Connecticut Medical Assistance Pharmacy Program Drug Utilization Review (DUR) Program DUR Board Meeting

Transcription

1 June 2008 Minutes ATTENDEES Board Members Present: Kenneth Fisher, R.Ph. (Chair); Dennis Chapron, M.S.; Richard Gannon, Pharm.D.; Keith Lyke R.Ph., Mike Moore, R.Ph., MPH; Bhupesh Mangla, M.D., Ram Illindala, M.D.; Lori Jane Duntz, R.Ph., Charles Caley, Pharm. D., BCPP; Angela Moemeka, M.D., F.A.A.P. Ex-Officio Non-Voting Member Present: Heather L. Wagner, Pharm. D. (HID DUR Board Coordinator and Secretary) Guests: Joe Paradis, Pharm.D. (HID); James Zakszewski, R.Ph. (DSS); Robert Zavoski, M.D. (DSS); Herman Kranc, R.Ph. INTRODUCTORY BUSINESS The DUR Board Chairman, Kenneth Fisher called the meeting to order at 6:45 p.m. OLD BUSINESS Heather Wagner introduced two new Board members, Charles Caley, Pharm. D., BCPP; and Angela Moemeka, M.D., F.A.A.P. The two new Board members were unanimously voted in by the existing Board members via an on-line poll conducted prior to the meeting. Robert Zavoski, M.D. was also introduced to the Board as the new Medical Director of the Department of Social Services. RETROSPECTIVE DRUG UTILIZATION REVIEW A. CMS Report The Board began reviewing the CMS report Heather Wagner reported that the table of contents and the CMS survey could be found on pages 2-6 of the CMS report.

2 June 2008 Minutes The Board members reviewed these sections and had no questions, changes, or suggestions. Heather Wagner reported that table 1 of the CMS report could be found on pages 7-10 and included Pro DUR criteria used during FFY 2007 submitted by EDS. The Board members reviewed table 1 and had no questions, changes, or suggestions. Heather Wagner reported that table 2 of the CMS report could be found on pages and included Retrospective DUR criteria used during FFY 2007 submitted by ACS. The Board reviewed table 2 and had no questions, changes, or comments. Heather Wagner reported that Attachment 1 of the CMS report could be found on pages Heather reported that Attachment 1 is a report on the monitoring of pharmacy compliance with all prospective DUR requirements performed by the State Medicaid agency and the State Board of Pharmacy. It was also included that Attachment 1 contained the Pharmacy Profile Data Sheet used to monitor compliance with oral counseling requirements. The Board reviewed Attachment 1 and had no questions, changes, or comments. Heather Wagner reported that Attachment 2 of the CMS report could be found on pages and is the year end summary report on prospective DUR screening using the on-line POS system. It was noted the top three pro DUR alerts set for FFY 2007 were therapeutic duplication, high dose, and drug-drug interaction. Charles Caley asked if alerts set and claims screened (columns found in all tables in Attachment 2) could be defined by EDS. Heather Wagner stated she would ask EDS and send a response to all Board members. The Board discussed possibly customizing the Pro DUR alerts due to some alerts seeming unnecessary. An example was given that the therapeutic duplication alert will hit on a patient taking two alternating strengths of coumadin.

3 June 2008 Minutes Mike Moore pointed out that pharmacists realize the patient is taking two different strengths and alternating the doses and simply over-ride the alert if the medications are written by the same prescriber and contain alternating directions. But the alert has a purpose and it is for safety reasons. Lori Jane Duntz stated the alert also notifies pharmacists when the patient is receiving a medication from another pharmacy Attachment 2 was further discussed by Robert Zavoski who commented on overridden alerts versus no response, found in the first table on page 17 The Board requested that EDS look into the denied claims for therapeutic duplication and therapeutic duplication versus ingredient duplication for the second quarter and provide the DUR outcomes. It was also requested to define drug-drug interaction, found in all tables in Attachment 2, and what EDS uses as a denominator for the value defined. It was stated the Board members had no additional questions, changes, or comments for Attachment 2. Heather Wagner reported that Attachment 3 of the CMS report could be found on pages and is a year end summary report on Retrospective DUR screening and interventions. Charles Caley commented that the Therapeutic Class Codes (HIC-3 codes) were non descriptive. The Board had no further questions, changes, or comments regarding Attachment 3. Heather Wagner reported that Attachment 4 of the CMS report could be found on pages and is a brief descriptive report on the DUR Board activities during the FFY It was stated that attachment 4 includes the summary of the FFY 2007 DUR Board meeting minutes, approved criteria selections, and quarterly provider newsletters. The Board reviewed Attachment 4 and had no questions, changes, or comments. Heather Wagner reported that Attachment 5 of the CMS report could be found on pages and describes and policies in place to encourage the use of therapeutically equivalent generic drugs.

4 June 2008 Minutes The Board questioned how the Generic Utilization Rate (GUR) could be increased. Keith Lyke commented on the OTC formulary for FFS and how helpful it is. It was suggested that Heather Wagner mention coverage of OTC s in the next quarterly newsletter. The Board had no further questions, changes, or comments regarding Attachment 5. Heather Wagner reported that attachment 6 of the CMS report could be found on pages and contains the evaluations and cost savings estimates for FFY RetroDUR and Lock-In cost savings from Recipient Profiling in FFY 2007 was $1,057, or $88, per month ProDUR cost savings in FFY 2007 was estimated to be a total of $604, on 14,366 prescriptions for recipients o $465, in Medicaid Savings o $113, in ConnPace Savings o $25, in CADAP Savings The Board reviewed Attachment 6 and had no questions, changes, or comments. The Board approved the CMS report contingent upon Heather Wagner and EDS following up with specific questions pertaining to the Pro DUR section of the report. B. Initial Criteria Exception Report (ICER) Heather Wagner went over the major and moderate severity top criteria exceptions from the April ICER. Charles Caley asked what ICER stood for and Heather explained it is the Initial Criteria Exception Report which illustrates the criteria exceptions (potential problem areas) for FFS pharmacy claims. Angela Moemeka asked for a brief explanation of the Lock-In program. Heather Wagner explained the Lock-In program is the monitoring of patients who frequently abuse controlled substances.

5 June 2008 Minutes It was also explained that DSS, upon recommendations from HID, can lock patients into a pharmacy if there is gross over-utilization of controlled substances occurring. A patient would then only be able to use one pharmacy to obtain all medications filled through the Connecticut Medical Assistance Program. Rich Gannon asked how a risk score is calculated. Joe Paradis explained risk score to be an internal ranking number assigned to patients that is based on a number of variables but is largely determined by the number of physicians, pharmacies, and medications that a patient utilizes. Heather Wagner stated she would send the risk score calculation document to the Board members. Joe Paradis stated that the most useful application of the risk score occurs when evaluating therapeutic duplication and over utilization criteria. Heather Wagner asked the Board members to look at criteria hit 454 (therapeutic duplication of atypical antipsychotics), under moderate severity. Heather explained that although there were 5519 patients who hit on therapeutic duplication of atypical antipsychotics, only 2291 were patients that were prescribed two different ingredients within the atypical class. Charles Caley commented that some patients do better on combination antipsychotic therapy, but there is no basis for it pharmacologically. The Board commented that a newsletter regarding atypical antipsychotics and metabolic syndrome might be useful. Lori Jane Duntz commented that HID should be careful of what specialty type HID sends intervention letters to. She further explained that a psychiatrist who discharged a patient from the hospital wrote for ibuprofen and received a letter regarding duplicate NSAID therapy because the patient had been prescribed ibuprofen from another physician. Heather Wagner stated that currently there is no way to tell the prescriber specialty when reviewing the profiles. Heather Wagner stated, going back to atypical antipsychotics and metabolic syndrome, that she would run a report in the next ICER to find the amount of patients who are taking an atypical antipsychotic and also at risk for metabolic syndrome.

6 June 2008 Minutes Dennis Chapron mentioned that HID should look into creating criteria for Diamox and Topamax, since both lower intraocular pressure. Diamox lowers intraocular pressure through the inhibition of carbonic anhydrase. Heather Wagner stated she would ask HID s criteria manager, Pam DeRuiter to develop a new criteria. C. New Criteria Selections Heather stated for future Board meetings the new criteria selection sheets would be sent to the Board members prior to the meeting so they would have a chance to review them. Criteria 1, Cardio Post MI Drugs, was rejected by the DUR Board sighting criteria number two as a more specific alert message to physicians. Criteria 2, Cardio Post MI Drugs, was approved by the DUR Board. Angela Moemeka suggested looking in the Federal Register to help with treatment guidelines for certain criteria. Criteria 3, Atypical Antipsychotics/ Triple Therapy, was rejected by the DUR Board. Criteria 4, Antipsychotics-All/ Triple Therapy, was approved by the DUR Board. Kenneth Fisher asked Charles Caley if Abilify should have its own column in the breakdown of criteria 4 since it is a partial dopamine agonist. Charles Caley stated while this is true, Abilify can stay where it is for now. Criteria 5, Risperdal Consta/ Oral Atypical Antipsychotics, was approved by the DUR Board. Charles Caley stated it is common to see a patient on both Risperdal Consta and Clozapine or on both Risperdal Consta and low dose quetiapine. Joe stated that if the Board members see anything in their daily practice that may be of interest, to let Heather Wagner know and HID can look into the request and evaluate it based on the Connecticut population. Criteria 6, Atypical Antipsychotics/ Therapeutic Appropriateness, was approved by the DUR Board contingent upon the removal of Oppositional Defiance Disorder from Util B.

7 June 2008 Minutes Charles Caley stated the diagnoses for Quetiapine are expanding. Soon there will be an FDA approved indication for the use of Quetiapine to treat Generalized Anxiety Disorder (GAD). Charles Caley also stated it would be interesting to look at the various indications that atypical antipsychotics are being prescribed for in Connecticut. Joe Paradis stated the reason for so many new criteria regarding Pristiq were included in the packet is because it is a new drug. Criteria 7, Desvenlafaxine/ High Dose, was approved by the DUR Board. Criteria 8, Desvenlafaxine/ Nonadherence, was approved by the DUR Board contingent upon the alert message reading: Pristiq (desvenlafaxine) nonadherence may result in sub-therapeutic effects, which may lead to decreased patient outcomes and additional medical cost. Criteria 9, Desvenlafaxine/ Renal Impairment Dose, was approved by the DUR Board. Criteria 10, Desvenlafaxine/ MAO Inhibitors, was approved by the DUR Board contingent upon the addition of linezolid and oral selegiline to Util B. Criteria 11, Desvenlafaxine/ Venlafaxine, was approved by the DUR Board. Criteria 12, Desvenlafaxine/ Serotonergic Agents, was approved by the DUR Board contingent upon the addition of venlafaxine to Util B. Criteria 13, Desvenlafaxine/ Aspirin & NSAIDs, was tabled by the DUR Board. Dennis Chapron stated Paxil and Prozac stand out more as medications that would interact with NSAIDs to increase risk of bleeding, and that low dose Aspirin does not carry the same risk. Criteria 14, Desvenlafaxine/ Warfarin, was tabled by the DUR Board. Dennis Chapron asked if HID could look into dual inhibitors (SNRIs) and their effect on platelets, and if they had the same effect as the SSRIs. Criteria 15, Desvenlafaxine/ Potent CYP 3A4 Inhibitors, was approved contingent to the addition of fluoxetine, nefazadone, and fluvoxamine to Util B. D. Lock-In Program Heather Wagner reviewed the April statistics for the lock-in program.

8 June 2008 Minutes Heather Wagner stated 453 lock-in profiles were reviewed, 526 cases were created, and 567 physician letters were mailed. This included lock-in and DUR letters. Heather Wagner commented that pharmacy letters, for both the lock-in and regular DUR programs, were sent out for the month of April due to a miscommunication. Sending pharmacy letters is an option Connecticut has chosen to not participate in at this time. E. Regular DUR Heather Wagner went over the April statistics for the regular DUR program. Heather Wagner stated 1150 regular DUR profiles were reviewed which resulted in 2635 prescriber letters generated and 1077 prescriber letters being mailed. Heather Wagner explained the reason 2653 letters were generated and only 1077 letters were mailed was mainly the result from the NPI implementation. Heather further explained that HID receives a provider file from EDS. Some of the NPIs sent in the provider file are missing physician names, and addresses that should be linked to the NPI. To address this issue HID has found a source for a national NPI database created and updated by CMS that can be used to run against the provider file sent from EDS. Heather discussed the criteria used from the April ICER which were listed as: o Therapeutic duplication of skeletal muscle relaxants o Therapeutic duplication of NSAIDs and/or COX 2 inhibitors o The brand name product Soma (Carisoprodol) has generic equivalents available o Carisoprodol is intended for short term use. Carisoprodol is metabolized by the liver to meprobamate and patients may be at risk for developing dependence. o Carisoprodol may be over-utilized. The manufacturer s recommended maximum daily dose is 1400mg. Higher doses may cause increased sedation and dizziness.

9 June 2008 Minutes Heather mentioned the top 200 top risk score patients were also selected and reviewed for the April cycle. After the list of criteria was read the Board members were shown the letter types physicians received for each criteria. F. Newsletter Heather briefly discussed the quarterly newsletter sent to all providers in Connecticut in June. Heather explained it discussed the use of tamper resistant prescription pads and the implementation of the NPI. NEW BUSINESS The Board agreed to review criteria 2532 {Ambien CR (zolpidem extendedrelease) may be over-utilized. The recommended dose of extended-release zolpidem in non-elderly adults is 12.5 mg immediately before bedtime}, and the methadone dose titration warning criteria for the July cycle. Dennis Chapron mentioned if a patient is receiving Ambien CR and a 3A4 inducer (e.g. carbamazepine, phenytoin) to take that into consideration the patient may need the higher dose of Ambien CR. The date for the next meeting was confirmed for September 11, The meeting was adjourned at 9:30 pm.