prevention

NIH Pain Consortium

National Institute on Drug Abuse

National Institute of Neurological Disorders and Stroke

4

Data Analysis Effectiveness No study of opioid therapy versus no opioid therapy

evaluated long-term (> 1 year) outcomes related to

Pain

Function

Quality of Life

Opioid abuse

Addiction

5

Data Analysis Harms Good and Fair Quality observational studies suggest

opioid therapy for chronic pain is associated with

Increased risk of overdose

Opioid abuse and dependence

Myocardial infarction

Increased use of medications to treat sexual dysfunction

For some harms higher doses are associated with increased risk

6

Bottom Line Conclusions Evidence is insufficient to determine the effectiveness

of long-term opioid therapy for improving chronic pain and function

Evidence supports a dose-dependent risk for serious harms

7

Risk Prediction Instruments for Predicting Misuse, Abuse or Addiction

Aberrant drug–related behaviors such as aberrant urine drug test results and medication agreement violations ranged from 6-37%

No study evaluated the effectiveness of risk mitigation strategies to reduce harms

Urine drug screening

Prescription drug monitoring program data

Abuse-deterrent formulations

8

Rates of Opioid Abuse or Dependence

Morphine –equivalent Dose (MED)

Percentage Odds Ratio

1-36 mg/day 0.7% 14.9

> or = 120 mg/day 6.1% 122.5

9

Factors Associated with Increase Risk for Misuse

History of substance use disorder

Younger age

Major depression

Use of psychotropic medications

10

Review of any outcome studies for long term narcotic use in chronic non-malignant pain

Questions/Comments ???

11

Hospice

12

Hospice

13

Hospice CMS Update – July 18, 2014

Hospice providers should provide all the medications that are reasonable and necessary for the palliation and management of a beneficiary’s terminal illness and related condition.

This will routinely include drugs in these four categories:

1) Analgesics

2) Antinauseants (antiemetics)

3) Laxatives

4) Antianxiety drugs (anxiolytics)

14

Hospice Hospice Diagnoses

Effective October 1, 2014: hospice agencies can no longer use Debility or Adult Failure to Thrive as a hospice diagnosis.

Idaho Medicaid is seeing an increase in Malnutrition and Nutritional Marasmus listed as hospice diagnosis.

The Pharmacy Unit had a meeting with the Medical Care unit who coordinates hospice care to express concern over the use of these non-specific diagnoses for patients with multiple chronic disease states (e.g. congestive heart failure, diabetes, kidney failure).

15

Hospice – Prior Authorization Requests for

Idaho Medicaid to Pay for Medications

Analysis of Requests Received Jan. – Dec. 2014

Requests received for 42 patients

164 total medication requests

16

Hospice Patients no longer on

hospice, n=11, 26%

Patients currently on

hospice, n=31, 74%

17

Hospice

Medication requests for patients no longer on

hospice, n=55, 34%

Medication requests for

patients currently on

hospice, n=109,

66%

18

Hospice

Approved, n=45, 41%

Denied, n=64, 59%

109 Medication Requests for Patients currently on hospice

19

Hospice

35

23

6

0

5

10

15

20

25

30

35

40

Insufficient documentation

Hospice should cover Medication should be discontinued

Denial Reasons (n=64)

20

Hospice Examples of medications that hospice should cover

Pain medications

Nausea medications

Management of terminal illness

Examples of medications that should be discontinued

Metformin in patient with kidney failure

Calcium and iron supplements

21

Hospice 1. Improve communication between Medical Care Unit

and Pharmacy Unit

- Pharmacy Unit needs to be notified when patients are NO LONGER on hospice.

- Appropriate hospice diagnoses

2. Pharmacy Unit will continue to provide feedback to hospice

- Required documentation

- Medication classes that hospice needs to cover

22

Hospice Questions/Comments ???

23

Ongoing Reviews Foster Children 2014

Hydrocodone compound products update

Buprenorphine

Hepatitis C

24

2014 Update

25

Use of Psychotropic Medications in Foster Children

Percentage of children (0-17 years old) prescribed psychotropic Medications in named State and year

Foster Children Nonfoster children Ratio of foster to nonfoster children

Florida 2008 22.0% 8.2% 2.7

Massachusetts 2008 39.1% 10.2% 3.8

Michigan 2008 21.0% 7.9% 2.7

Oregon 2008 19.7% 4.8% 4.1

Texas 2008 32.2% 7.1% 4.5

Idaho 2008 38.8% 14.8% 2.6

Idaho 2011 42.9% 14.8% 2.9

Idaho 2012 44.6 % 15.7 % 2.8

Idaho 2013 43.6% 15.8% 2.8

Idaho 2014 46.1% 16% 2.9

26

Comparison of Idaho Medicaid to Five States in GAO Study

Foster Children and Non-Foster Children Population Basis

27

Year Total # of Foster Children

Total # of Non-Foster Children

2007 2,384 85,894

2008 2,516 86,419

2009 2,658 96,979

2010 2,718 103,199

2011 2,785 106,024

2012 2,631 104,553

2013 2,708 105,915

2014 2,707 110,337

Percentage of Children Receiving Psychotropic Medications Over Time

2007 2008 2009 2010 2011 2012 2013 2014

Foster 34% 39% 39% 41% 43% 45% 44% 46%

Non-Foster 14.4% 14.8% 14.4% 14.3% 14.8% 15.7% 15.8% 16.0%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Pe

rce

nta

ge

of

Ch

ild

ren

28

29

Percent of Total Foster and Non-Foster Children Receiving Psychotropics by Class 2014

39%

6% 6%

25%

19%

10%

2% 2%

7% 4%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

ADHD Antianxiety Mood Stabilizers Antidepressants Atypical Antipsychotics

% Foster % Non-Foster

Total Foster = 2707 Total Non-Foster = 110,337

30

Total Claims and Cost Comparison Foster and Non-Foster Children Drug Class Foster

Children Claims

Non-Foster Children Claims

Foster Children

Cost

Non-Foster Children Cost

ADHD 10,394 88,052 $ 1,119,792 $ 10,968,106

Antianxiety 626 7,539 $ 10,208 $ 116,780

Mood Stabilizers 890 11,476 $ 30,236 $ 877,091

Antidepressants 5,066 47,913 $ 66,450 $ 698,506

Atypical Antipsychotics

4,361 29,192 $ 879,571 $ 6,762,859

Total 21,337 134,172 $ 2,106,259 $ 19,423,342

31

Claims Comparison Foster Children and Non-Foster Children

3.84

0.23 0.33

1.87 1.61

7.88

0.8

0.07 0.1 0.43 0.26

1.67

0

1

2

3

4

5

6

7

8

9


Total

Claims per Foster Child Claims per Non-Foster Child

32

Cost Comparison Foster Children and Non-Foster Children

$414

$4 $11 $25

$325

$778

$99

$1 $8 $6 $61

$176

$-

$100

$200

$300

$400

$500

$600

$700

$800

$900


Total

Cost per Foster Child Cost per Non-Foster Child

33

Percent of Foster Children Receiving Psychotropics by Year

2011 2012 2013 2014

ADHD 48% 38% 39% 39%

Antidepressants 14% 24% 23% 25%

Mood Stabilizers 10% 6% 6% 6%

Atypical Antipsychotics 21% 21% 20% 19%

0%

10%

20%

30%

40%

50%

60%

34

ADHD Drugs in Foster Children

6%

2%

34%

18%

24%

16%

8%

3%

40%

15%

23%

11%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

0-6 M 0-6 F 7-12 M 7-12 F 13-17 M 13-17 F

Foster (total = 1050) Non-Foster (total = 11,154)

35

Mood Stabilizers in Foster Children

3% 2%

22%

13%

35%

25%

7%

4%

21%

15%

25% 28%

0%

5%

10%

15%

20%

25%

30%

35%

40%

0-6 M 0-6 F 7-12 M 7-12 F 13-17 M 13-17 F

Foster (total = 151) Non-Foster (total= 1996)

36

Antidepressants in Foster Children

2% 0%

19%

14%

30%

36%

2% 1%

20%

12%

26%

39%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

0-6 M 0-6 F 7-12 M 7-12 F 13-17 M 13-17 F

Foster (total = 665) Non-Foster (total = 8186)

37

Atypical Antipsychotics in Foster Children

5%

1%

28%

13%

33%

20%

7%

2%

30%

12%

29%

21%

0%

5%

10%

15%

20%

25%

30%

35%

0-6 M 0-6 F 7-12 M 7-12 F 13-17 M 13-17 F

Foster (total = 518) Non-Foster (total = 3995)

38

Prescriber Type by Claims Volume Statewide

Child and Adolescent Psychiatrist

5%

Psychiatrist 21%

Behavioral/ Developmental

Pediatrician 3%

Pediatrician 14%

Family Medicine/General Practice/Internal

Medicine 13%

Nurse Practitioner 34%

Physician Assistant 9%

Other 1%

39

Change in Prescriber Type 2013 and 2014

Prescriber Type 2013 2014

Child and Adolescent Psychiatrist 18% 5%

Psychiatrist 13% 21%

Behavioral/Developmental Pediatrician 5% 3%

Pediatrician 13% 14%

Family Medicine/General Practice/Internal Medicine 19% 13%

Nurse Practitioner 22% 34%

Physician Assistant 7% 9%

40

Regional Prescriber Variation 2013: By Prescriber Type

0%

10%

20%

30%

40%

50%

60%

70%

80%

% Specialist % Generalist % Midlevel

Prescriber Type by Region By Percentage of Psychotropic Prescriptions for Foster Children 2014

Region 1

Region 2

Region 3

Region 4

Region 5

Region 6

Region 7

41

Regional Prescriber Variation 2013: Prescriber Type By Region

17%

4%

33%

18%

45%

25%

69%

39%

48%

18%

24%

32%

52%

16%

44%

48% 49%

58%

23% 24%

15%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7

% Specialist

% Generalist

% Midlevel

42

Foster Children and Psychotropic Drugs

43


April 2015

44

Background

All new prescriptions for Hydrocodone combination products are Schedule II as of October 6, 2014

These drugs rank number 1 in utilization by volume for Idaho Medicaid

45

DUR Board Questions How will this effect other Opioid initiatives?

> 1 long-acting

> 1 short-acting

> 300 mg daily morphine equivalents

What shift in other agent utilization will be seen?

Tramadol

Acetaminophen with Codeine

46

8028

7012 6932

6277

7078 7058 7055

1750 1771 1678 1655 1771 1777 1823

504 699 611 558 637 677 618

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15

Hydrocodone Combination Products and Alternatives by Claim Count

Hydrocodone Combinations

Tramadol/Tramadol + APAP

APAP and Codeine

47

$156,215

$137,568 $143,492

$130,098

$145,991 $147,988

$179,478

$22,363 $22,500 $21,586 $21,118.45 $22,500.36 $22,997.04 $23,169.74

$6,630 $9,140 $8,163 $7,391.53 $8,206.91 $8,604.35 $8,055.70

$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000

$180,000

$200,000


Hydrocodone Combination Products and Alternatives by Expenditures



APAP and Codeine

48

6425

5828 5737

5331

5947 5888 5965

1546 1540 1457 1453 1543 1538 1615

472 639 558 512 584 618 566

0

1000

2000

3000

4000

5000

6000

7000


Hydrocodone Combination Products and Alternatives by Unique Recipients



APAP and Codeine

49

61.20

64.96

70.41 69.94 68.18

71.43 71.87

$19.27 $19.45 $20.55 $20.59

$16.16

$20.70

$25.35

12.96 13.95 14.21 14.29 13.90 14.23 13.83

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00


Hydrocodone Combination Product Prescription Characteristics

Average Quantity per Claim

Average Payment per Claim

Average Days Supply per Claim

50

Hydrocodone Compounds

51


Buprenorphine DUR

52

PMP Interconnect Search

More states have been added to the list (must select each individual state to search) – up to thirteen now including Idaho (new one from last quarter in Yellow)

Colorado Mississippi

Illinois Nevada

Indiana New Mexico

Kansas North Dakota

Michigan Ohio

Minnesota Utah

Buprenorphine DUR Identified all participants with at least one claim

paid for oral buprenorphine by Idaho Medicaid between 12/1/14 to 2/28/15. n=223

Ran Board of Pharmacy report for all of these participants to identify anyone who had received any other opioid with overlapping days of service and noted payment method (cash, Idaho Medicaid, other insurance).

53

Buprenorphine DUR

When Idaho Medicaid identifies patients on oral buprenorphine, they are blocked from payment for any other opioid.

54

Buprenorphine DUR

200

26

201

27

210

23

223

20

222

36

211

31

212

20

223

31

0

50

100

150

200

250

Total number of participants on oral buprenorphine

Participants who paid cash for an opioid while on oral

buprenorphine

2/1/2013 - 4/30/2013

6/1/2013 - 8/31/2013

9/1/2013 - 11/30/2013

12/1-2013 - 2/28/2014

3/1/2014 - 5/31/2014

6/1/2014 - 8/31/2014

9/1/2014 - 11/30/2014

12/1/2014 - 2/28/2015

55

Buprenorphine DUR

17

10

6

2 2 1 1

Other Opioids Dec 2014 – Feb 2015

hydrocodone

oxycodone

tramadol

hydromorphone

codeine

fentanyl patch

methadone

56

17

11

1

7

1 1 1 1

Other Opioids Jun – Aug 2014

hydrocodone

oxycodone

fentanyl patch

tramadol

hydromorphone

methadone

morphine

codeine

12

7

1

3

1 1 1

Other Opioids Sep – Nov 2014

hydrocodone

oxycodone

fentanyl patch

tramadol

methadone

morphine

codeine

Buprenorphine DUR

Called Suboxone Prescribers

Was prescriber aware of other opioids paid for with cash?

What was the consequence to the patient?

57

Buprenorphine DUR

23

4 4

0

5

10

15

20

25

MD Aware MD Not Aware No Call Back

# o

f p

ati

en

ts

Contacted Prescribers of Patients Who Paid Cash for Other Opioids

58

Buprenorphine DUR

59

4

9

5

5

MD Aware

Contacted us ahead of time

Aware and counseled patient

Aware - pt having surgery/kidney stones/car accident

Aware and already discharged patient from Suboxone program

Buprenorphine DUR

60

Feedback from prescribers

Prescribers are appreciative of the information provided

All prescribers are using the Idaho Board of Pharmacy PMP report

Buprenorphine DUR

61


Christopher Johnson PharmD

Pharmacy Service Specialist

62

Hepatitis-C Update Review of Jan-Mar 2014 Hepatitis-C treatment requests.

New FDA approved agents:

Harvoni (10/10/2014)

Combination of Ledipasvir (NS5A inhibitor) and Sofosbuvir (Nucleotide analog NS5B polymerase inhibitor)

Viekira Pak (12/19/2014)

Combination of Ombitasvir (NS5A inhibitor), paritaprevir (HCV NS3/4A protease inhibitor), ritonavir (protease inhibitor), and dasabuvir (non-nucleoside NS5B polymerase inhibitor)

63

64

65

66

67

68

Hepatitis-C Update Updated therapeutic criteria and prior Authorization form for newer agents.

• General guidelines for approval as a group instead of individual agents.

Questions/Comments?

69

Current Interventions/Outcomes Studies Foster children high utilizers

Ziprasidone multiple dosage strengths

Synagis

Continuous oral plus injectable AAP

DUR Annual Report – Other state highlights/comparison

ADURS Annual Meeting

70

Calendar Year 2014

71

72

Foster Children on Psychotropic Drugs 2014

Total Foster Children on

Psychotropic Drugs

High Utilizers * Percent High

Utilizers

Total Foster Children meeting criteria

2172 65 3%

Psychotropic Drug Claims

21,780 3,942 18%

Claims/Child 10 50 – 87 N/A

Total Cost Foster Children

$2,129,568 $ 432,935 20%

Cost/Child $ 989 (range $2-$25,467)

$ 6,660 (range $330 - $25,467)

N/A

* > 50 psychotropic drug claims during calendar year 2014 73

Age and Gender Characteristics for High Utilizers 2014

1 0

20

11

22

11

0

5

10

15

20

25

0-6 Male 0-6 Female 7-12 Male 7-12 Female 13-17 Male 13-17 Female

74

Comparison 2013 and 2014 2013 2014

High Utilizers 68 65

Percent High Utilizers 6% 3%

Psychotropic Drug Claims 7381 3942

Percent of Total Drug Claims 21% 18%

Claims per child 50-97 50-87

Average Cost per high utilizer child $ 6100 $ 6600

Range of Cost $ 71- $ 22,513 $ 330- $ 25,467

% 0-6 years old male 3% 2%

% 0-6 years old female 0 0


% 7-12 years old female 13% 17%


% 13-17 years old female 15% 17%

75

Comparison Individuals 2013 and 2014

Characteristic Number of Children

Children who had > 50 psychotropic claims in both 2013 and 2014

30

Children with > 50 psychotropic claims in 2014, but not in 2013

• Increase ranged from 3-53 more claims in 2014 • 3 were new to Medicaid in 2014

34

Children with > 50 claims in 2013, but < 50 in 2014 • Some no longer on Medicaid

37

76

Children with > 50 Psychotropic claims in both 2013 and 2014

Characteristic Number Range

Decrease in total claims 16 1-40 less

Increase in total claims 13 2-21 more

No change 1

77

78

Patient 001 16 year old male

Psychiatric Diagnoses 313.9: Unspecified emotional disturbance of childhood

296.33: Recurrent Major Depressive Disorder

311: Depressive disorder

V62.84: Suicidal Ideation

Other Diagnoses 278.00: Obesity

401.9: Hypertension

277.7: Dysmetabolic Syndrome

493.90: Asthma, Unspecified

79

Patient 001

Number of claims 2013: 87


Change in Claims: 0

Current Active claims/month: 3 -4

Currently receiving weekly mental health services

Monitoring labs completed: thyroid, CBC, comprehensive metabolic

80

Current Medications (001)

Medication Daily Dose

Guanfacine 3mg

Methyphenidate 27 mg

Oxcarbazepine 1200 mg

Hydroxyzine 50 mg

Montelukast 10 mg

Fluticasone 50 mcg

Ranitidine 300 mg

ProAir 90 mcg

Metformin 1000 mg

81

Prescribers (001) 5

3 family practice for non-mental health drugs

2 nurse practitioners for mental health drugs

82


Psychiatric Diagnosis

None listed

Other Diagnosis 278.00: Obesity

83

Patient 002



Change in Claims: +2

Current Active claims/month: 9 (2 for dose splitting)

No mental health services or labs in last 6 months

84



Trazodone 150 mg

Divalproex ER 750 mg

Quetiapine 75 mg

Olanzapine 15 mg

Clonidine 0.3 mg

Adderall 30 mg

Methylphenidate 55mg

85

Prescribers (002) 4

all nurse practitioners for mental health drugs

86


Psychiatric Diagnoses

314.01: ADHD

296.90: Episodic mood disorder

299.90: Pervasive Developmental disorder, unspecified

Other Diagnosis

783.41: Failure to thrive

87

Patient 003 Number of claims 2013: 74


Change in Claims: +7

Current Active claims/month: 6

No mental health services

Monitoring labs completed: thyroid, CBC, comprehensive metabolic, lipid panel

88



Clonazepam 4 mg

Clonidine 0.15 mg

Adderall 10 mg

Adderall XR 30 mg

Abilify 30 mg

Citalopram 20 mg

89

Prescribers (003) 2

Both pediatricians

90


Psychiatric Diagnoses 313.9: Unspecified emotional disturbance of childhood

314.01: ADHD

301.3: Explosive Personality (borderline personality disorder)

299.80: Pervasive developmental disorder

296.90: Episodic mood disorder

Other Diagnosis

- none

91

Patient 004



Change in Claims: -9

Current Active claims/month: 5


Monitoring labs completed: thyroid, CBC, comprehensive metabolic

92

Current Medications (004) Medication Daily Dose

Chlorpromazine 150 mg

Quetiapine 25 mg

Intuniv 4 mg

Focalin XR 15 mg

Trazodone 100 mg

On 10/3 was given concurrent prescriptions for Abilify, olanzapine and quetiapine.

93

Prescribers (004) 2

Both physician assistants

94


Psychiatric Diagnoses 299.00: Autistic disorder

314.01: ADHD

309.81: Post-traumatic stress disorder

299.80: Other specified pervasive developmental disorders

312.30: Impulse control disorder

Other Diagnosis 307.42: Persistent insomnia

95

Patient 005



Change in Claims: + 14

Current Active claims/month: 4-5


Monitoring labs completed: none

96



Citalopram 60 mg (40 + 20 mg)

Abilify 15 mg

Guanfacine 3 mg

Vyvanse 50 mg

Prazosin 2 mg

Hydroxyzine 50 mg

Ranitidine 300 mg

Cetirizine 10 mg

Montelukast 10 mg

Pantoprazole 40 mg

97

Prescribers (005)

2

1 nurse practitioner

1 physician assistant

98

Foster children high utilizers


99

Multiple Dosage Forms of Ziprasidone Prescribed Concomitantly

100

Usual maximum FDA approved daily dose for ziprasidone (Geodon) is 160mg.

Capsules available in the following strengths:

20mg

40mg

60mg

80mg


101

Baseline

Paid claims for oral ziprasidone between 9/1/2014 and 11/30/2014 were evaluated.

85 patients identified with two or more fills for two or more capsule strengths

66 (78%) on ≤ 160mg daily

19 (22%) on > 160mg daily


102

Paragraph in letter: The usual maximum recommended daily dosage for ziprasidone is

160mg (80mg twice daily). The DUR board is reviewing Idaho Medicaid participants who are receiving more than 160mg/day of ziprasidone using multiple capsule strengths. As of 3/1/15, multiple strengths of ziprasidone capsules will no longer pay at the pharmacy without prior authorization. During a recent review it was noted that your patient, $MEMBER NAME, has been receiving more than 160 mg/day of ziprasidone using multiple capsule strengths. If you feel that it is clinically justified for your patient to remain on multiple strengths of ziprasidone capsules, please submit a quantity override prior authorization request for review by the department. A copy of

this form is enclosed for your convenience.


103

DUR letter sent to prescribers of 19 patients on 1/14/2015.

As of 3/23/2015

9 - No response, still on same dose

2 - No response, but dose decreased to ≤ 160mg daily

3 - No response, but drug discontinued

4 - Quantity override request received

1 - Patient no longer eligible for Medicaid


104

Paid claims for oral ziprasidone between 1/1/15 and 3/8/15 were evaluated.

65 patients identified with two or more fills for two or more capsule strengths

48 on ≤ 160mg daily

17 on > 160mg daily

Nine repeat patients from 9/1/14 – 11/30/14

Eight new patients identified

Second round of DUR letters sent on 3/25/2015


105

6

4

1

6

0

1

2

3

4

5

6

7

180mg 200mg 220mg 240mg

Daily dose > 160mg, n=17 1/1/15 – 3/8/15

Patients


106

Plan:

Sent out two batches of DUR letters to prescribers of patients who were receiving > 160mg daily.

Magellan has created a new initiative to make therapeutic duplication for multiple capsule strengths of ziprasidone a “hard stop” edit. Same as was done for olanzapine on 6/17/2014.

Hard Stop for multiple dosages of ziprasidone was initiated on 4/1/2015.

Proactively entered duplicate therapy prior authorization for patients on ≤ 160mg daily

Feedback to date:


107


Synagis

131

81

As of 4-7-2015, 212 prior authorization requests have been processed

Approved

Denied

108

Only 12 requests denied because of new 2014 AAP criteria

Synagis

109

Idaho Medicaid is authorizing Synagis from Dec 1, 2014 to April 30, 2015 if patients meet criteria for a maximum of five doses.

Synagis Questions/Comments ???

110

Christopher Johnson PharmD

Pharmacy Service Specialist

111

Long Acting Injectable Antipsychotics (LAIA)

Idaho Medicaid is observing treatment of LAIA with oral long acting antipsychotics.

Evaluate the impact of this practice.

Guidelines are limited with LAIA recommendations

Commonly used in patients with non-compliance, frequent relapses or who pose a risk to others.

Recommendations to consider LAIA to any patient for whom maintenance antipsychotic treatment is indicated (BMC Psychiatry 2013, 13:340)

112

Aripiprazole (Abilify®, Abilify Discmelt ®, Abilify Maintena®) FDA approved indications:

Autistic disorder - Psychomotor agitation.

Bipolar disorder - Psychomotor agitation.

Bipolar I disorder, Adjunctive therapy with lithium or valproate.

Bipolar I disorder, Monotherapy, manic or mixed episodes.

Gilles de la Tourette's syndrome.

Major depressive disorder, Adjunctive treatment in patients receiving antidepressants.

Psychomotor agitation – Schizophrenia.

Schizophrenia.

113

114

115

116

117

Risperidone (RisperDal®, Risperdal® Consta ®) FDA approved indications:

Bipolar I disorder

Schizophrenia

Autistic disorder

Risperdal® Consta ® is approved for the treatment of schizophrenia or as monotherapy or as adjunctive therapy to lithium or valproate for the maintenance treatment of Bipolar I disorder.

118

119

120

121

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Paliperidone (Invega®, Invega® Sustenna ®)

FDA approved indications:

Schizoaffective disorder

Schizophrenia

Invega ® Sustenna ® is approved for the treatment of schizophrenia or schizoaffective disorder as monotherapy and as an adjunct to mood stabilizers or antidepressants.

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Injectable Atypical Antipsychotics

Use with oral paliperidone (Invega®) or with risperidone (RisperDAL®)

Concomitant use of Invega® Sustenna® with oral paliperidone or oral or injectable risperidone has not been studied. Since paliperidone is the major active metabolite of risperidone, consideration should be given to the additive paliperidone exposure if any of these medications are coadministered with Invega® Sustenna®.

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Continuous Oral Plus Injectable Atypical Antipsychotics Data suggest crossover use of oral and injectable

agents

Starting on oral agents and transitioning to injectable or vice versa.

Concurrent use of oral long acting atypical

antipsychotics and long acting injections is limited.

No guidelines for the concurrent use of oral and injectable use of the same agents.

Questions/Comments?

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Federal Fiscal Year 2013

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Background Each State Medicaid Program is required to submit an

annual report on the operation of its Medication DUR Program

Prescribing patterns

Cost Savings generated from DUR

Program operations

Adoption of new innovative DUR practices

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General Information Physician administered drugs : 10 states have

redesigned their MMIS systems to incorporate Physician Administered Drugs into their DUR criteria (prospective and retrospective)

DUR activities saved an average of 18% on drug cost savings/cost avoidance compared to the total drug spend

Range is 0-73%

Idaho is 14%

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Medication Therapy Management CMS Approval

Colorado

Florida

Iowa

Minnesota

Missouri

Oregon

Wisconsin

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Fraud, Waste and Abuse Detection

Identification of Fraud and Abuse –documented process

Beneficiary – all states but South Dakota

Prescriber Fraud – 38 states

Pharmacy Fraud – 34 states

Actions taken

Denying claims

Alerting Integrity or Compliance Unit to investigate

Referring to licensing Board or another governmental agency such as Attorney General, OIG, DEA

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Lock-in Criteria

49 states have Lock-in programs

Criteria

Number of controlled substances 41

Different prescribers of CS 47

Multiple pharmacies 47

Number days’ supply of CS 21

Exclusivity of short-acting opioids 11

Multiple ER visits 33

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Prescription Monitoring Programs

PDMP in all but one state (Missouri)

27 states have ability to query the database

Only 7 states require prescribers to access the patient history of the database prior to prescribing controlled substances

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Morphine Equivalent Daily Dose (MEDD) 9 states have set limits

including WA, OR, WY at 120

8 states have an algorithm in their POS system that alerts the pharmacy provider that the morphine equivalent daily dose prescribed has been exceeded

11 states give providers information on how to calculate the MEDD

3 states require that Pain Management providers be certified

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Psychotropic Drugs Second Generation Antipsychotics

KY: all require a diagnosis MO: Clinical consultant review for < 5 years SC: < 6 years requires psyche assessment, informed consent WI: Child and adolescent psychiatrists review and adjudicate

PAs

WA: Psychotropics not meeting thresholds (ex. 5 or more polypharmacy) require consult with contract Pediatric Mental Health experts

WY: Patient that exceed limits (too young, high dose, therapeutic duplication, > than 5 psychotropics ) are referred to Seattle Children’s Hospital for second opinion review

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Stimulants Stimulants in Adults

Not paid for in California

Delaware – must fail 2 long-acting before can get a short-acting

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Innovative Practices

Controlled substances

Mailing to Top Prescribers of Controlled Substances: CT

Biweekly High Dose Narcotic/Therapeutic Case Management Workgroup for complex narcotic cases: MA

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Children on Psychotropics

Dashboard: OR

Consult required: VA, VT

Atypical Antipsychotic Metabolic Monitoring: MD

Peer Review Program for mental health drugs: MD

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Statin Medication Therapy Management: ME

Provider Outreach/Academic Detailing: MA, MI

Online Provider Education Modules: TX

Live Provider Education: IL, MI

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Hemophilia Management: IL, MI, WA

Pharmacy Case Management: MT

Benzodiazepine restrictions: DE

Informed Consent on high risk or high dollar medications: DE

Prior authorization on drug shortages: IL

Prohibit Automatic Refills: IL

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(American Drug Utilization Review Society)

February 26-28, 2015

39 states sent representatives to this meeting.

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ADURS Annual Meeting Two speakers on hepatitis C

1. MD from Delaware

Background on disease state

Potential therapeutic targets in the HCV replication cycle

Review of current therapeutic treatment guidelines

His personal “possibly reasonable criteria for approval”

Included NOT treating patients unless they are drug abuse/alcohol abuse free for one year

Not treating patients with life expectancy less than one year

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ADURS Annual Meeting Two speakers on hepatitis C

2. PharmD from Massachusetts Medicaid

Reviewed first 500 patients with HCV who received treatment with the new agents

Clinical pharmacy service involvement

Review genotype and liver disease stage for appropriateness of therapy chosen

Check that approved patients actually filled their prescriptions

Require follow-up SVR at 12 weeks

Concerning that 31 of 380 patients who have completed therapy still have detectable viral load AFTER treatment has been completed

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ADURS Annual Meeting Delaware’s Limits on High Dose Immediate Release

Oxycodone

Instituted March 1, 2012

Oxycodone 30mg IR: 60 units per YEAR



Huge increase in number of prescriptions for short acting opioids

By Q3 2014 92% of all short acting opioids were for ≤ 60 pills/fill

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ADURS Annual Meeting National Association of Medicaid Directors

Pharmacy workgroup launched in 2013

Goal is to improve communication between CMS and state pharmacy administrators

Monitor legislation in Senate and Congress

Using Pharmacy Quality Measures in Medicaid DUR Programs

Measurement ALONE is not enough, must be part of quality improvement initiatives

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ADURS Annual Meeting CMS: A Federal Update of DUR in Medicaid

Discussed annual state DUR program survey

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ADURS Annual Meeting New Drugs 2015

Antibiotics: Dalvance, Sivextro, Orbactiv, Zerbaxa

Hepatitis C: Sovaldi, Harvoni, Viekira PAK

Allergies: Grastek, Ragwitek

CV: Zontivity

Sedatives: Belsomra

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ADURS Annual Meeting New Drugs 2015

Respiratory: Striverdi

Diabetes: Jardiance, Tanzeum, Trulicity, Afrezza

Constipation: Movantik

Anticoagulant: Savaysa

Nail fungus: Jublia

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ADURS Annual Meeting Pipeline Preview 2015

Oncology drugs approximately 1/3 of drugs in pipeline

Narcotics: abuse deterring agents are a high priority

Multiple sclerosis

Diabetes

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ADURS Annual Meeting Risk and Benefit of Concomitant Benzodiazepines and

Opiates

Speaker from University of Mass Medical School/Clinical Pharmacy Services

In patients who abuse opioids, 75% are also on benzodiazepines

Often started as prescriptions from two separate prescribers

Greater respiratory depression and increased euphoria when on both benzodiazepines and opiates

Usually wean off benzodiazepines first

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ADURS Annual Meeting Psychotropic Medication Monitoring Program for

Children in Texas Foster Care

Court authorizes DFPS or an individual to consent to medical care

If DFPS is authorized, a specific individual must be designated

May be live-in caregiver, emergency shelter staff, cottage parents in children’s home

Medical consenter must complete online training on informed consent

Medical consenter must participate in each medical appointment of child

154

ADURS Annual Meeting Psychotropic Medication Monitoring Program for

Children in Texas Foster Care

Children taking psych meds must be seen by prescriber every 90 days (minimum)

Mandatory review (peer-to-peer) with child psychiatrist if:

Four or more psychotropic medications prescribed concomitantly

Two or more stimulants or antidepressants or antipsychotics

Exceed maximum FDA approved dosing

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ADURS Annual Meeting Questions/Comments ???

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Proposed Studies for Next Quarter: Narcotics > 1 LAO

Antipsychotics in children and ER visits

Narcotics: short-acting > long-acting

Buprenorphine plus benzodiazepines

Atypical Antipsychotics without metabolic testing

Abilify multiple dosage strengths

Atypical Antipsychotics in children ≤ 6 years of age

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Narcotics > 1 LAO

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Antipsychotics in children and ER visits

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Request to consider DUR of prevalence of adverse effects associated with antipsychotics in Medicaid Pediatric population.

Hampton LM, Daubresse M, Chang H, Alexander G, Budnitz DS. Emergency Department Visits by Children and Adolescents for Antipsychotic Drug Adverse Events. JAMA Psychiatry. January 14,2015.(E1-E3)

Please refer to Research Letter in the Packet

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Data Collection Methods

(NEISS-CADES) National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance system (2009-2011) for emergency room visits for adverse events in adolescents.

National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys (2009-2010) for outpatient prescriptions visits

Results reported about 6.6% of emergency room visits are related to atypical antipsychotics in children.

Unable to determine chronic disorders (metabolic side effects) with data.

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Idaho Medicaid reviewed the study to determine if a similar report could be obtained in the Idaho Medicaid pediatric population.

Limitations with data source collection

Available: Drug data and demographics

Problematic: Availability of collection of adverse events related to drug use.

Question/Comments?

162

Narcotics: short-acting > long-acting

163

Buprenorphine plus benzodiazepines Per Suboxone package insert: Suboxone sublingual film

should be prescribed with caution to patients taking benzodiazepines or other drugs that act on the CNS, regardless of whether these drugs are taken on the advice of a physician or are being abuse/misused.

How many oral buprenorphine patients are on concomitant benzodiazepines or controlled sedatives?

Are these concomitant medications prescribed by the buprenorphine prescriber?

164

Atypical Antipsychotics without metabolic testing

165

Abilify multiple dosage strengths

166

Atypical Antipsychotics in children ≤ 6 years of age

167

Prospective DUR Report History Errors:

• DD – drug-to-drug

• PG – drug to pregnancy

• TD – therapeutic duplication

• ER – early refill

• MC – drug-to-disease

Non-History Errors:

• PA – drug-to-age

• HD – high dose

• LD – low dose

• SX – drug-to-gender

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Prospective DUR Report Idaho Medicaid Program

ProDUR Message Report

March 2015

ProDUR ProDUR Message Message

Message Severity Count Amount

Drug To Drug 1 2,019 $616,589.22

2 17,070 $5,729,811.60

3 83,743 $17,016,279.58

9 8 $134.76

Drug To Gender 1 199 $31,266.48

2 2,084 $245,318.67

Drug To Known Disease 1 76,219 $11,160,515.45

2 263,457 $62,624,551.13

3 338,409 $76,792,225.01

Drug To Pregnancy 1 11 $44.00

2 9 $149.01

A 8 $98.05

B 58 $11,317.81

C 132 $14,170.94

D 13 $116.13

X 13 $441.45

Duplicate Therapy 0 131,074 $49,716,856.25

Min Max 0 33,546 $7,326,514.04

Too Soon Clinical 0 23,816 $8,002,753.47

ALL 971,888 $239,289,153.05

Total Number of Claims with Messages 237,585

Average ProDUR Message Per Claim 4.09

169

DUR Spring Newsletter Clinical Alerts and Quarterly Trends

Brainstorm for new topics

170

DUR Board Meeting April 16, 2015

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Documents

Idaho Medicaid Drug Utilization Review Program · 2015-04-16 · Urine drug screening ... This will routinely include drugs in these four categories: 1) Analgesics 2) Antinauseants