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

Transcription

1 March 2015 Minutes ATTENDEES Board Members Present: Kenneth Fisher, R.Ph. (Chair), Keith Lyke R.Ph., Bhupesh Mangla, MD, Richard Gannon, Pharm.D., Charles Caley Pharm.D. BCPP, Ram Illindala, MD, Carol Drufva R.Ph. Ex-Officio Non-Voting Member Present: Heather Kissinger, Pharm. D. (HID), James Zakszewski, R.Ph. (DSS), Herman Kranc, R.Ph. (DSS), Jason Young, Pharm.D. (HP) Guests: Gillian Stephens (Astra Zeneca), David Putelo (ViiV), Janice Pertoso (Alkermes) INTRODUCTORY BUSINESS Ken Fisher called the meeting to order at 6:42 p.m. It was announced that Herman Kranc is the DSS pharmacy manager. A. Previous Meeting Minutes The December 2014 DUR meeting were approved with no changes. B. Follow-Up from Previous Meeting The Board reviewed section 3 titled Follow-up from the December Follow-up 1, a request was made to know whether pregabalin use exacerbates congestive heart failure from a blood volume aspect. Heather Kissinger stated that pregabalin induced CHF seems to be caused by an increase in fluid retention that can be attributed to the inhibition of L type calcium channels. Follow-up 2, a request was made to create an informational alert at the point of sale stating that buprenorphine dosages higher than 24 mg daily have not been demonstrated to provide a clinical advantage. Heather stated that this alert is set to post and pay if a patient is receiving > 24mg/day of buprenorphine. Follow-up 3, a request was made to have query results for the following: Recipients who received controlled substances from 5 or more prescribers in a 30 day period Recipients who received controlled substances from 5 or more prescribers in a 60 day period Recipients who received controlled substances from 5 or more pharmacies in a 30 day period Recipients who received controlled substances from 5 or more pharmacies in a 60 day period Recipients who received any controlled substance prescription with a concurrent diagnosis of poisoning in the past 180 days. 1

2 March 2015 Minutes Heather reviewed the results of the queries with the Board and noted that these query requests stemmed from possible new pharmacy restriction criteria being developed for the Connecticut Medicaid Program. Heather requested to know if the DUR Board was interested in developing additional pharmacy restriction criteria based on the results of the requested queries. Ram Illindala requested to know if a patient s dose of a controlled substance was reduced after the poisoning event, would the criteria still hit. Heather stated that it would but the pharmacist reviewing the individual patient profiles would take a dosing reduction into consideration post poisoning when deciding to send an alert letter. Ram suggested requiring two poisoning diagnoses to be required for the criteria to identify patients. Heather stated that patients will often have multiple poisoning diagnoses on the same date of service, especially if the poisoning was due to a combination of medications. Rich Gannon asked if the criteria could be further targeted to identify patients receiving controlled substances from 5 or more prescribers. Heather stated that the pharmacist reviewing the individual profiles does include a prescriber count for controlled substances. Jim Zakszewski stated that if the Board wanted to approve this criteria for use, the Department of Social Services legal department would have to review and approve also. Jim requested that a reference to the Prescription Monitoring Program (PMP) be placed in the alert message of the criteria and that the word poisoning be underlined. Keith requested to know if all prescribers are required to enroll in the PMP. Ram stated that all prescribers of controlled substances are required to enroll. Herman added that prescribers are also required to report all controlled substances they write for. Rich added that patients who may be paying cash for controlled substances can be identified by utilizing the PMP. The Board requested that the controlled substance use with a concurrent diagnosis of poisoning within the past 180 days be added as an additional pharmacy restriction criteria. Heather stated that once the requested modifications were made to the alert message and letter type, she would send the documents to Jim, who would request the legal department s approval. Follow-up 4, a request was made to have the 2015 DUR meeting dates sent to the DUR members after the meeting. Heather stated that this request was completed. C. Criteria Trend Summary Heather discussed the criteria trend analyses tables included in the DUR Board meeting packet. The tables list the number of criteria exceptions found before and after DUR intervention letters are mailed. Criteria are suppressed for patients who are selected for intervention for 6 months after letters are mailed so that prescribers do not receive the same letter for the 2

3 March 2015 Minutes same patient month after month. In almost all cases the number of criteria exceptions noted 7 months after DUR letters were mailed was reduced as compared to the number of exceptions prior to letters being mailed. D. Program Summary Review The Board reviewed the program summary for 4 th quarter Heather stated that compared to the 3 rd QTR 2014 prescription claims cost increased by approximately $11 million, the number of prescriptions increased by approximately 50,000, the number of unique recipients receiving a prescription increased by approximately 13,000 and the average paid per prescription increased by about $13 during 4 th QTR Heather stated that the program summary from 4 th QTR 2010 was also included in the program summary review to show the Board that the Average paid per unique recipient per month has increased by approximately $115 and the average paid per prescription has nearly doubled in the past 5 years, all while the number of prescriptions and total number of unique recipients has stayed about the same. Also included in the program summary was a bar graph depicting CT average paid per recipient/month and average paid per RX/month compared with two other states in New England. Both the average paid per recipient/month and the average paid per RX/month were more than double what the other two states in the comparison group were reporting. Jim stated that Connecticut is required to cover medications that bring in Federal Rebate dollars, which could explain why there is such a difference in the comparative paid per recipient and RX amounts. E. Intervention Activity Report Heather reviewed the Intervention Activity Report included in the DUR Board packet. It was stated that the Intervention Activity Report is a monthly summary of the distribution of letters mailed to prescribers and also summarizes the main criteria that were reviewed each month. In October 2014, 2,835 profiles were reviewed and 2,640 letters were sent. The main intervention reviewed for the adult population was: ACEI may cause cough (649 letters) Lock-in criteria (658 letters) The main intervention reviewed for the pediatric population was: Underutilization of antimania medications, antidepressants, atypical antipsychotics, and long acting ADHD medications (161 letters) In November 2014, 2,843 profiles were reviewed and 3,506 letters were sent. The main intervention reviewed for the adult population was: Atypical Antipsychotics may exacerbate pre-existing diabetes (1359 letters) Lock-in criteria (654 letters) 3

4 March 2015 Minutes The main intervention reviewed for the pediatric population was: Antibiotic Utilization during the first year of life (1073 letters) In December 2014, 2,833 profiles were reviewed and 2,939 letters were sent. The main intervention reviewed for the adult population was: Overutilization of Narcotics and Therapeutic Duplication of Long Acting Opiates (318 letters) Lock-in criteria (893 letters) The main intervention reviewed for the pediatric population was: Guanfacine used concurrently with CNS depressants (542 letters) F. RetroDUR Criteria New Criteria The following criteria as written in the DUR Board packet were approved by the DUR Board 1. Vorapaxar / Overutilization 2. Vorapaxar / Therapeutic Appropriateness (Black Box Warning) 3. Vorapaxar / Other Antiplatelet Agents Negating 4. Vorapaxar / Other Antiplatelet Agents Negating 5. Vorapaxar / Anticoagulants 6. Vorapaxar / Agents Affecting Hemostasis 7. Vorapaxar / Strong CYP3A4 Inhibitors 8. Vorapaxar / Strong CYP3A4 Inducers 9. Vorapaxar / Hepatic Impairment 10. Vorapaxar / Non-adherence 11. Vorapaxar / Therapeutic Appropriateness 12. Umeclidinium-Vilanterol/ Overutilization 13. Umeclidinium-Vilanterol/ Black Box Warning 14. Umeclidinium-Vilanterol/ Cardiovascular, Convulsive Disorders, Thyrotoxicosis & Diabetes 15. Umeclidinium-Vilanterol / Strong CYP3A4 Inhibitors 16. Umeclidinium-Vilanterol / MAOIs, TCA & Other QT Prolong Meds *Charlie requested to know if this criteria was due to a class warning or if the list of drugs associated with the criteria came directly from the Anoro Ellipta prescribing information. Heather stated that she would follow-up in June. 17. Umeclidinium-Vilanterol / Non-Potassium Sparing Diuretics 18. Umeclidinium-Vilanterol / Nonselective Beta Blockers 19. Umeclidinium-Vilanterol / Anticholinergics 20. Umeclidinium-Vilanterol / Narrow Angle Glaucoma 21. Umeclidinium-Vilanterol / Urinary Retention 22. Fluticasone-Vilanterol / Overutilization 4

5 March 2015 Minutes 23. Fluticasone-Vilanterol / Black Box Warning 24. Fluticasone-Vilanterol / Cardiovascular, Convulsive Disorders, Thyrotoxicosis & Diabetes 25. Fluticasone-Vilanterol / Strong CYP3A4 Inhibitors 26. Fluticasone-Vilanterol / MAOIs, TCA & Other QT Prolong Meds 27. Fluticasone-Vilanterol / Non-Potassium Sparing Diuretics 28. Fluticasone-Vilanterol / Nonselective Beta Blockers 29. Dapagliflozin/Metformin / Overutilization 30. Dapagliflozin/Metformin / CKD Stage 3, 4 & 5 & ESRD 31. Dapagliflozin/Metformin / Therapeutic Appropriateness 32. Dapagliflozin/Metformin / Insulin & Insulin Secretagogues 33. Dapagliflozin/Metformin / Hypotension 34. Dapagliflozin/Metformin / Loop diuretics 35. Dapagliflozin / Nonadherence 36. Dapagliflozin/Metformin / LDL-C Increases 37. Dapagliflozin/Metformin / Bladder Cancer 38. Beclomethasone 40 mcg / Overutilization 39. Beclomethasone 40 mcg / Therapeutic Appropriateness 0-3 yoa 40. Amphetamine Sulfate / Overutilization 41. Amphetamine Sulfate / Overutilization Heather stated that criteria 40 and 41 were for new drug Evekeo, an amphetamine product indicated for the treatment of narcolepsy, obesity, and ADHD. Charlie stated that Vyvanse was recently approved to treat moderate to severe binge eating disorder in adult patients. He has already seen clinicians use this as treatment for binge eating associated with atypical antipsychotic treatment regimens. Charlie stated Prozac is the only other psychotropic medication that has an indication for an eating disorder. Jason Young stated that Evekeo to treat obesity would not be covered under Medicaid. Jim requested to know that if a claim came in for Evekeo and the patient had a diagnosis of narcolepsy and obesity, would the claim deny. Jason stated that the claim would pay because the patient has an approved diagnosis for treatment (narcolepsy), covered under the Medicaid benefit. The covered diagnoses are inherited through class for new drugs. The diagnosis of obesity would not negate the claim from paying because the patient has a valid diagnosis to use Evekeo. G. Top 50 Pharmacies and Prescribers of Controlled Substances The Board reviewed the top 50 pharmacies and prescribers of controlled substances report for 4 th QTR Charlie requested to know if poisoning diagnoses could be mapped to patients who received controlled substances from some of the top prescribers on the list. 5

6 March 2015 Minutes Heather stated she would request if this type of query could be run but suggested that benzodiazepines be added back to the top 50 pharmacies and prescribers reports since many drug poisonings are associated with this class of medications or combinations of opioids and benzodiazepines. Rich agreed that it would be beneficial to add BZDs back to the report and include them in the potential mapping query. Jim requested a cut off age of 70 for the mapping query. Heather stated she would follow-up during the June DUR meeting. H. Newsletter Heather stated an updated version of the March DUR newsletter had been included in the DUR packets. The Board approved the March 2015 Newsletter with minor changes. New Business Heather requested that the September DUR meeting date be moved to August. The Board approved the request and agreed on Wednesday August 26, The remainder of the 2015 DUR meeting dates were confirmed as o Wednesday June 10 th o Wednesday August 26 th o Wednesday December 9 th Heather stated the first draft of the CMS report would be sent to the DUR members on or before May 13 th (one month prior to the June meeting). The meeting was adjourned at 8:35 pm. 6