Idaho Medicaid Drug Utilization Review Program
10 October 2013
1
Follow-up to Previous ReviewsNystatin/Triamcinolone Combo DUR (re-
run summer months to compare to previous, as well as potent steroid combos – these fall in combo rule so no claims)
Suboxone and Participants Paying Cash for Other Opioids
Hepatitis C DURGeo‐Mapping Analysis
Utilization of Narcotic Analgesics (HIC3 = H3A) 16YO+
2
Nystatin/Triamcinolone Combo DUR
What are the utilization numbers on the various nystatin/triamcinolone combo products?
3
Nystatin/Triamcinolone Combo DUR
Cream Ointment0
20406080
100120140160180200
161
39
123
24
175
44
138
24
nystatin/triamcinolone products
Recipients 1/1/13 - 4/30/13
Recipients 5/1/13 - 8/31/13
Claims 1/1/13 - 4/30/132
Claims 5/1/13 - 8/31/13
4
Nystatin/Triamcinolone Combo DUR
betamethasone products
clotrimazole products0
200
400
600
800
1000
1200
1400
427
1119
532
1254
Claims data from 1/1/2013 through 4/30/2013
recipientsclaims
5
Nystatin/Triamcinolone Combo DUR
Questions/Comments ???
6
Buprenorphine DURSuboxone and Participants Paying Cash for
Other Opioids(includes Suboxone film, Suboxone tablets, buprenorphine/naloxone tablets, buprenorphine
tablets)
7
Buprenorphine DUR Follow-Up Identified all participants with at least one
claim paid for oral buprenorphine by Idaho Medicaid between 6/1/13 and 8/31/13. n=201
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).
8
Buprenorphine DUR Follow-Up
050
100150200250 200
26
201
27
2/1/2013 - 4/30/20136/1/2013 - 8/31/2013
9
Buprenorphine DUR Follow-Up
20
7
31
Other Opioids
hydrocodoneoxycodonecodeinefentanyl patch
10Note: Adds up to more than 27 as some patients paid cash for multiple opioids.
Buprenorphine DUR Follow-Up 2 patients had both Suboxone and another
opioid prescribed by the same doctor. The other 25 patients had different prescriber(s) for the other opioids.
11
Buprenorphine DUR Follow-Up
1 other prescriber
2 other prescribers
3 other prescribers
8 other prescribers
0
5
10
15
20
25
20
31 1
Number of other prescribers
# o
f p
ati
en
ts
12
Buprenorphine DUR Follow-Up Case Study:
Patient identified during DUR done the previous quarter and payment was blocked for Suboxone after it was filled in June. Between June through August 2013, patient filled hydrocodone 18 times, oxycodone 4 times, and codeine once. This patient obtained prescriptions from 9 different prescribers and used 9 different pharmacies during this three month period. Letters were sent to all 9 prescribers and she is in the process of being enrolled into the lock-in program. Prescribers included two ER physicians, 2 internal medicine physicians, 2 family medicine physicians, an orthopedic surgeon, an otolaryngologist, and a physician’s assistant. At this time, Idaho Medicaid has blocked payment for Suboxone as well as other opioids. She is paying cash for all of these drugs and is getting medication filled every several days. 13
Buprenorphine DUR Follow-Up Called Suboxone Prescribers
Was prescriber aware of other opioids paid for with cash?
What was the consequence to the patient?
14
Buprenorphine DUR Follow-Up
02468
87 7
21
# o
f p
atie
nts
15
Buprenorphine DUR Follow-Up
0
2
44
21 1
Called prescriber who was unaware that patient had paid cash for other opioids
(n=8)
# of p
atien
ts
16
Buprenorphine DUR Follow-Up
0
2
4
1
4
2
Called prescriber who was aware that patient had paid cash for other opioids
(n=7)
# of p
atien
ts
17
Buprenorphine DUR Follow-Up
Suboxone therapy has been discontinued New Suboxone start with single opioid fill on same day as starting Suboxone or within a few
days
0
1
2
3
4
5
4
3
Did not call prescriber (n=7)
18
Buprenorphine DUR Follow-Up
19
Unable to contact one prescriber (n=2) Left three voicemail messages and sent letters
on two of his patients that had paid fills for hydrocodone as well as Suboxone. Blocking payment to Suboxone one week after letters sent.
Buprenorphine DUR Follow-Up
20
All prescribers were appreciative of the information Idaho Medicaid provided to them.
Future Plans The department plans on running routine
board of pharmacy reports every 3 to 6 months on all Suboxone patients.
Hepatitis C DURTotal Medicaid patients who received HepC
treatment:53 (36 Incivek, 17 Victrelis)
Letters were sent to prescribers in June 2013 and for those who did not respond sent again August 2013
Requested information returned from prescribers:46 (29 Incivek, 17 Victrelis) (13% no response
from provider) 21
Hepatitis C DUR1A-10, 1B-10, Type 1 unspecified-9
1A-10, 1B-3, Type 1 unspecified-4
1A35%
1B34%
Type 1-Unspecified31%
Incivek Genotypes
1A59%1B
18%
Type 1-Unspecified24%
Victrelis Genotypes
22
Hepatitis C DUR
23
Incivek Victrelis0
5
10
15
20
25
6
3
22
12
12
Previous Dual-Therapy Treatment Received
Yes No
Unknown# P
ati
en
ts
Hepatitis C DURAll patients from both groups who reported
back underwent triple therapy with Pegylated Interferon and Ribavirin
No patients who reported back had an HIV co-infection
Initial Viral LoadsLowest – 18,029, Highest – 69,000,000, Average –
5,777,694Info not received for 5 patients (11%)
24
Hepatitis C DUR
25
Incivek Victrelis0
5
10
15
20
25
30
27
13
1 11
3
HCV Levels After Treatment
Not Detected
High Viral Load
Unkown
# P
ati
en
ts
Hepatitis C DUR
26
Incivek Victrelis0
1
2
3
4
5
6
7
8
9
10
9
3
7
4
9
44
6
Completed Successful Therapy
Yes
No
In Progress
Unknown
# P
ati
en
ts
Hepatitis C DURYes-9, No- 6 d/t SEs & 1 d/t Non-response, In progress-9, Info not provided-4
Yes-3, No-3 d/t SEs & 1 d/t infection, In progress-4, Info not provided-6
27
31%
24%31%
14%
% Completion of Incivek Therapy
Yes No In Progress Unknown
18%
24%24%
35%
% Completion of Victrelis Therapy
Yes No In Progress Unknown
Hepatitis C DUR
28
Incivek Victrelis0
1
2
3
4
5
6
7
1
0
6
3
0
1
Reason for Failed Therapy
Non Responder (9%)
Side Effects (82%)
Co-Morbid Condition (9%)
# P
ati
en
ts
Hepatitis C DURNon-responder-1, Side effects-6,Co-Morbid Condition-0
Non-responder-0, Side effects-3,Co-Morbid Condition-1
Non Responder14%
Side Effects86%
%Failed Therapy With Incivek
Side Effects75%
Co-Morbid Condition25%
%Failed Therapy With Victrelis
29
Hepatitis C DURQuestion/comments ???
30
Geo Mapping Analysis‐Utilization of Narcotic Analgesics (HIC3 = H3A) 16 YO+
Prepared by MMA 6/13/2013 originally Age specific prepared by MMA 8/5/2013
Please refer to handout in Packet
31
Current Interventions/Outcomes StudiesUse of Psychotropic Medications in Foster
Children – Next Steps2012 Data Analysis Update
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
32
Current Interventions/Outcomes StudiesNon-Preferred Growth HormoneLevofloxacinOral ketoconazoleImitrex Pens
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Use of Psychotropic Medications in Foster Children: Next Steps
51
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior authorization criteria instituted 01-
01-13 for immune globulin (intravenous and subcutaneous) on both the medical side (J-code medical claims) and on the pharmacy side.
52
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectTherapeutic criteria
1. FDA approved indications such as hypogammaglobulinemia (require laboratory confirmation of diagnosis plus follow-up IgG levels while on therapy) and inflammatory demyelinating polyradiculoneuropathy.
2. Other indications that have evidence to support their usage (e.g. Guillain-Barré syndrome).
3. Use ideal body weight or adjusted body weight (ideal body weight plus 50% of the difference between actual body weight and ideal body weight) in obese patients.
4. Round dosages to +/- 5% (note: literature states up to +/- 10%) to use whole vials and reasonable dosages. We discovered during 2012 DUR project that some pharmacies were using many vial sizes to give exact dose – examples would be 57.5gm using two 200ml vials, one 100ml vial, one 50ml vial, one 20ml vial, ½ of 10ml vial.
53
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims
J1459 PrivigenJ1557 GammaplexJ1559 HizentraJ1561 Gamunex-C or GammakedJ1566 Immune Globulin IntravenousJ1568 OctagamJ1569 Gammagard
54
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 20130
102030405060708090
10088
29
Number of paid claims (medical)
55
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 20130
5
10
15
20
25
20
8
Number of Unique Patients (medical)
56
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 2013$0
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
$160,000 $148,765
$52,368
$$ (medical)
57
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims
Annualized Cost Savings since prior authorization implementation: $192,794
67% reduction in claims60% reduction in number of unique patients65% reduction in expenditure
58
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims
20 Patients with Medical Claims in 2012 5 of these patients continued on IVIG in 2013
All 5 patients had immunodeficiency diagnoses 15 of these patients with no paid medical claims (or
pharmacy claims) in 2013
59
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
6
4
2
3
Summary (medical)
Diagnosed with hypogammaglobulinemia and received 1-4 doses of IVIG in 2012 but never received prior authorization request to con-tinue therapy in 2013
No longer eligible for Idaho Medicaid or became Medicare/Medicaid dual
Billing error - meant to bill for phenergan not Privigen (IVIG)
Completed course of therapy in 2012 (congen-ital hemochromatosis, optic neuritis, heart transplant)
60
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims – Prior Authorization Issue
Unbeknownst to us until July 2013, prior authorization for medical claims was only instituted for drugs administered in physician offices and not for drugs administered in outpatient settings such as an infusion clinic where the majority of patients would receive this drug.
61
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims – Prior Authorization Issue
Only 1 out of 8 patients who received immune globulin as a medical claim between January – June 2013 had a prior authorization request submitted.
Patient descriptions of the 7 patients without prior authorization requests who still had paid claims in 2013: CVID – 5 patients infantile spasms – 1 patient pregnant – 1 patient (don’t know indication for
IVIG)
None of these patients are currently receiving any more IVIG so their prescribers were not contacted for additional information.
62
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims – Prior Authorization Issue
Even though medical claims would still have paid at medical clinics without prior authorization, the number of patients and number of claims dropped substantially from 2012 to 2013 most likely due to the notification to providers that prior authorization was going to be required effective 01-01-2013.
63
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 201370
75
80
85
90
95
100 98
82
Number of claims (pharmacy)
64
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 201310
11
12
13
14
15
11
13
Number of Unique Patients (pharmacy)
65
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 2013$230,000
$240,000
$250,000
$260,000
$270,000
$280,000
$290,000
$300,000 $290,814
$251,653
$$ (pharmacy)
66
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPharmacy Claims
No individual patient had claims paid as both medical and pharmacy claims.
9 of 11 patients who received IVIG in 2012 continued therapy in 2013 with prior authorization approval. One patient on IVIG in 2012 died in 2012. Another patient on IVIG in 2012 switched over to Medicare in December 2012.
67
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPharmacy Claims
17% reduction in claims18% increase in number of unique patients
(two more patients)13% reduction in expenditure
68
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 20130
20406080
100120140160180200 186
111
Number of claims (medical and pharmacy claims)
69
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 20130
5
10
15
20
25
30
3531
21
Number of Unique Patients (medical and pharmacy claims)
70
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project
Jan - Jun 2012 Jan - Jun 2013$0
$50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000
$439,579
$304,021
$$ (medical and pharmacy claims)
71
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical and Pharmacy Claims Combined
40% reduction in claims32% reduction in number of unique patients31% reduction in expenditure
Annualized cost savings since prior authorization requirement instituted January 1, 2013: $271,116
72
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior Authorization Requests Received
Between January – June 2013Total of 26 requests – 25 were approved.The one denial was for IVIG weekly for a child with
encephalitis – no evidence provided to support efficacy for this indication.
14 approvals with paid claims (medical and pharmacy) 13 approvals – paid pharmacy claims 1 approval – paid medical claims
11 approvals with no paid claims
73
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior authorization approvals with no paid
claimsIdaho Medicaid no longer payor: 2Just approved June 2013 with no paid claims yet as
of 6-30-13: 2Requested prn low IgG levels (ITP, s/p liver
transplant) with no paid claims: 2Requested for hypogammaglobulinemia but no paid
claims: 3Single dose approved for ITP but never billed to
Medicaid: 1Myasthenia gravis patient - 1 74
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior Authorization Example - #1
Specialty Pharmacy insisting on using exact mg dose of 1000mg/kg in an obese patient with dose being adjusted every month as patient was gaining weight. The supporting documentation that the pharmacy provided stated that adjusted body weight should be used (ideal body weight plus 50% of the difference between actual and ideal body weight if patient was obese) and that doses could be rounded +/- 10% to use whole vials. Physician was contacted by phone and agreed to using both adjusted body weight and rounding dose to whole vials. 75
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectExample - Rounding doses in obese
patientsIdeal body weight = 60kgActual body weight = 100kgAdjusted body weight = 80kgCost savings when using adjusted body weight
for 1gm/kg/dose monthly: $29,114 per year per patient. Total cost of therapy is still $116,448 per year per patient.
76
Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior Authorization Example - #2
N.P. prescribing high dose IVIG (500mg/kg/daily for 4 days every 4 weeks) and wanting to shorten frequency to every 3 weeks in myasthenia gravis patient who was very symptomatic. N.P. agreed to decrease IVIG dose to usual dose of 500mg/kg monthly and increase oral medications instead. Prescriber’s rationale for wanting to increase IVIG was that patient had a Staph infection and was having difficulty walking. Patient was also on a contra-indicated drug (beta blocker) for a myasthenia gravis patient as well as on lots of sedating medications that could affect walking (methadone, oxycodone, diazepam, diphenhydramine, and carisoprodol).
77
Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectQuestions/Comments ???
78
Non-Preferred Growth Hormone
79
Preferred Growth HormonesNorditropin, Nutropin, Nutropin AQ
Non-Preferred Growth HormonesGenotropin, Humatrope, Omnitrope, Saizen,
Serostim, Tev-Tropin, Zorbtive
Non-Preferred Growth Hormone
Growth Hormone Product05
1015202530354045 39
119
41
POS Claims 5/25/2013 through 8/25/2013
Norditropin*GenotropinNutropin*HumatropeOmnitrope
# o
f re
cip
ien
ts
80
* preferred products
Non-Preferred Growth Hormone
12
1
11
Prescribers
Endocrinologists
P.A. at Endocrinology Clinic
Nephrologist
P.A. (located in Missoula, Mt but prior auth request came from endocrinologist in Idaho)
81
Non-Preferred Growth Hormone
Each endocrinologist prescribes multiple different growth hormone products so his/her office is familiar with multiple product lines and devices from the different pharmaceutical companies. The actual growth hormone medication is exactly the same.
82
Non-Preferred Growth Hormone
Potential Cost SavingsSubstantial cost savings will be achieved by
Idaho Medicaid when patients previously on non-preferred growth hormone products are switched over to preferred growth hormone products.
83
Non-Preferred Growth Hormone
Reviewed profiles of 16 patients on non-preferred growth hormone products.9* – growth hormone product was
preferred when first approved; grandfathered ever since
2 - Medicaid is secondary insurance and only paying a small co-pay
84
Non-Preferred Growth HormoneReviewed profiles of 16 patients on non-
preferred growth hormone products.2* – Started on a preferred agent but then
switched to a non-preferred agent (stinging noted with one, can’t call up the old faxes on the other one for the details of why switched)
1 – database error so claim paid for a non-preferred agent even though prior authorization for the medication had been denied
85
Non-Preferred Growth HormoneReviewed profiles of 16 patients on non-
preferred growth hormone products.2 – no clear notes on why started a non-
preferred agent; drug has been grandfathered for years (one patient started therapy in 2003 and the other in 2004*). Not sending a letter to the patient who started therapy in 2003 as medication is up for renewal in October 2013 so will deal with this issue then (and anticipate that growth hormone therapy may be discontinued soon due to patient’s age).
86
Non-Preferred Growth Hormone
Letter sent to prescribers of grandfathered non-preferred growth hormone patients.
Please refer to packet for a copy of the letter sent to the prescribers
87
Non-Preferred Growth Hormone9* – growth hormone product was
preferred when first approved; grandfathered ever sinceSwitched to preferred agent –4Renewal request received for non-preferred
agent – sent back fax to prescriber stating that growth hormone would be approved but patient needed to be switched to a preferred agent; still waiting for response back – 2
NO response yet to letter asking prescriber to switch – 3
No response back from all other letters sent
88
Non-Preferred Growth Hormone
Questions or Comments ???
89
Levofloxacin DURBased on the recommendations from the DUR
Board at the August 2012 meeting, the minimum age was changed from 16 years down to zero on 11/1/2012 for levofloxacin.
90
Levofloxacin DUR
Recipients Claims0
5
10
15
20
25
30
811
22
27
Recipients 0 to 15 years old
1/1/2012 to 6/30/20121/1/2013 to 6/30/2013
91
Levofloxacin DUR
Recipients Claims0
200
400
600
800
1000
1200
1400
821
1023951
1169
Recipients 16 years of age and older
1/1/2012 to 6/30/20121/1/2013 to 6/30/2013
92
Levofloxacin DURWhile the number of claims and number of
patients has increased somewhat since the age restriction was removed, claims for children < 16 years old remain a very small percentage of total paid claims for levofloxacin.
27 paid claims for 22 unique patients aged 0-15 years between 1-01-2013 and 6-30-2013Diagnoses on following slides
93
Levofloxacin DURDiagnoses
Pneumonia – 4 patients 15 year old, only antibiotic prescribed 2 year old with trache, one previous antibiotic tried 9 year old, three previous antibiotics tried 2 year old with trache, only antibiotic prescribed
CF – 3 patients (one with 4 paid claims)Tracheitis – 3 patients with CLD with
tracheostomies (one with 3 paid claims)
94
Levofloxacin DURDiagnoses
Bronchitis – 2 patients (15 year old; 10 year old with chronic lung disease s/p Augmentin)
URI – 2 patients (13 year old s/p other antibiotic; 4 year old s/p other antibiotic)
UTI – 2 patients (11 years old, chronic kidney disease, s/p other antibiotics; 15 years old, s/p other antibiotic)
Pharyngitis – 1 patient (11 years old)Typhoid fever – 1 patient (12 years old)
95
Levofloxacin DURDiagnoses
Orchitis – 1 patient (15 years old)Open wound/fracture – 1 patient (15 years old)Sinusitis – 1 patient (12 years old, s/p 3 other
antibiotics tried)Otitis media – 1 patient (1 year old, s/p 3 other
antibiotics tried)
96
Levofloxacin DURQuestions or comments???
97
Oral Ketoconazole DUROn July 26, 2013 the U.S. Food and Drug
Administration (FDA) released a safety announcement regarding the safe use of oral ketoconazole tablets due to potentially fatal liver injuries, adrenal problems, or drug interactions.
A copy of the Drug Safety Communication handout is available in your packet.
98http://www.fda.gov/downloads/Drugs/DrugSafety/UCM362444.pdf
Oral Ketoconazole DURA report of the paid pharmacy claims for
Idaho Medicaid was run for the time period of 4/26/2013 to 7/26/2013 for oral ketoconazole tablets.
Results31 patients33 claims (one patient had 3 paid claims)
99
Oral Ketoconazole DUROnly 3 patients currently on oral
ketoconazole as of 7/26/13
1. 9 year old male who has been on ketoconazole continuously since January 2011. Diagnosis in electronic profile is unspecified immunity deficiency. His prescriber was sent a letter asking for diagnosis and therapeutic justification for the medication. A copy of the FDA Safety Announcement was included with the letter. Continued on next slide 100
Oral Ketoconazole DUR1. 9 year old male: Did not receive a response to
DUR letter. However, received a prior authorization request on 8-16-13 which was approved in error by a pharmacy technician as a renewal as patient had been on the medication. This error was caught in September 2013 when reviewing patient profiles for this DUR project. Prior authorization for this medication has now been denied with new information faxed back to prescriber and dispensing pharmacy (claim did pay for this medication in September 2013).
101
Oral Ketoconazole DUR1. 9 Year old male:
The information that was on the 8-16-13 prior authorization request stated the diagnosis as GI candidiasis for a patient with “low NK cell and abnormal hyper-sensitivity.”
There has been no response to the September prior authorization denial.
102
Oral Ketoconazole DUR2. 2 year old patient who had a paid claim for 28
days of oral ketoconazole on 7/2/2013 who also had a paid claim for topical ketoconazole on the same day. Not sending a letter as assuming for a topical infection and therapy should be completed soon. No more claims run for oral ketoconazole.
3. 12 year old with a paid claim for 30 days of oral ketoconazole on 7/16/2013. No diagnoses in electronic profile corresponding to oral ketoconazole. Not sending a letter. Will wait and see if prescription is refilled. No more claims run for oral ketoconazole. 103
Oral Ketoconazole DURThe other 28 patients had a single claim paid
for oral ketoconazole with days of service ranging from 2 to 30.1-7 days: 13 patients8-14 days: 7 patients≥15 days: 8 patients
104
Oral Ketoconazole DURInstituted prior authorization requirement on
8/2/2013. Prior to this date, claims would just pay at the pharmacy.
Will track how many prior authorization requests received and how many approved vs. denied
105
Oral Ketoconazole DUR
106
Series10
1
2
3
4
1
3
PA Requests since 8/2/2013
PA ApprovedPA Denied
Oral Ketoconazole DURDenied Prior Authorization Requests
1. Tinea corporis with failure of prednisone and cephalexin
2. Onychomycosis with failure of nystatin cream
107
Oral Ketoconazole DUR
patients claims0
1
2
3
4
5
6
7
8
98 8
2 2
Pharmacy POS paid claims
9/1/2012 - 9/29/20129/1/2013 - 9/29/2013*
108*one claim initially ran as Qty #4 for 4 day supply and claim denied for PA, pharmacy then ran through with emergency override codes and a qty#4 for 3 day supply
Oral Ketoconazole DURQuestions or Comments ???
109
Imitrex Pens DUR
110
Imitrex Pens DUR
111
Paid Claims for injectable Imitrex (sumatriptan) between 2/1/2013 – 7/31/201356 unique patients165 total claims$82,597 paid at POS
Imitrex Pens DUR
112
cartridges only pen x 1 then cartridges
single fill of pen
multiple pens filled
0
5
10
15
20
25
20
8
12
16
Claims from 2/1/13 – 7/31/13
Imitrex Pens DUR
113
2 pe
ns
3 pe
ns
4 pe
ns
5 pe
ns
6 pe
ns
8 pe
ns
9 pe
ns
2 pe
ns +
1 car
trid
ge
3 pe
ns +
1 car
trid
ge0
1
2
3
4
5
16 patients with multiple pens filled
# o
f p
ati
en
ts
Imitrex Pens DUR
114
Wal
gree
ns
Sav-
on
Ridle
y's
Fred
Mey
er
Broul
im
Ont
ario
Rx-00
1
Unk
nown
0
2
4
6
8
Pharmacies filling multiple pens 2/1/13 – 7/31/13
Imitrex Pens DUR
115
Letters were sent out to pharmacies filling pens more than once in six months.
A copy of the letter is included in the packet
Questions or comments ???
Proposed Studies for Next Quarter:P&T Committee Narcotic Analgesic
Studies – Next StepsUse of Psychotropic Medications in Foster
Children – Next StepsTamiflu/Influenza Vaccine DURUloric and Colcrys DURAntipsychotic Indication Evaluation- Hold
for Future
116
P&T Committee Narcotic Analgesic Studies – Next Steps
117
Use of Psychotropic Medications in Foster Children The U.S. Government Accountability Office
released the results from a study that they performed examining the rates of psychotropic medications for foster and nonfoster children in 2008.
It was determined that HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions.
118
Foster Children Psychotropic Drugs Red Flags
7/18/2013
119
Red FlagsFive (5) or more psychotropic medications prescribed
concomitantly (reviewed August 2012)Two (2) or more concomitant antidepressants
(reviewed October 2013)Two (2) or more concomitant antipsychotic
medications (current)Two(2) or more concomitant stimulant medications
long-acting plus short-acting okThree (3) or more concomitant mood stabilizer
medicationsPsychotropic polypharmacy (2 or more agents) for a
given mental disorder prescribed before utilizing psychotropic monotherapy 120
121
Implementation of Red Flags
Retroacti
ve Evaluatio
n
Identify outliers
Profile
Review
DUR Board Intervention• Targ
eted education
Re-evaluation• indi
viduals
• overall
Further
Action
Point of service edits• Inform
ational (soft) – pharmacist override
• Hard Stop
ADHD Drugs Anti-depressants Mood Stabilizers Atypical Antipsychotics0%
5%
10%
15%
20%
25%
30%
35%
40%
36%
23%
13%
21%
9%
6%
0%
4%
Percent of Foster and Non-Foster Children Psychotropics by Drug Class
Calendar Year 2011
% Foster Children% Non-foster Children
Total foster =2785Total Non-Foster = 106,024
122
123
Use of Psychotropic Medications in Foster Children: Next Steps
124
Tamiflu/Influenza Vaccine DUR
125
Uloric and Colcrys DUR
126
Antipsychotic Indication Evaluation- Hold for Future
127
Prospective DUR ReportHistory 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
128
Prospective DUR ReportIdaho Medicaid ProgramProDUR Message Report
August-13
ProDUR ProDUR Message MessageMessage Severity Count Amount
Drug To Drug 1 1,618 $515,012.15 2 14,344 $2,509,235.49 3 72,191 $14,625,291.32Drug To Gender 1 177 $33,523.42 2 2,530 $318,273.49Drug To Known Disease 1 72,327 $11,171,612.78 2 255,198 $50,785,564.33 3 313,531 $59,952,053.52Drug To Pregnancy 1 29 $260.80 2 6 $445.83 A 3 $34.95 B 69 $5939.85 C 124 $9849.41 D 6 $37.46 X 2 $43.89Duplicate Therapy 0 115,769 $26,336,886.92Min Max 0 30,794 $4,989,431.70Too Soon Clinical 0 21,579 $7,832,898.27
ALL 900,297 $179,086,395.58 Total Number of Claims with Messages 216,998 Average ProDUR Message Per Claim 4.15
129
DUR Fall NewsletterCopy of Summer Newsletter in packetBrainstorm for new topics
130
Medicaid Update
131