TennCare Drug Utilization Review Board (DUR) Minutes

Transcription

1 March 8, 2011 State f Tennessee Department f Finance and Administratin Bureau f TennCare 310 Great Circle Rad Nashville, TN TennCare Drug Utilizatin Review Bard (DUR) Minutes In attendance: DUR Cmmittee: Randall Ellis, MD, Rland Gray, MD, Jasn Kizer, PharmD, Rebecca Brewer Mills, PharmD, Richard Randlph, PharmD, Peter Swarr, MD Bureau f TennCare: David Cllier, MD, Ray McIntire, DPh, Nicle Wds, PharmD SXC Health Slutins: Tie Alstn, PharmD, Bill Hudsn, PharmD, Tracey Lvett, PharmD, Jud Jnes, PharmD, Brian Laird, DPh, Leigh Ann Mre, CPhT Intrductin: The meeting was called t rder by Dr. Tie Alstn, wh welcmed everyne t the TennCare Drug Utilizatin Review (DUR) Bard meeting. DUR Bard Appintees, Bureau f TennCare Representatives, and SXC Health Slutins Representatives intrduced themselves. Dr. Cllier gave the fllwing TennCare update: The secnd enrllment perid fr the TennCare Standard Spend Dwn prgram pened. As mentined in the last meeting, this year s budget allws up t 7000 peple t be enrlled in the prgram. The Standard Spend Dwn Prgram is fr individuals such as the elderly, disabled, r blind. Individuals are allwed t call in t a specific telephne number s there is equal access. Applicatin requests are limited t 2500 each time t allw time fr prcessing the applicatins within federal timeline limits. The line received 2500 applicatins and clsed in nly 1 hur and 50 minutes. Individuals that called were reviewed fr eligibility and sent applicatins. In Octber, 1821 f the applicatins ut f 2500 were returned t DHS. Sme f the applicants were already enrlled in TennCare. The TennCare Electrnic Health Recrds (EHR) Prvider Incentive Prgram is due t the Health Infrmatin Technlgy fr Ecnmic and Clinical Health Act (HITECH), which is part f the American Recvery and Reinvestment Act f 2009 (ARRA). This act supprts the adptin f electrnic health recrds thrugh financial incentives administered thrugh Medicare r Medicaid t eligible prfessinals and hspitals. TennCare is administering the Medicaid incentive part f this prgram. There has been a tremendus respnse t the EHR prvider incentive prgram. Over 600 prviders and hspitals have applied s far. The amunts available t healthcare prfessinals depend n whether incentive payments are chsen frm Medicaid r Medicare. Medicaid has the higher payment amunt: $63,750 per prvider ver 6 years beginning in 2011 and nt t extend past The payment amunt via Medicare is $44,000 per prvider ver 5 years beginning in 2011 thrugh Prviders have t chse the prgram in 1

2 which they wish t participate. Hspitals can participate in bth categries. N mney has been dispersed yet, but interest level is high. Funds culd pssibly be dispersed as early as April. TennCare presented its prpsed budget t the Gvernr back in January. The Gvernr has nt presented his prpsal t the legislature (suppsed t happen arund March 15 th ) s the TennCare budget is nt a dne deal. The Gvernr has nt annunced which TennCare prpsals he will accept in his budget prpsal. Over the last tw years benefit reductins and prvider rate reductins have been avided utilizing nnrecurring funds. In Fiscal Year (FY) 2010 the stimulus funds helped ffset reductins that wuld have been necessary withut thse funds. In FY 2011 the State was able t utilize the Clawback dllars, and the legislature passed the Hspital Fee which helped buy back the benefit limits that was passed by the legislature. TennCare had submitted a waiver amendment (#9) t CMS and was in discussin with them when the Hspital Fee passed and thse discussins were discntinued. The Tennessee Hspital Assciatin has indicated their willingness t renew the Hspital Fee, which must still be apprved by the legislature. CMS categrizes prviders as mandatry (physicians and nurse practitiners) and ptinal (pdiatry and physician assistants (PA s)). CMS ppsed cmbining mandatry and ptinal prviders under ne limit last year. TennCare prefers t include bth in the limit s that enrllees wh d nt need pdiatry r PA services will have thse visits available with their physician r nurse practitiner. Splitting the limits where enrllees can have six mandatry and tw ptinal prvider visits wuld further limit access fr enrllees. The State wuld nt achieve the needed savings if eight mandatry prvider and eight ptinal prvider visits were allwed. Dr. Cllier mentined fur categries r levers fr cntrlling csts: Enrllment The State nly has cntrl ver ptinal categries. Any change in eligibility is prevented by the federal maintenance f effrt requirement assciated with the ARRA. Tw-thirds f TennCare is mandatry enrllment. Prvider reimbursement There is a limit t what the State can d in this area. It is easy t jepardize the netwrk if changes make prviders nt want t participate. Cst-sharing CMS limits wh can be subjected t cst-sharing. Als, there are severe restrictins n enfrceability. The amunt f cinsurance is als restricted, as is enfrceability. Any change made in cst-sharing requires CMS apprval. Benefits TennCare cannt change the benefit package fr children and pregnant wmen. The State has mandated cverage currently fr 750,000 children and 60,000 pregnant wmen. Any change t the benefit package als requires CMS apprval. Additinally there is a disadvantage that Medicaid has cmpared t Medicare and cmmercial insurance in that there are nt premiums invlved that can be raised. Amendment #12 has been prpsed t CMS with benefit changes that include a prvider rate reductin and limits n hspitalizatin, utpatient visits and services, lab, X-ray, Physical Therapy, Occupatinal Therapy, Speech Therapy, Pdiatry and PA s. PA s in rural health are cncerned that their livelihd is in jepardy if this ges frward. Hpefully this will nt happen. Fr FY 2012 If the Hspital Fee is nt apprved by the legislature: 2

3 TennCare will have t implement the prvider rate reductin f 7% with a pssible additinal 1% reductin. TennCare will reimburse delivery at a flat rate fr vaginal & C-sectin (currently reimbursed at a blended rate higher than vaginal delivery). Emergency physician prvider reimbursement fr nn-emergency ER visits wuld be paid at a lwer rate. Limits wuld be placed n hspice benefits fr services unique t hspice (emtinal, scial services t member and family). Medical benefits wuld still be present fr hspice nly behaviral health and cunseling wuld be limited. Slides f this presentatin are available n the TennCare website. Jhn B. Lawsuit Update Dr. Cllier mentined during the last meeting that the 6 th Circuit Curt ruled and appinted a new Judge; Senir Judge Thmas Wiseman, Jr. in US District Curt fr the Middle District f Tennessee. Judge Wiseman wants bth parties t wrk things ut, and if nt, he will wrk it ut. TennCare wanted the lawsuit vacated, but the party representing TennCare enrllees did nt want this. Hpefully Judge Wiseman will encurage the parties t reach an agreement. Dr. Wds gave an update n the TennCare Pharmacy Department: TennCare has been asked t make significant budget reductins fr the past several years. Fr the last tw years, we have received ne-time funds (ARRA, Clawback, and Hspital Fee) that have allwed us t pstpne sme f the anticipated cuts. Fr FY 2012, it is prbable that sme if nt all f these funds will nt be available. We need t be prepared t implement the budget reductins, as well as prvide an additinal 1-3% reductin in csts. Sme f the prpsed reductins fr FY 2011 in pharmacy include: Implementatin f a $4 generic list TennCare wuld select drugs cmmnly fund n multiple $4 generic lists and set a MAC price n them such that an average 30-day supply f the medicatin wuld MAC at $1. Then with the $3 dispensing fee, the ttal reimbursement wuld be $4 fr the claim. As with ur current MAC pricing plicy, there wuld be a dispute prcess. S if pharmacies felt that pricing had changed and they culd n lnger btain the prduct fr under $4, they culd dispute and we wuld remve the prduct frm the $4 list if apprpriate. Changes t MAC pricing list TennCare is prpsing mving frm an average discunt f arund 79% ff f AWP t 82% ff f AWP. This wuld be accmplished with a few small changes t large vlume prducts, and f curse, the MAC dispute prcess wuld remain in place. The budget prpsal fr FY2012 invlves 4 different methds t curb pharmacy csts: Dsage limit n Subxne Over the past tw years Subxne usage has dubled (frm apprximately 1800 Rxs/mnth in January 2009 t apprximately 3800 Rxs/mnth in August 2010), and the average dse f patients n this medicatin hvers very clse t the maximum quantity limit. We d nt see gradual reductin f dse ver time. In fact, the average reductin was 0.6mg/day frm the start f therapy thrugh the last paid claim, per recipient, ver a 3.5 year perid, s we are definitely nt seeing individuals cming ff f these drugs. 3

4 This is especially a cncern t TennCare given the ptential fr abuse and diversin f this medicatin. At a dse f 16mg/day f buprenrphine, 85-92% f mu piid receptrs are blcked which wuld nt create issues f withdrawal. Studies have cmpared bth dses (16mg/day and 32mg/day) and the dses d nt differ significantly in mu piid receptr binding ptential. Based n these results, TennCare prpsed lwering the quantity limit n Subxne t 16mg/day. In additin, in rder t ensure that members being treated with Subxne are truly cmmitted t detxing, the prpsed plan wuld mandate individuals t be tapered t 8mg/day by the end f the first 6 mnths. There is nt currently a limit n the ttal time a patient can be n the medicatin, and in fact, studies/data shw that patients d better if maintained fr lnger perids f time n these dses. Dr. McIntire mentined that Dr. Cllier fund a study that indicated increased mrtality in patients wh use buprenrphine fr ne year r less. Dr. Kizer asked hw sn these changes wuld g int effect. Dr. Wds said if passed the changes wuld be in effect in July, and that this prpsal is expected t result in annual savings f arund $5.5 millin. In respnse t anther questin frm the Bard, Dr. Wds als explained that cunseling is required fr these patients as part f the criteria. The requirements have been established based n reviewing the criteria, recmmendatins frm this cmmittee, PAC, and ther experts. The criteria als require the patient t have a specific physician fr their buprenrphine prescriptins. A change t a new physician requires that crdinatin f care ccur with the previus physician, and a new prir authrizatin is required fr the new physician. Lwer quantity limit n hypntics Prevalence data n insmnia shws that nly apprximately 10% f patients experience chrnic symptms lasting greater than 3 weeks. Recmmendatins frm the Natinal Sleep Fundatin state that treatment with medicatins shuld begin with the lwest pssible effective dse; be shrt-term if used nightly, r be intermittent if used lng-term. In additin, they recmmend that hypntics be used nly in cmbinatin with gd sleep practices and/r behaviral appraches. TennCare is prpsing t lwer the quantity limit n hypntics t 14 per mnth. This will make ur plicy mre in line with the insmnia treatment recmmendatins, and is expected t save the State an estimated $1.7 millin per year. Other states that currently restrict this class t between pills per mnth include Delaware, Iwa, Gergia, Nrth Carlina, and Oregn. Exclusin f acne and rsacea prducts fr adults As yu may be aware, Sectin 1927 f the Scial Security Act allws Medicaid prgrams t exclude agents when used fr 4

5 csmetic purpses. While TennCare has histrically cvered acne and rsacea agents fr adults, these are inncuus cnditins that can be cnsidered csmetic. Several classes f drugs are used t treat acne and rsacea, including: benzyl perxide, tpical retinids, sdium sulfacetamide/sulfur prducts, tpical clindamycin, tpical erythrmycin, and ral retinids. TennCare will cntinue t cver the retinids fr actinic keratsis (AK) and preventin / treatment f skin cancers via a prir authrizatin prcess. In additin, althugh sebrrheic dermatitis can be cnsidered a csmetic prblem, it can lead t secndary skin infectins. Therefre, TennCare will cntinue t ffer selenium sulfide shamps, tpical antifungals, and tpical sterids as treatment ptins fr recipients with sebrrheic dermatitis. By excluding cverage f acne and rsacea prducts fr adults, it is estimated that TennCare can achieve apprximately $600,000/year in savings. Implementatin f a new hemphilia management prgram As yu all are aware, hemphilia prducts are very cstly and require special handling and strage. Currently, hemphilia prducts are handled thrugh ur specialty pharmacy netwrk. When filling a hemphilia prduct, pharmacies must fill the prescriptin within a certain allwed variance range, typically +/- 10%. In situatins where the prescriptin is filled at the tp f the allwed dsing range, TennCare can pay significantly mre fr that prescriptin than if it were filled at the lwer end f the acceptable range. The prpsed budget reductin invlves creating a specific pharmacy agreement fr hemphilia pharmacies t fill hemphilia prescriptins at n mre than +2% f the target dse. By reducing the number f prescriptins filled at the higher end f the acceptable range, TennCare wuld expect t achieve savings f arund $1.2 millin/year. If pharmacies have prblems meeting the new requirements, recipients can be directed t ther pharmacies. In additin, an verride prcess will be in place t ensure that the recipient can get their medicatin. Miscellaneus Pharmacy updates: Re-cntracting the TennCare Pharmacy Netwrk As f February this prcess is essentially cmplete. Pharmacies can still jin the netwrk and are encuraged t cntact SXC Prvider Educatrs fr assistance if they have any questins abut the enrllment prcess. Exclusin f Active Pharmaceutical Ingredients (APIs) TennCare received guidance frm CMS stating that as f January 1, 2011, certain bulk chemicals used in cmpunds called active pharmaceutical ingredients (APIs), and excipients, d nt meet their definitin f cvered utpatient drugs, and therefre, are n lnger eligible fr the federal rebate prgram. TennCare sent ut a ntice t prviders infrming them f this change, and instructing pharmacies t use ther cmmercially available dsage frms in cmpunds as ppsed t these bulk chemical entities. 5

6 Hwever, at this time, TennCare has received additinal guidance frm CMS indicating that APIs and excipients can be cvered, as lng as they are listed in a different categry within the State Plan (nt as a drug since they are nt eligible fr federal rebates). TennCare is in the prcess f submitting a State Plan Amendment t allw us t cver selective APIs in situatins where they wuld either be mre cst effective t the State, r are cnsidered standards f care and are nt available in cmmercial dsage frms. Requirement fr Pharmacies t Transmit Prescriber NPIs The Department f Health and Human Services issued a final Rule in January 2004 which established the Natinal Prvider Identifier (NPI) as the standard unique health identifier fr Health Care Prviders, and mandated that the NPI be used in all electrnic transmissins f health infrmatin effective May 23, Given that we are nw almst 3 years ut frm the deadline, and mst prescribers have NPIs r can readily btain ne usually in less than an hur, we have decided t finally make it mandatry fr pharmacies t submit the prescriber NPI n a pharmacy claim. This requirement will g int effect March 15, Dr. Wds intrduced Dr. Brian Laird, DPh as a new SXC emplyee stepping int the rle f Prvider Educatr. SXC has acquired the pharmacy where Dr. Wldridge is practicing. Per federal DUR regulatins, it is necessary fr the DUR Bard members t cnsist f practitiners utside f TennCare r the PBM. We hate t see Dr. Wldridge g and we appreciate his cntributin, but will be lking fr a replacement. Dr. Kizer suggested that since we place a lnger day supply n prducts such as Dep-Prvera (84 days), maybe the same adjustment (fr example a 50 day supply) culd be made t prducts such as test strips and insulin syringes which are dispensed in bulk. This culd limit use and create a cst savings. Dr. Wds mentined that TennCare has certain prvisins fr allwing mre than a 30 days supply n certain prducts, and agreed that this wuld be wrthy f cnsideratin fr extending t ther prducts. Dr. Kizer asked if there has been any discussin t limiting hydrcdne frm the 1200mg/mnth limit t a lwer limit f 600mg/mnth after 6 mnths t encurage tapering f dsing. Dr. Wds mentined that TennCare currently requires the patient t wait exactly 30 days befre refilling after reaching the 1200mg/mnth limit. TennCare definitely has given cnsideratin t further limits n hydrcdne, but the lgistics f implementing these limits culd be a cncern. Dr. Hudsn mentined that attempts have been made t lwer utilizatin f thse n chrnic usage. Maybe lwering dsing as Dr. Kizer mentined wuld be a wrthy ptin. Dr. Alstn added that the apprach is such that if patient has a certain diagnsis that des nt justify the use f shrt-acting narctic, after 6 mnths f use they wuld need t be placed n a lng-acting narctic. Dr. McIntire mentined that a big cncern is patients that are paying cash fr a large prtin f the prescriptin. 6

7 Review f minutes: The Bard was asked t review minutes frm the December 7, 2010 meeting. A mtin was made and secnded t apprve the minutes as presented. Minutes were apprved with n changes. DUR Pharmacy Update discussin: Dr. Alstn reminded the Bard that Dr. Wds wuld like examples sent t her f cmpunds where it is mre cst effective t dispense the API rather than the cmmercially available prduct. 4 th quarter 2010 cntinues t see an increased use f ADHD meds, ADHD plus sleepers, and ADHD plus narctics. Ttal claims cmparisn f shrt-acting ADHD medicatins vs. lng-acting ADHD medicatins was presented by Dr. Alstn. The claims are basically half and half shrt and lng-acting. The mst cmmnly used shrt-acting medicatins are amphetamine salts. The mst cmmnly used lng-acting medicatins are Adderall XL and Vyvanse. The average age f the adults reviewed was 33. Dr. Wds mentined that this 50/50 break ut f shrt and lng-acting ADHD medicatins culd be representative f patients getting bth. Dr. Alstn said this was nt the case in these patients, and that bth categries represent separate patients. Dr. Hudsn made the cmment that ne culd assume that the 50 percent receiving lng acting ADHD agents culd use the same shrt acting ADHD agents being used by the ther half f the patients. Dr. McIntire added that he is currently in the middle f a study f patients using narctics, hypntics, and ADHD medicatins shwing an alarming increase in the use f Prvigil and Nuvigil, and an alarming amunt f these prducts being used cncmitantly with Subxne. Dr. Swarr stated that the pediatric criteria indicate that lng-acting ADHD medicatins d have benefits ver the shrt-acting in the pediatric ppulatin, but this is nt pediatric ppulatin the Bard is reviewing. This ppulatin is ften nt emplyed, r in schl, and therefre it is hard t justify a lng-acting agent fr these peple. Dr. Alstn suggested that fr the adult ppulatin, cncurrent therapy with lng and shrt acting ADHD medicatins shuld be a hard edit. Dr. McIntire pinted ut that these reviews wuld need t be dne physically by SXC pharmacists in rder t accurately determine cncmitant usage. Dr. Kizer asked fr infrmatin like this t be prvided t pharmacists in sme frm in rder t arm them fr discussins with prviders. Dr. Alstn added that Prvider Educatrs culd be helpful in relating infrmatin t pharmacies and prescribers after prblem areas are identified frm the data. Dr. McIntire asked fr feedback frm the Bard related t checking the message sectin n the Cntrlled Substance Database (CSD). Dr. Randlph mentined that this message is nt usually nticed. Mst pharmacists are nt sure when it is updated, and simply nt a fcus when ging int CSD fr a specific search. 7

8 Dr. Swarr prpsed that the Bard start smewhere with a hard edit that wuld affect nly the mst bvius cncmitant usage. He suggested Subxne with a shrt r lng-acting stimulant. Dr. Randlph agreed that this wuld be a gd place t start. Dr. Alstn called fr a mtin frm the Bard. A mtin was made t create a hard edit n Subxne with a shrt r lng-acting stimulant, and that the State wuld determine the criteria fr the call center. The mtin was secnded and it passed. Dr. McIntire presented a study he is cnducting which is lking at the CSD fr adults using lng-acting ADHD medicatins. He has fund multiple ADHD recipients using lng-acting ADHD drugs with hypntics, ADHD drugs with narctics, and even all tgether including benzdiazepines. In sme cases different physicians were writing fr each f the different medicatins. Dr. Swarr pinted ut that sme might be n chrnic usage f a lng-acting ADHD medicatin and then experience an acute rthpedic situatin that wuld create the need fr a shrt acting narctic and a benzdiazepine. This wuld als explain different prescribers in sme cases. Dr. Hudsn mentined that it wuld be gd t set threshlds abve certain dsages and quantities that wuld define aberrant usage. Dr. Alstn ffered that the matter culd be studied mre and additinal data brught back t further study this issue. Dr. Alstn presented a prescriber letter as requested in the last meeting RE: ADHD agents used cncmitantly with a CNS depressant and asked the Bard t read ver the letter and review. Dr. Swarr suggested making the secnd t the last paragraph the first paragraph since it is impactful and wuld catch the attentin f the prescribers with the purpse f the letter. Dr. Alstn mentined that the letters wuld be sent ut the next week t the prviders. Dr. Hudsn cnfirmed that the target audience wuld be prescribers fr recipients using bth CNS depressants and stimulants. Dr. Alstn shared infrmatin n a Bard apprval that created a hard reject fr drugs that had an abslute gender cntraindicatin. Dr. Alstn shwed a list f drugs that TennCare cvers that have a level-1 cntraindicatin fr gender. Of these, Prscar (finasteride) is the nly drug that has been in the Tp 10 Drug t Gender PrDUR Edits. Dr. Alstn then shwed a list f tp level-1 and level-2 gender edits. A few f these medicatins have ff label uses fr the ppsite sex hwever, there are alternatives. There is n reasn t pay fr these medicatins in the ppsite sex. If the level-1 hard edit alne were implemented, then nly Prscar wuld be affected. Dr. Wds mentined the cncern that pharmacies are verriding the claim withut crrecting the patient prfile t prperly reflect whether the patient is male r female. Sme prducts are used imprperly, i.e., prenatal vitamins fr males. 8

9 Dr. Kizer asked if sme f these cases culd be data that is incrrect in the TennCare system. Dr. Alstn respnded that mst are simply being submitted incrrectly by the pharmacy. The hard edit wuld message the pharmacy t check gender. Dr. Mills asked abut the use f teststerne in creams where it is apprpriately being used fr females in hrmne replacement therapy. Dr. McIntire respnded that teststerne is nt indicated fr hrmne replacement fr females, and that it is nly indicated fr females fr use in mammary cancer. Dr. McIntire added that in the last meeting, Dr. Randlph made a mve that a hard reject be implemented fr abslute cntraindicatin with a DUR text message fr the pharmacist t check and crrect gender if pssible. Dr. Wds added that the pharmacist can always call the call center if it is imprtant fr the patient t get the medicatin and it is apprpriately being submitted as prescribed. A mtin was made recmmending that a hard edit be put in place fr level-1 and level-2 gender edits with a free text message t the pharmacy t check gender. The mtin was secnded and passed. TennCare Pharmacy Data: A review f TennCare pharmacy data fcused n TennCare statistics and utilizatin data was presented by Dr. Alstn. TennCare Ppulatin Fr 1Q2010 vs. 1Q2009, the TennCare ppulatin has decreased 1.3%. Utilizatin in children, which cmprises apprximately 60% f the ttal ppulatin, cntinues t decrease while adult utilizatin has cntinued t increase. TennCare Utilizing Members There has been a slight increase in the number f utilizing members per mnth (+1.24%), the ttal number f prescriptins per mnth (+1.35%), and the ttal payment amunt per mnth (3.35%). Average Prescriptin Payment Amunt Brand refers t bth single surce brand agents as well as c-licensed brands. Brand Originatr refers t brand agents with generics available. As we wuld like t see, ur brand percentage is decreasing while generic percentage is increasing. We have a 99.7% generic substitutin rate. Dr. Alstn pinted ut that we see that generic utilizatin is increasing, and generic cst cntinues t decrease. Dr. McIntire added the fllwing as a pint f recrd: a White Paper went ut frm NACDS and the American Pharmaceutical Assciatin t state gvernrs abut state Medicaid prgrams. It mentined specifically that pharmacists and cmmunity pharmacists still wanted t increase generic utilizatin and that if everyne culd increase t the level f Massachusetts (which was the highest in the cuntry at 72%), we culd save billins f dllars. We are at 81% in Tennessee. Dr. Wds added that this is definitely a testament t the fact that we are n par with the best f the best as far as generic utilizatin. TennCare Drug Utilizatin Data fr 2010: Ttal Ppulatin Highlights Overall seasnal changes cntributed t an increase in antibitics, antihistamines, and asthma meds. Pinting ut ADHD agents, we again saw a 7% PMPM increase in spend since 4Q2009 due t increased 9

10 utilizatin. Payment fr anticnvulsants decreased apprximately 17% PMPM ver last quarter due t mre generics cming n the market. The antiretrviral class payment increased 14% PMPM since 4Q2009. Drugs with ntable increases in payment amunt since 4Q2009 include: Abilify, methylphenidate, Subxne, and Vyvanse. Claim Vlume Per Age Grup Adults ver age 45 have the highest number f claims PUPQ with an average f Payment Amunt Per Age Grup The payment amunt fr the PPI categry decreased apprximately 34% PMPM, cinciding with TennCare switching the preferred PPI n the PDL n Octber 1, TennCare has nt seen a decrease in PPI use, hwever, preferred PPIs n the PDL are nw lwer-csting drugs. Dr. Wds mentined that the 34% decrease is prir t any rebates; factring in rebates results in a lwer verall cst. Tp 10 Therapeutic Classes by Payment Amunt (Adults) The payment amunt fr the atypical antipsychtics has increased apprximately 11.2% since 4Q2009 ptentially due t an increase in use fr MDD. Atypical antipsychtic use in MDD has been added as ne f ur DUR activities. Claim Vlume fr Children The highest ttal number f scripts is in the 0-6 year ld age grup, and the highest average number f claims PUPQ is amng ages 7-13 years ld. There was a decrease in narctic claim amunt f 8% PMPM ver 4Q2009 and 5% ver last quarter. Payment Amunt fr Children Ttal payment amunt as well as the highest payment amunt per claim PUPQ is in the 7-13 year ld age grup. Tp 10 Therapeutic Classes by Claim Vlume (Children) There was a 7% increase in claim vlume fr ADHD agents. Tp 10 Therapeutic Classes by Payment Amunt (Children) ADHD agents saw a 16% increase in ttal spend. Prspective Drug Utilizatin Review (PrDUR): Hard Rejects These edits will cause the claim t deny at the pint f sale (POS). Sft Rejects These edits will cause the claim t deny at the pint f sale; hwever with apprpriate dcumentatin, the pharmacy will be able t resubmit the rejected claim using Prfessinal Pharmacy Service (PPS) cdes. Sft Edits These edits will cause an alert r warning message t be returned t the dispensing pharmacist t infrm them f a ptential prblem. Tp 10 Therapeutic Duplicatin PrDUR Edits These include narctics, albuterl, and antidepressants. Tp 10 Early Refill PrDUR Edits Hydrcdne with acetaminphen is the mst cmmn early refill request, almst twice as many as gabapentin at #2. Dr. Randlph mentined the effect f February having 28 days n creating sme f these early refills. Dr. McIntire asked if there was any awareness f gabapentin abuse. Dr. Kizer mentined that he had heard frm the TBI that gabapentin prlngs crack highs, althugh Bard members did nt have any ther supprting infrmatin t this effect. Tp 10 Max Dse PrDUR Edits The tp edits in this categry include antibitics, H2 antagnists, narctics, PEG3350, and prmethazine. 10

11 Tp 10 Drug t Drug PrDUR Edits Mst cmmn are between ptassium supplements and ptassium-sparing diuretics. Als included are several warfarin interactins. Tp 10 Drug t Gender PrDUR Edits Drug t drug gender edits result in either a message r a sft reject. The message at the pint f sale fr pregnancy 4Q2010 was inferred frm the use f prenatal vitamins, althugh it is difficult t filter ut this infrmatin since nt all patients n prenatal vitamins wuld necessarily be pregnant. Dr. Randlph mentined that a hard diagnsis-gender edit shuld help decrease edits in patients receiving prenatal vitamins. Pharmacy Lck-In Prgram: Dr. Lvett presented an update n the Pharmacy Lck-in prgram. Evaluatin f candidates fr the lck-in and re-review prgram fr 1Q2011 had been cmpleted as f the start f the meeting. Letters had been sent and re-reviews thrugh 4Q2010 have been cmpleted. As previusly mentined, the criteria fr lck-in includes a review f the fllwing in a 90 day perid: Multiple cntrlled substances Multiple pharmacies Multiple prescribers Maximum daily dsage Pharmacy Lck-in Numbers are steadily increasing Fr 4Q 2010, a ttal f 163 recipients were lcked in fr Octber, Nvember, and December. In Octber 2010, 37 recipients were lcked in In Nvember 2010, 55 recipients were lcked in In December 2010, 71 recipients were lcked in The ttal number f recipients lcked in during 2010 was 462 Re-review criteria Recipients wh are lcked in and are fund t be nncmpliant may be escalated t PA status fr all cntrlled substances, if they meet 3 f 4 f the fllwing criteria ver a 3 mnth perid: 3 cash prescriptins verified by CSD review 2 prescribers 2 pharmacies Cncurrently using Subxne with anther narctic Unlck criteria Recipients wh are already lcked in may be unlcked during the re-review prcess if they meet the fllwing criteria ver a 6 mnth perid: N cash prescriptins fr medicatins cvered by TennCare N cntrlled substances while taking Subxne Utilizing nly 1 pharmacy Utilizing nly 1 physician Dr. McIntire mentined that the State is trying t figure ut the lgistics f lcking peple in t ne pharmacy wh are using Subxne. 4Q2010 Re-review A ttal f 75 recipients currently in the lck-in prgram were selected fr re-review, including referrals received frm prviders and OIG. 4Q2010 results: 13 Enrllees escalated t PA status 11

12 5 unlcked 44 remain lcked in In respnse t Dr. Swarr s request frm the September 2010 DUR Bard meeting, Dr. McIntire presented examples f recipients being cnsidered fr remval frm lck-in (unlck), with bth 6-mnths and 12-mnths f claims histry. In mst recipients it did nt make a difference in terms f utcmes. Dr. Wds mentined that currently if they meet criteria then the recipient will be unlcked r escalated t PA. It has been prpsed that a review step is included s that if they meet criteria, then they wuld be cnsidered t be unlcked. Dr. Swarr added that he felt it shuld be harder t de-escalate r remve frm lck-in. Lck-in Pharmacy change requests Lck in candidates are allwed 1 pharmacy change per calendar year Exceptins: Pharmacy des nt have medicatin in stck Pharmacy is clsed and an SXC Clinical Pharmacist, after reviewing with the pharmacist making the request, determines that the situatin is an emergency Recipient has mved (verified by address in system nt just patient prvided infrmatin) Candidates requesting 1 change during the year that is nt deemed an emergency r wh have medicatin remaining are nt allwed an verride. Dr. McIntire mentined that plicy currently states that recipients are allwed 1 change a year. He prpsed that maybe the plicy shuld state they may be allwed 1 change a year t allw review fr numerus factrs. It was the cnsensus f the Bard that this wuld be apprpriate. Dr. Lvett added that ne-time change patients remain lcked-in t the riginal pharmacy. Als, cnsideratin will need t be given t lcking patients int a particular physician. Lcking int a pharmacy is nt always sufficient since sme patients d s much dctr hpping. 4Q2010 lck in verride requests: Ttal f 88 requests 29 were denied 59 requests were apprved Review f RetrDUR Activities: Dr. Alstn reviewed the RetrDUR activities which were perfrmed in RetrDUR Activities fr 2010 An activity in 4Q2010 fcused n recipients using lng-acting narctics at dses greater than 400mg/day f mrphine r mrphine equivalent 51 recipients reviewed 59 prescribers were cntacted via letter Respnses received frm activities in 2010: 1Q2010 we cnducted a Plypharmacy activity fcused n recipients with at least 14 prescriptins written by at least 4 different prescribers and filled by at least 3 different pharmacies. Recipient claims histries were reviewed ver a 90-day perid. The prescriber respnse rate was 22.22%, and f that 54.24% 12

13 thught it was useful. The Bard fund it interesting that 20.34% f the respndents said they were aware f the situatin, and yet the respndents did nt appear t be cncerned. The 2Q2010 activity fcused n tramadl addictin. Letters were sent t prescribers f recipients with 150 days f therapy in a 180 day perid. The respnse rate was 19.22% and ut f that 77.21% thught that it was very useful. The DUR activity fr 3 rd and 4 th quarter f 2010 fcused n recipients using Singulair with an inferred diagnsis f Allergic Rhinitis. Letters were sent t 1711 prescribers that invlved 5328 recipients. Prescribers fr recipients wh did nt have claims submitted fr any asthma medicatin and did nt have a first-line agent in their prfile fr allergic rhinitis (nn-sedating antihistamine, nasal antihistamine, r nasal sterid) within the past 12 mnths received a letter. We received apprximately a 15% respnse rate t the letter and 62% thught it was useful. Ideas fr Future DUR Activities fr RetrDUR it was mentined earlier in the meeting that TennCare will cnduct an activity arund the use f atypical antipsychtics by recipients diagnsed with Majr Depressive Disrder (MDD). In additin, the fllwing ideas were presented: cncmitant therapy with ADHD meds and narctics/hypntics, use f atypical antipsychtics in yung children, use f high dse lng-acting narctics (>400 mg/day f mrphine r equivalent), and cmpliance with ribavirin. Review f Prvider Practice Analysis Activities: Prvider Practice Analysis Activities 2010 An educatinal ntice was sent t prescribers with The Advisry Cmmittee n Immunizatin Practices (ACIP) recmmendatins and the TennCare criteria fr the influenza seasn. Apprximately 3000 prescribers were lettered. During 4Q2010, an educatinal letter n Nrvir was sent t prescribers infrming them f TennCare s preference fr the use f Nrvir capsules ver the tablets, due t a difference in cst. Infrmatin in the letter als cvered details regarding heat-sensitivity issues with the Nrvir capsules, and that the heat-sensitivity issue shuld nt be a cncern since the capsules can be stred at rm temperature fr 30 days and TennCare nly allws dispensing f ne mnth at a time. Cpies f the letters were prvided t Bard members. The semiannual Tp Narctic Prescribers letter saw a great respnse rate f 81.5%. 56% said they were aware f the situatin. Dr. Wds mentined that with this activity, we ften receive a lt f feedback frm the prescribers justifying their prescribing habits. Dr. Wds als mentined this is nly sent ut t the tp 100 since it is a tedius prcess t review these prescribers fr their specialties. Our Fraud and Abuse activity in 1Q2010 fcused n identifying suspected cases f fraud and abuse, and addressed prper ways t reprt ccurrences t the Tennessee Drug Diversin Task Frce as well as OIG. There was nt a big respnse t this letter, but the few respnders gave really gd ntes and really appreciated the effrts. 13

14 In 2Q2010 a letter was sent ut t prescribers n the prper tapering f PPIs. The target audience was prescribers fr recipients using PPIs fr 150 days ut f a 180 day perid. The respnse rate was 14% f which 50% said they were aware, and 62% said it was useful. A shrt-acting narctic initiative letter was sent t prescribers fr recipients wh received greater than 6 mnths f a shrt-acting narctic withut als using a lng-acting narctic. 17% f the prescribers respnded f which 76% thught it was useful. The State is lking t make changes s that a patient wh des nt have a diagnsis f chrnic irretractable pain wuld need t be switched t a lng-acting narctic. A graph was presented that shwed that each time the letters have been sent, there has been a crrespnding decrease in usage. Fr the time perid f September f 2009 t September f 2010 there was a 6% decrease in shrt-acting narctics claims. Fr the perid f September 2010 t December 2010 there was apprximately a 7.5% decrease in shrt-acting narctic claims that crrelated with timing f the letters. Dr. Wds mentined that unfrtunately we still have apprximately 90,000 claims/mnth hitting s we still have a ways t g befre it wuld nt verlad the call center t have a PA required n these prducts. Dr. Hudsn mentined the ptential benefit f cycling these letters mre ften. Dr. Wds asked the cmmittee if cycling letters quarterly wuld be apprpriate and all agreed. Dr. Alstn mentined the pssibility f having Prvider Educatrs visit specific prescribers f recipients wh shw n decrease in shrt-acting narctic vlume fllwing receipt f the letters. During 3Q2010 an influenza refresher was sent ut. Only a 6% respnse was received, f which 63% fund it useful. During 4Q2010 the letter was sent ut related t Nrvir. 8% respnded, 85% fund it useful, and 42% said they were aware f the difference between capsules and tablets, but preferred t keep their patients n the tablets. Ideas fr Future Prvider Practice Analysis Activities The fllwing ideas fr future Prvider Practice Analysis Activities were presented: tp narctics prescribers, smking cessatin in pregnant wmen, A/B rated generics, Andrgel /Testim educatin, rhabdmylysis risk with statin therapy cmbinatins, and use f prmethazine in children less than 2 years ld. The letters fr smking cessatin in pregnant wmen were annunced t be ging ut within the next tw weeks. Wrap-Up: Dr. Swarr asked if the TBI ever visits the tp 10 physicians with this data. Dr. Randlph mentined that the TBI is restricted frm sme f this data. Dr. Kizer added that all parties invlved are wrking tward the same reasnable gal versus letting everybdy with a badge in the state lk at any patients list f medicatins in the state. 14

15 Dr. Wds asked that the Bard members cmplete the Cnflict f Interest Statements, add any disclsures, and sign and date. These are required t be cmpleted annually. Next DUR Bard Meeting scheduled fr June 14, Meeting Adjurned 15