Idaho Medicaid Drug Utilization Review Program 18 July

  • Slides: 90
Download presentation
Idaho Medicaid Drug Utilization Review Program 18 July 2013 1

Idaho Medicaid Drug Utilization Review Program 18 July 2013 1

Follow-up to Previous Reviews Botulinumtoxin DUR Hydrocodone/APAP DUR Nystatin/triamcinolone Combo DUR 2

Follow-up to Previous Reviews Botulinumtoxin DUR Hydrocodone/APAP DUR Nystatin/triamcinolone Combo DUR 2

Botulinumtoxin DUR Only payable on the medical side (not self‐ administered and not safe

Botulinumtoxin DUR Only payable on the medical side (not self‐ administered and not safe for patient to “brown bag” to physician’s office). Prior authorization was instituted 7/1/2013. Before June 2013: Prior authorization requests received were returned to prescriber with a note that prior authorization was not required at this time but would be required starting 7/1/13. 3

Botulinumtoxin DUR Starting June 1, 2013: Prior authorization requests were processed. Approvals were dated

Botulinumtoxin DUR Starting June 1, 2013: Prior authorization requests were processed. Approvals were dated 7/1/13 with a note that prior to July, prior authorization was not required. Denials were sent back with an explanation of why request was denied. Claims still paid through 6/30/13. 4

Botulinumtoxin DUR Chronic daily headaches/migraines New prior authorization form specifically for Botox for chronic

Botulinumtoxin DUR Chronic daily headaches/migraines New prior authorization form specifically for Botox for chronic daily headaches/migraines was written and posted on the website in June 2013. Letter was sent in June with a copy of this prior authorization form to the Boise physician that was prescribing and administering the majority of Botox for this indication. 5

Botulinumtoxin DUR Botox for indications other than chronic daily headaches/migraines Another prior authorization form

Botulinumtoxin DUR Botox for indications other than chronic daily headaches/migraines Another prior authorization form was created for all other indications. 6

Botulinumtoxin DUR Therapeutic criteria for chronic daily headaches/migraines 1. At least 15 days per

Botulinumtoxin DUR Therapeutic criteria for chronic daily headaches/migraines 1. At least 15 days per month 2. At least four hours per day (on average) 3. Prophylactic medication tried and failed 4. Abortive medications (e. g. triptans) filled monthly for at least 3 months 7

Botulinumtoxin DUR Documentation provided by prescribers has dramatically improved after feedback from Idaho Medicaid

Botulinumtoxin DUR Documentation provided by prescribers has dramatically improved after feedback from Idaho Medicaid on what information is needed. Prescriber is now sending us a “Chronic Daily Headache” two page data collection sheet that the patient fills out. Majority of requests received for this indication have been approved. For new patients, two injections (12 weeks apart) are approved. This duration was chosen as in the licensing trial, reduction in headache frequency was seen by this length of time. 8

Botulinumtoxin DUR For patients who have already received one dose prior to 7/1/13, a

Botulinumtoxin DUR For patients who have already received one dose prior to 7/1/13, a second dose will be approved if the patient meets therapeutic criteria. For patients with a positive response who have already received two or more doses, therapy will be approved for six months. 9

Hydrocodone/APAP DUR What are the utilization numbers on the various hydrocodone/APAP products? 10

Hydrocodone/APAP DUR What are the utilization numbers on the various hydrocodone/APAP products? 10

Hydrocodone/APAP DUR GCN Seq Brand Name Number (GSN) Strength Desc 60338 5 MG-300 MG

Hydrocodone/APAP DUR GCN Seq Brand Name Number (GSN) Strength Desc 60338 5 MG-300 MG 39 43 4. 26 Q 06 $1. 41 7. 5 -300 MG 20 22 2. 85 Q 06 $1. 55 5 MG-325 MG 6, 149 9, 425 3. 98 Q 06 GAAC=$0. 14 7. 5 -325 MG 2, 267 4, 273 3. 75 Q 06 GAAC=$0. 17 10 MG-325 MG 4, 500 12, 591 4. 24 Q 06 GAAC=$0. 15 7 7 1. 96 Q 06 GAAC=$0. 13 2, 230 3, 291 3. 78 Q 06 GAAC=$0. 05 7. 5 -500 MG 879 1, 591 3. 65 Q 06 GAAC=$0. 09 10 MG-500 MG 198 506 3. 74 Q 06 GAAC=$0. 14 10 MG-650 MG 12 29 2. 99 Q 03 GAAC=$0. 10 10 -660 MG 7 19 2. 36 Q 03 GAAC=$0. 16 7. 5 -750 MG 72 110 2. 64 Q 03 GAAC=$0. 58 7. 5 -325/15 5 5 16. 96 Q 90 $0. 25 7. 5 -500/15 1, 367 1, 647 32. 80 Q 60 GAAC=$0. 18 60533 47430 47431 30623 4202 4204 4205 26439 16899 27684 4207 53582 53428 HYDROCODONEACETAMINOPHEN HYDROCODONEACETAMINOPHEN HYDROCODONEACETAMINOPHEN HYDROCODONEACETAMINOPHEN 2. 5 -500 MG 5 MG-500 MG Unique Total Avg Qty Max Qty per Cost per tablet or ml Recipients Claims per Days Day in System (WAC) Supply Idaho Medicaid pharmacy claims between 1/1/2013 and 4/30/2013 11

Nystatin/Triamcinolone Combo DUR What are the utilization numbers on the various nystatin/triamcinolone combo products?

Nystatin/Triamcinolone Combo DUR What are the utilization numbers on the various nystatin/triamcinolone combo products? 12

Nystatin/Triamcinolone Combo DUR Paid Pharmacy Claims 1/1/2013 through 4/30/2013 200 180 160 140 120

Nystatin/Triamcinolone Combo DUR Paid Pharmacy Claims 1/1/2013 through 4/30/2013 200 180 160 140 120 100 80 60 40 20 0 175 161 Recipients Claims 39 Cream 44 Ointment 13

Nystatin/Triamcinolone Combo DUR Paid Pharmacy Claims 1/1/2013 through 4/30/2013 100 90 80 70 60

Nystatin/Triamcinolone Combo DUR Paid Pharmacy Claims 1/1/2013 through 4/30/2013 100 90 80 70 60 50 40 30 20 10 0 90 80 60 66 34 34 13 13 0 to 3 4 to 6 7 to 18 19 to 55 Age of Recipients 12 16 Claims 56 to 67 14

Current Interventions/Outcomes Studies Hepatitis C DUR Demographics of the Idaho Medicaid Utilizer of Rx’s

Current Interventions/Outcomes Studies Hepatitis C DUR Demographics of the Idaho Medicaid Utilizer of Rx’s Population CHIC – Children’s Healthcare Improvement Collaboration Geo‐Mapping Analysis Utilization of Narcotic Analgesics (HIC 3 = H 3 A) 15

Current Interventions/Outcomes Studies P&T Committee Narcotic Analgesic Studies Narcotic Analgesics in Chronic Non‐Malignant Pain

Current Interventions/Outcomes Studies P&T Committee Narcotic Analgesic Studies Narcotic Analgesics in Chronic Non‐Malignant Pain 2012 Update Participants Receiving More Than 1 Long Acting at a Time Suboxone and Participants Paying Cash for Other Opioids 16

Hepatitis C Agents Incivek and Victrelis Review past 6 months of data for usage

Hepatitis C Agents Incivek and Victrelis Review past 6 months of data for usage Are patients that started on therapy continuing therapy? Will be requesting chart notes to determine why patients discontinued therapy (e. g. intolerable side effects vs. non‐ responders to therapy based on viral counts) vs. non‐ compliance. Will look for trends in patients that discontinued therapy (e. g. does rate vary between practices or geographically) Are patients on TRIPLE therapy with ribavirin and interferon? Check for adherence to all three medications. Audit for checking viral counts at appropriate time intervals 17

Hepatitis C Agents Incivek and Victrelis Look at quarterly trends in usage since Incivek/Victrelis

Hepatitis C Agents Incivek and Victrelis Look at quarterly trends in usage since Incivek/Victrelis were approved by the FDA in May 2011 as patients were not started on double therapy (ribavirin/interferon) as the specialists were waiting for triple therapy to be available. In the future an all oral regimen is going to be available for treatment of Hepatitis C so there may be patient “warehousing” again. 18

Hepatitis C DUR Incivek & Victrelis 50 40 30 20 10 0 2 Q

Hepatitis C DUR Incivek & Victrelis 50 40 30 20 10 0 2 Q 2011 3 Q 2011 4 Q 2011 1 Q 2012 2 Q 2012 3 Q 2012 4 Q 2012 1 Q 2013 2 Q 2013 Total Paid Claims Unique Prescribers Unique Recipients 19

Hepatitis C DUR Incivek & Victrelis 60 50 40 30 20 10 0 2

Hepatitis C DUR Incivek & Victrelis 60 50 40 30 20 10 0 2 Q 2011 3 Q 2011 4 Q 2011 1 Q 2012 2 Q 2012 3 Q 2012 4 Q 2012 1 Q 2013 2 Q 2013 Total Paid Claims Unique Prescribers Unique Recipients 20

Hepatitis C DUR Incivek & Victrelis 35 30 25 20 15 10 5 0

Hepatitis C DUR Incivek & Victrelis 35 30 25 20 15 10 5 0 2 Q 2011 3 Q 2011 4 Q 2011 1 Q 2012 2 Q 2012 3 Q 2012 4 Q 2012 1 Q 2013 2 Q 2013 Total Paid Claims Incivek Total Paid Claims Victrelis 21

Hepatitis C DUR Review from 5/1/2012 thru 5/26/2013 Total of 53 patients prescribed Incivek

Hepatitis C DUR Review from 5/1/2012 thru 5/26/2013 Total of 53 patients prescribed Incivek or Victrelis 36 Incivek 17 Victrelis Mean age: 47 years (range: 18 – 61) Female: 26 Male: 27 **All patients had a diagnosis for Hepatitis C (ICD‐ 9 code 070. 4 or 070. 5) 22

Hepatitis C DUR 36 Incivek Patients Mean age: 46 years (range 28 – 61)

Hepatitis C DUR 36 Incivek Patients Mean age: 46 years (range 28 – 61) Female: 16 Male: 20 29 completed treatment (3 months) 5 did not complete treatment 1 patient was co‐infected with HIV (2 months) 2 patients exceeded 3 months 5 months (50 y/o male) 4 months (28 y/o male) 23

Hepatitis C DUR Incivek Payment Total payment $1, 613, 601. 00 Payment/month $18, 000.

Hepatitis C DUR Incivek Payment Total payment $1, 613, 601. 00 Payment/month $18, 000. 00 6 months should not have been submitted ($108, 000. 00) **All Incivek patients were started on Interferon and Ribavirin 24

Hepatitis C DUR 17 Victrelis patients Mean age: 47 years (range 18 – 60)

Hepatitis C DUR 17 Victrelis patients Mean age: 47 years (range 18 – 60) Female: 10 Male: 7 8 completed treatment Mean # of months: 7 2 did not complete treatment 7 active treatment 25

Hepatitis C DUR Victrelis Payment Total payment $355, 187. 00 Payment/month $5074. 00 **All

Hepatitis C DUR Victrelis Payment Total payment $355, 187. 00 Payment/month $5074. 00 **All Victrelis patients were on Interferon and Ribavirin for 4 weeks prior to Victrelis treatment 26

Hepatitis C DUR Letters sent out requesting the following information: HCV Genotype Baseline Laboratory

Hepatitis C DUR Letters sent out requesting the following information: HCV Genotype Baseline Laboratory values (CBC, LFT’s, SVR) Follow‐up Laboratory values while on Incivek or Victrelis (SVR, LFT’s) Documentation/chart notes of follow‐up treatment and response to treatment If documented: Co‐infection of HIV If applicable: reason why therapy was discontinued (side effects, inadequate response, etc) 27

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Paid Pharmacy Claims 1/1/2013 through

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Paid Pharmacy Claims 1/1/2013 through 4/30/2013 Unique Recipients 25, 000 20, 000 15, 000 10, 000 5, 000 ‐ 0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99 100 to 109 Age in Years Male Female 28

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Total Claims Paid Pharmacy Claims

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Total Claims Paid Pharmacy Claims 1/1/2013 through 4/30/2013 90, 000 80, 000 70, 000 60, 000 50, 000 40, 000 30, 000 20, 000 10, 000 ‐ 0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99 100 to 109 Age in Years Male Female 29

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Paid Pharmacy Claims 1/1/2013 through

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Paid Pharmacy Claims 1/1/2013 through 4/30/2013 $ 9, 000 Total Payment Amount $ 8, 000 $ 7, 000 $ 6, 000 $ 5, 000 $ 4, 000 $ 3, 000 $ 2, 000 $ 1, 000 $‐ 0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99 100 to 109 Age in Years Male Female 30

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Paid Pharmacy Claims 1/1/2013 through

Demographics of the Idaho Medicaid Utilizer of Rx’s Population Paid Pharmacy Claims 1/1/2013 through 4/30/2013 100, 000 23, 059, 720 50, 027, 771 26, 968, 052 10, 000 1, 000 100, 000 260, 503 46, 096 61, 189 445, 347 705, 850 107, 285 10, 000 Unique Recipients Total Claims Male Female Total Payment Amount Combined 31

CHIC – Children’s Healthcare Improvement Collaboration Mental Health Learning Collaborative – Depression Screening in

CHIC – Children’s Healthcare Improvement Collaboration Mental Health Learning Collaborative – Depression Screening in Adolescent Patients 32

CHIC Target Prescribers: Pediatricians and Family Practice Goal: Increase screening for depression in adolescent

CHIC Target Prescribers: Pediatricians and Family Practice Goal: Increase screening for depression in adolescent patients with appropriate follow‐up for those patients with positive screenings Psychosocial support including counseling Medications (e. g. SSRIs) Target Dates: Learning session for enrolled providers in August 2013. Sessions to be held in Boise, Twin Falls, and Pocatello Start tracking screenings and follow‐up in October 2013 Duration of project: 6 months 33

CHIC Baseline Data for 2012 3265 unique patients age 12‐ 17 years with at

CHIC Baseline Data for 2012 3265 unique patients age 12‐ 17 years with at least one paid claim for an SSRI 18, 063 total paid claims for SSRIs $265, 842 4604 unique patients age 12‐ 17 with at least one paid claim for any antidepressant 30, 198 total paid claims for all antidepressants $467, 419 34

Geo‐Mapping Analysis Utilization of Narcotic Analgesics (HIC 3 = H 3 A) Prepared by

Geo‐Mapping Analysis Utilization of Narcotic Analgesics (HIC 3 = H 3 A) Prepared by MMA 6/13/2013 Please refer to handout in Packet 35

P&T Committee Narcotic Analgesic Studies Narcotic Analgesics in Chronic Non‐Malignant Pain 2012 Update Participants

P&T Committee Narcotic Analgesic Studies Narcotic Analgesics in Chronic Non‐Malignant Pain 2012 Update Participants Receiving More Than 1 Long Acting at a Time 36

Narcotic Patterns of Use in Chronic Non‐Malignant Pain Follow‐Up from 2011 Study 37

Narcotic Patterns of Use in Chronic Non‐Malignant Pain Follow‐Up from 2011 Study 37

Profile Review �Generated profiles for the top 150 recipients by total narcotic claim count

Profile Review �Generated profiles for the top 150 recipients by total narcotic claim count from the recipients who had at least one narcotic claim in each of the 24 months of the period ending March 2013 �Time Period: October 1, 2012 through March 31, 2013 �Original study: May 1, 2011 through December 31, 2011 �Evaluated 142 Cancer Diagnosis found in 8 �All profiles were hand reviewed by Idaho Medicaid Pharmacists 38

Review Focus �Years of opioid use �Number of different opioids used �Daily morphine equivalents

Review Focus �Years of opioid use �Number of different opioids used �Daily morphine equivalents �Number of different prescribers �Other concurrent central acting/ potentially addictive drugs �Diagnosis or indication for chronic opioid use �Average days between refills �History of abuse diagnosis �Currently in lock‐in program? �Additional opioid use paid outside of Medicaid 39

Length of Time for Continuous Opioid Use 40

Length of Time for Continuous Opioid Use 40

Number of Different Opioids Includes different drugs or dosage forms May or may not

Number of Different Opioids Includes different drugs or dosage forms May or may not be concurrent, but over course of therapy 41

Daily Morphine Equivalents Lowest = 14 mg Highest = 1340 mg 42

Daily Morphine Equivalents Lowest = 14 mg Highest = 1340 mg 42

Number of Prescribers per Participant 43

Number of Prescribers per Participant 43

44

44

Diagnosis/Indications Most patients had multiples diagnoses Diagnosis Number of Participants (incidence) lubago: unspecified disorder

Diagnosis/Indications Most patients had multiples diagnoses Diagnosis Number of Participants (incidence) lubago: unspecified disorder of back; back pain 92 chronic pain; chronic pain syndrome; other chronic pain 73 intevertebral disc disorder; lumbar disc degeneration; cervicalgia; sciatica; disc degeneration; spondylosis 30 knee injury; shoulder injury; pain in limb; lower leg pain; neck injury; hip and thigh injury; wrist injury 20 hand joint pain; osteoarthritis; rheumatoid arthritis; pain in joint of ankle and foot; ankylosing spondylitis; other disorders of synovium tendon and bursa headache; migraine 37 disorders of muscle ligament and fascia; other disease of bone and cartilage; myalgia abdominal pain, generalized pain 9 2 12 multiple sclerosis 1 peripheral neuropathy; diabetic peripheral neuropathy 1 chronic pancreatitis 4 Unknown 2 45

Average Days Prior to Refill 46

Average Days Prior to Refill 46

Other Information Gathered Number on Medicaid Pharmacy Lock‐In 5 currently on lock‐in Non‐Medicaid Opioid

Other Information Gathered Number on Medicaid Pharmacy Lock‐In 5 currently on lock‐in Non‐Medicaid Opioid Fills From Board of Pharmacy Reports Many gaps in Board of Pharmacy Reports 34 of the 142 patients ( 24%) had fills not paid for by Medicaid Concurrent Drug Abuse Diagnosis 66 (46%) 47

Comparison of Original and Follow-up Data 2011 Current Number with Cancer DX 6 8

Comparison of Original and Follow-up Data 2011 Current Number with Cancer DX 6 8 Average # of Years on Opioids 8. 2 (Range 3‐ 14) 9 (Range 2‐ 13) Average # of Different Opioids 2. 9 ( Range 1‐ 10) 3 (Range 1‐ 7) Average Daily Morphine Equivalents 256 (Range 10 mg ‐ 2421 mg) 208 (Range 14 mg‐ ) Average # of Prescribers/Participant 4 ( Range 1‐ 12) 1 (Range 1‐ 8) Average Days Prior to Refill 27 25 Lock‐in Patients 3 5 Patients with Prescriptions Paid Outside of Medicaid 30% 24% Concurrent Drug Abuse Diagnosis 39% 46% Does not include non‐Medicaid paid 48

Evaluation of Participants Receiving More than One Long ‐Acting Narcotic Analgesic Concurrently 49

Evaluation of Participants Receiving More than One Long ‐Acting Narcotic Analgesic Concurrently 49

Long-Acting Narcotic Evaluation Goal: To evaluate impact of planned change that would only allow

Long-Acting Narcotic Evaluation Goal: To evaluate impact of planned change that would only allow one long‐acting and one short‐ acting narcotic analgesic per participant without further prior authorization Report was run and profiles generated for participants who had a claim for more than one unique long‐ acting narcotic analgesic between 12/1/2012 and 5/31/2013 N = 65 50

Evaluation Profiles were reviewed and all eliminated for further review that did not meet

Evaluation Profiles were reviewed and all eliminated for further review that did not meet the following criteria: Two or more consecutive months of receiving two or more long‐acting agents. Must include most recently evaluated month (May 2013) Participants meeting criteria = 6 Refer to attached table for characteristics of use for these 6 participants 51

Buprenorphine DUR Suboxone and Participants Paying Cash for Other Opioids (includes Suboxone film, Suboxone

Buprenorphine DUR Suboxone and Participants Paying Cash for Other Opioids (includes Suboxone film, Suboxone tablets, buprenorphine/naloxone tablets, buprenorphine tablets) 52

Buprenorphine DUR Identified all participants with at least one paid claim by Idaho Medicaid

Buprenorphine DUR Identified all participants with at least one paid claim by Idaho Medicaid between 2/1/13 and 4/30/13. 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). This DUR includes opioid claims from January 2013 that would overlap into February (e. g. paid cash for hydrocodone tablets 1/31/13 and had Idaho Medicaid pay for Suboxone 2/1/13). As the Board of Pharmacy only reports number of tablets and not days of service, we assumed a reasonable number of tablets used per day (e. g. six for hydrocodone/acetaminophen, two for Oxy. Contin). Idaho Medicaid has a manual system for entering a block from paying for opioids for patients on Suboxone therapy but an occasional participant is overlooked allowing Idaho Medicaid to pay for opioids for patients also on Suboxone. 53

Buprenorphine DUR Data Collected 1. 2. 3. 4. 5. 6. 7. 8. Sex (M/F)

Buprenorphine DUR Data Collected 1. 2. 3. 4. 5. 6. 7. 8. Sex (M/F) Age as of 4/30/13 (years) Overlapping paid claims for opioids (Y/N) What is opioid in addition to Suboxone ? Quantity of paid claims Duration of therapy of Suboxone Concomitant benzodiazepine usage Cost of therapy ($ and percentage) for patients paying cash for opioids 54

Buprenorphine DUR For those patients identified who had paid claims for other opioids that

Buprenorphine DUR For those patients identified who had paid claims for other opioids that overlapped with days of service for Suboxone, a letter was sent to prescribers of both Suboxone and any other opioid. The Board of Pharmacy report was included as an attachment to these letters. (See packet for copy of letter) One week after the letter was sent, payment for Suboxone was blocked by Idaho Medicaid and the lock on paying for other opioids was removed. 55

Buprenorphine DUR Patients identified who paid cash for opioids while Idaho Medicaid was paying

Buprenorphine DUR Patients identified who paid cash for opioids while Idaho Medicaid was paying for Suboxone Paid Cash, 26, during time period 2/1/13 - 4/30/13 13% Did not pay cash, 174, 87% 66 letters sent out between June 3‐ 10, 2013 to 56 unique prescribers. Gave prescribers one week to respond prior to initiating Suboxone payment block. 56

Buprenorphine DUR Sex 132 140 # of patients 120 100 80 60 42 40

Buprenorphine DUR Sex 132 140 # of patients 120 100 80 60 42 40 20 0 19 7 Paid Cash Didn't pay cash Male Female 57

Buprenorphine DUR Percentage in DUR study 151/200, 75. 5% 160 140 120 100 80

Buprenorphine DUR Percentage in DUR study 151/200, 75. 5% 160 140 120 100 80 60 49/200, 24. 5% 40 20 0 Male Female 58

Buprenorphine DUR Paid Cash 19/26, 73% 20 18 16 14 12 10 8 6

Buprenorphine DUR Paid Cash 19/26, 73% 20 18 16 14 12 10 8 6 4 2 0 7/26, 27% Male Female 59

Buprenorphine DUR 50 45 40 35 30 Average Age: 38. 3 Standard Deviation: 10.

Buprenorphine DUR 50 45 40 35 30 Average Age: 38. 3 Standard Deviation: 10. 8 Average Age: 30. 8 Standard Deviation: 5. 0 Average Age: 33. 8 Standard Deviation: 9. 7 25 20 15 10 5 0 Paid Cash Didn’t Pay Cash All Patients in DUR 60

Buprenorphine DUR All patients in DUR Patients who paid cash for opioids and who

Buprenorphine DUR All patients in DUR Patients who paid cash for opioids and who were also on benzo's 60/200, 30% 16/26, 62% 140/200, 70% benzo use no benzo use on benzo 10/26, 38% not on benzo 61

Buprenorphine DUR: Analysis of Prescribers 16 14 14 # of patients 12 10 8

Buprenorphine DUR: Analysis of Prescribers 16 14 14 # of patients 12 10 8 6 4 2 0 4 3 1 1 2 1 One prescriber for Two prescribers Three prescribers Four prescribers Ten prescribers both Suboxone and (one for Suboxone (two prescribers for (one for Suboxone (one for suboxone other opioid and one for other buprenorphine and two for other buprenorphine, and three for other and nine for other opioid) Oxycontin, second opioids) third prescriber for opioids) prescriber for hydrocodone) 62

Buprenorphine DUR Suboxone Three Month Time Periodpaid for patients paying cash, $25, 889 Suboxone

Buprenorphine DUR Suboxone Three Month Time Periodpaid for patients paying cash, $25, 889 Suboxone paid for patients not paying cash, $202, 230 11. 3% of total expenditure ‐ potential cost savings: $103, 557 annually 63

Buprenorphine DUR # of patients # of opioid prescriptions paid cash for by patients

Buprenorphine DUR # of patients # of opioid prescriptions paid cash for by patients during 3 month time period 14 12 10 8 6 4 2 0 12 5 1 2 2 2 3 4 1 5 2 9 1 1 10 12 # of opioid prescriptions 64

Buprenorphine DUR Of 12 patients with one cash paid opioid prescription during the three

Buprenorphine DUR Of 12 patients with one cash paid opioid prescription during the three month DUR study 32 7 had paid for additional opioids before/after study period were patients recently started on Suboxone had been on Suboxone for a while with only the one paid opioid claim 65

Buprenorphine DUR Opioids paid cash for 3 2 1 hydrocodone oxycodone hydromorphone methadone morphine

Buprenorphine DUR Opioids paid cash for 3 2 1 hydrocodone oxycodone hydromorphone methadone morphine 15 60 66

# of patients Buprenorphine DUR 50 45 40 35 30 25 20 15 10

# of patients Buprenorphine DUR 50 45 40 35 30 25 20 15 10 5 0 paid cash did not take other opioids 13 012 011 010 09 08 07 06 05 04 03 0 2 2 20 20 r n p p Ja Se ‐ ‐ A 12 ‐ n b 0 Ja Fe t 2 c O Suboxone Therapy Initiated 67

Buprenorphine DUR Bottom Line: Patients were found to be paying cash for opioid therapy

Buprenorphine DUR Bottom Line: Patients were found to be paying cash for opioid therapy even after many years on Suboxone therapy. Example – Patient who has been on Suboxone since 2006 paid cash 9 times for opioids during the 3 months of this DUR and 52 times total in the last two years (42 fills for oxycodone and 10 fills for hydrocodone). 68

Buprenorphine DUR Feedback from week 1 One physician called and left message. Pharmacist called

Buprenorphine DUR Feedback from week 1 One physician called and left message. Pharmacist called back and spoke to his nurse to explain what was happening. The physician never called back. One participant called to complain, Pharmacist called and spoke to physician and re‐authorized payment for Suboxone (second chance). 69

Buprenorphine DUR Feedback from week 2 Participant called to state that Norco was not

Buprenorphine DUR Feedback from week 2 Participant called to state that Norco was not filled by her. Pharmacist called prescriber of both Suboxone and Norco. Giving her a second chance. Physician called and stated that patient had knee surgery and was “off” Suboxone immediately post‐op but plan is to stop other opioid and restart Suboxone. Physician called and stated that patient had one fill of hydrocodone for dental surgery and would like patient to continue on Suboxone. 70

Buprenorphine DUR Continued feedback Patient’s Suboxone discontinued by prescriber due to other opioid use:

Buprenorphine DUR Continued feedback Patient’s Suboxone discontinued by prescriber due to other opioid use: 2 patients Prescriber requested (and was granted) re‐ authorization for Suboxone after fill of other opioid s/p surgery: 2 patients 71

Buprenorphine DUR Future Plans The department plans on running routine Board of Pharmacy reports

Buprenorphine DUR Future Plans The department plans on running routine Board of Pharmacy reports every 3‐ 6 months on all Suboxone patients. Questions/Comments ? 72

Proposed Studies for Next Quarter: Synagis P&T Committee Narcotic Analgesic Studies – Next Steps

Proposed Studies for Next Quarter: Synagis P&T Committee Narcotic Analgesic Studies – Next Steps Use of Psychotropic Medications in Foster Children – Next Steps 2012 Data Analysis Update Three (3) or more concomitant mood stabilizer medications IVIG 73

Proposed Studies for Next Quarter: Levofloxacin Antipsychotic Indication Evaluation‐ Hold for Future 74

Proposed Studies for Next Quarter: Levofloxacin Antipsychotic Indication Evaluation‐ Hold for Future 74

Synagis DUR http: //healthandwelfare. idaho. gov/Portals/0/Health/Epi/RSV%20 graph. pdf 75

Synagis DUR http: //healthandwelfare. idaho. gov/Portals/0/Health/Epi/RSV%20 graph. pdf 75

Synagis DUR What should the focus be for the DUR project for the concluded

Synagis DUR What should the focus be for the DUR project for the concluded 2012‐ 2013 RSV season? 76

P&T Committee Narcotic Analgesic Studies – Next Steps 77

P&T Committee Narcotic Analgesic Studies – Next Steps 77

Use of Psychotropic Medications in Foster Children The U. S. Government Accountability Office released

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. 78

Foster Children Psychotropic Drugs Red Flags 7/18/2013 79

Foster Children Psychotropic Drugs Red Flags 7/18/2013 79

Red Flags Five (5) or more psychotropic medications prescribed concomitantly (reviewed August 2012) Two

Red Flags Five (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 ok Three (3) or more concomitant mood stabilizer medications Psychotropic polypharmacy (2 or more agents) for a given mental disorder prescribed before utilizing psychotropic monotherapy 80

Implementation of Red Flags Retroactive Evaluation Identify outliers Profile Review DUR Board Intervention Re‐

Implementation of Red Flags Retroactive Evaluation Identify outliers Profile Review DUR Board Intervention Re‐ evaluation Point of service edits • Targeted education • individuals • overall • Informational (soft) – pharmacist override • Hard Stop Further Action 81

40% 35% Percent of Foster and Non-Foster Children Psychotropics by 36% Drug Class Calendar

40% 35% Percent of Foster and Non-Foster Children Psychotropics by 36% Drug Class Calendar Year 2011 Total foster =2785 Total Non-Foster = 106, 024 30% 25% 23% 21% % Foster Children 20% % Non‐foster Children 15% 10% 13% 9% 6% 4% 5% 0% 0% ADHD Drugs Anti‐depressants Mood Stabilizers Atypical Antipsychotics 82

Use of Psychotropic Medications in Foster Children: Next Steps 2012 Data Analysis Update Three

Use of Psychotropic Medications in Foster Children: Next Steps 2012 Data Analysis Update Three (3) or more concomitant mood stabilizer medications 83

IVIG follow‐up as implemented prior authorization criteria 1‐ 1‐ 13. Will look at cost

IVIG follow‐up as implemented prior authorization criteria 1‐ 1‐ 13. Will look at cost of therapy (pharmacy and medical) January – June 2012 vs. same dates 2013 as well as some comments on prior authorization requests received. 84

Levofloxacin – changed minimum age from 16 down to zero 11‐ 1‐ 12 so

Levofloxacin – changed minimum age from 16 down to zero 11‐ 1‐ 12 so look at usage Jan – June 2012 vs. same dates 2013 for children and compare utilization. 85

Antipsychotic Indication Evaluation. Hold for Future 86

Antipsychotic Indication Evaluation. Hold for Future 86

Prospective DUR Report History Errors: Non‐History Errors: • DD – drug‐to‐drug • PA –

Prospective DUR Report History Errors: Non‐History Errors: • DD – drug‐to‐drug • PA – drug‐to‐age • PG – drug to pregnancy • HD – high dose • TD – therapeutic duplication • LD – low dose • ER – early refill • SX – drug‐to‐gender • MC – drug‐to‐disease 87

Prospective DUR Report Idaho Medicaid Program Pro. DUR Message Report June-13 Pro. DUR Message

Prospective DUR Report Idaho Medicaid Program Pro. DUR Message Report June-13 Pro. DUR Message Drug To Gender Drug To Known Disease Drug To Pregnancy Duplicate Therapy Min Max Too Soon Clinical ALL Pro. DUR Severity 1 2 3 1 2 A B C D X 0 0 0 Message Count 1, 381 13, 026 67, 204 146 2, 195 65, 499 229, 816 291, 920 23 15 4 70 126 7 10 108, 162 29, 517 19, 545 Message Amount $373, 620. 15 $2, 521, 971. 05 $12, 025, 994. 08 $34, 461. 03 $265, 410. 63 $9, 849, 442. 93 $42, 448, 043. 20 $54, 632, 417. 89 $301. 97 $483. 73 $39. 35 $10, 458. 15 $12, 492. 54 $130. 78 $844. 76 $24, 283, 884. 93 $4, 838, 004. 04 $3, 632, 514. 43 828, 666 $154, 930, 515. 64 Total Number of Claims with Messages 200, 209 Average Pro. DUR Message Per Claim 4. 14 88

DUR Summer Newsletter Copy of Spring Newsletter in packet Brainstorm for new topics 89

DUR Summer Newsletter Copy of Spring Newsletter in packet Brainstorm for new topics 89

Medicaid Update 90

Medicaid Update 90