TennCare Drug Utilization Review Advisory Board. November 13 th, 2012 Catamaran

Transcription

1 TennCare Drug Utilization Review Advisory Board November 13 th, 2012 Catamaran

2 Agenda Call to Order Introductions Approval of Previous Minutes / Additions to the Agenda TennCare Update Guest Speaker Dr. Mitchell Mutter, MD, Medical Director Special Projects, State of Tennessee Department of Health, Division of Health Licensure and Regulation Old Business Retrospective Category Review- Amphetamines Standing Business Blocking Non-Participating Providers TennCare Drug Utilization Data RetroDUR and Provider Practice Activity Review Pharmacy Lock-In Review New Business Adjournment SXC Health Solutions, Inc

3 Review of Minutes September 11 th, 2012 Catamaran

4 TennCare Updates David Collier, MD Ray McIntire, D.Ph Catamaran

5 Guest Speaker Dr. Mitchell Mutter Medical Director Special Projects Department of Health Division of Health Licensure and Regulation

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7 A State Comparison: Annual Prescriptions per Capita 2011 All Products Rank State Per Capita Rank State Per Capita 1 West Virginia Florida Kentucky Oklahoma Tennessee Illinois Alabama Wisconsin Rhode Island Virginia District of Columbia New Jersey Louisiana South Dakota Mississippi Vermont North Dakota Minnesota Ohio Maryland Pennsylvania Texas Massachusetts Arizona South Carolina New Hampshire Missouri Oregon Arkansas Montana New York Nevada Nebraska Utah North Carolina Idaho Maine Washington Kansas Wyoming Michigan New Mexico Indiana Hawaii Connecticut California Georgia Colorado Iowa Alaska Delaware Puerto Rico N/A Average of all states = annual prescriptions per capita

8 A State Comparison: Annual Prescriptions per Capita 2011 CII Products Rank State Rx per Capita Rank State Rx per Capita 1 Delaware Indiana Tennessee Virginia Maine Arkansas Massachusetts Washington District of Columbia Georgia New Hampshire Oklahoma Rhode Island Colorado West Virginia North Dakota Maryland Nevada Ohio Montana Louisiana New Mexico North Carolina Minnesota Pennsylvania Michigan South Carolina Mississippi Connecticut New York Alabama Iowa Kentucky Nebraska Vermont Alaska Oregon Idaho Wisconsin South Dakota Arizona Wyoming Utah Illinois Kansas Hawaii New Jersey Texas Florida California Missouri Puerto Rico NA All states =.41 annual prescriptions per capita

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12 The individuals or entities that have access to the database are: personnel of the committee; authorized committee, board or department of health personnel; pharmacists; prescribers; Office of Inspector General and other authorized TennCare personnel, and the Medicaid Fraud Control Unit. Law enforcement personnel engaged in an official investigation and enforcement of state and federal controlled substance laws are allowed to request information from the database pursuant to Tenn. Code Ann (a)(6). In order to ensure that only those authorized individuals and entities have access, the Board of Pharmacy employs the following security measures:

13 Each user has separate ID and password Only prescribers and dispensers have password access Prescription data is submitted twice monthly Release of data to unauthorized party may result in a Class A misdemeanor Failure of a dispenser to repeatedly report to the database is referred to the appropriate board for disciplinary action Legislature mandated using the database to evaluate prescribing and dispensing habits in 2011 Annual Report generated and presented to the General Assembly by February 1

14 Before initial prescribing of opioids and benzodiazepinesmay add other drugs later At least annually thereafter if that treatment continues Exceptions: o Hospice Patient o Post-Surg patient (from a licensed facility) with a prescription which is non-refillable o Non-refillable prescription for 7 day supply or less o Veterinarians

15 As of today we have approximately 275 certified pain clinic in the state of Tennessee since beginning certifying pain clinics. In order to obtain a certificate as a pain management clinic, an applicant shall submit the following to the Department: Completed application on a form prescribed by the department. Proof of a medical director who is a physician who practice in TN. Medical Director also need to be on-site at the clinic at least 20% of the clinic weekly total number of operating hours

16 Proof of having obtain DEA registration for the clinic Proof of DEA registration for all individual who provide pain management services at the clinic Criminal background checks for all owner (whole or partial) List of everyone who will provide pain management services for the clinic (employee or contract employee) Disclosure of any license denial, restrictions or discipline imposed on the owner and any employee who provide services at the clinic Payment of the application fee and initial certification fee and Any other information requested by the Department

17 Upon the inspection of a pain management clinic by the boards regulating the health care providers working for or at the clinic, the owners, officers, employees, or authorized representatives of the pain management clinic shall allow board representatives access to the pain management clinic and the records contained therein, including, but not limited to medical records. The owners, officers, employees or authorized representatives of the pain management clinic or independent contractors working at the pain management clinic shall provide copies of all documentation, including but not limited to medical records, requested by the board regulating the health care providers working for or at the clinic, in connection with an inspection or investigation of the pain management clinic in accordance with T.C.A

18 The medical director shall ensure that each health care provider employed by or working at a certified pain management clinic shall maintain complete and accurate medical records of patient consultation, examination, diagnosis, and treatment, which shall include, but not be limited to the following: Patient medical history Physical examination Diagnostic, therapeutic, and lab results Evaluation and consultations

19 Treatment objectives Documentation of informed consent and discussion of risks and benefits of treatment provided Treatment and treatment options Medication prescribed (including date, type, dosage and quantity prescribed) Instructions and agreements Periodic reviews Reason for prescribing and dispensing more than a 72 hour dose of controlled substances for the treatment of chronic nonmalignant pain Notation indicating whether the controlled substance monitoring database had been accessed for the patient Copies of records and reports or other documentation obtain from other health care providers Result of urine drug screen to be performed as indicated but a minimum upon new admission (6 months thereafter)

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21 Retrospective Category Review Amphetamines Catamaran

22 Amphetamine Class Review Retrospective review of TennCare Claims Indications and Contraindications Dosage recommendations in the manufacturer s package insert (as approved by the FDA) Treatment Guidelines Prospective DUR (MAX dose) edits currently used by TennCare via Catamaran Board Recommendations SXC Health Solutions, Inc

23 Amphetamine Class Review Retrospective review of TennCare Claims Amphetamine claims for the six month period from 4/25/ /24/2012 were used. Total of 5488 adult users within the six month period Total of 3588 adult users with at least 3 claims or greater in the six month period Average daily dose among 3588 adult users with at least 3 claims = 41.84mg 301 users with a daily dose greater than 70mg Average daily dose for the subset of users taking over 70mg per day = 87.03mg 111 users with a daily dose greater than or equal to 90mg SXC Health Solutions, Inc

24 Amphetamine Class Review Retrospective review of TennCare Claims Review concentrated on those users of greater than or equal to 90mg of amphetamine per day In addition to TennCare pharmacy claims, the following were also added to the analysis for each user: State of Tennessee s Controlled Substance Database profile Encounter data from TennCare s MIS system, including diagnoses and procedure information SXC Health Solutions, Inc

25 Amphetamine Class Review SXC Health Solutions, Inc

26 Amphetamine Class Review Retrospective review of TennCare Claims Diagnoses that were labeled as problematic : Essential hypertension (14) Bipolar 1 (13) General Anxiety Disorder (7) Anxiety state, unspecified (7) Opioid dependence (5) Insomnia related (4) Post-traumatic Stress Disorder (4) Type II Diabetes (4) Agoraphobia (4), Atrial Fibrillation (1), Edema (1) SXC Health Solutions, Inc

27 Amphetamine Class Review Retrospective review of TennCare Claims Diagnoses that were labeled as possible off-label : Malaise and fatigue (11) Major Depressive Disorder (9) Depressed Mood, or depression not elsewhere classified (7) Obesity (4) Obstructive Sleep Apnea (1) SXC Health Solutions, Inc

28 Amphetamine Class Review Indications and Contraindications FDA approved for treatment of attention-deficit hyperactivity disorder (ADHD), treatment of narcolepsy Diagnoses that were labeled as possible off-label : Malaise and fatigue (11) Major Depressive Disorder (9) Depressed Mood, or depression not elsewhere classified (7) Obesity (4) Obstructive Sleep Apnea (1) SXC Health Solutions, Inc

29 Amphetamine Class Review Dosage recommendations in the manufacturer s package insert (as approved by the FDA): Max Ped Daily Dose Narcolepsy Max Adult Daily Dose ADHD Max Adult Daily Dose Narcolepsy Max Ped Daily Brand Name Dose ADHD Adderall 40mg 60mg 40mg 60mg Adderall XR 30mg N/I 30mg N/I Desoxyn 25mg N/I 25mg N/I Dexedrine spansule 40mg 40mg 40mg 60mg Dextrostat 40mg 40mg 40mg 60mg ProCentra 40mg 40mg 40mg 60mg Vyvanse 70mg N/I 70mg N/I SXC Health Solutions, Inc

30 Amphetamine Class Review Treatment Guidelines: No U.S. based treatment guidelines with suggested maximum doses by product exist. Commonly used, universally accepted guidelines available: NICE- National Institute for Health and Clinical Excellence (UK) CADDRA- Canadian ADD Resource Alliance SXC Health Solutions, Inc

31 Amphetamine Class Review SXC Health Solutions, Inc

32 Amphetamine Class Review Prospective DUR (MAX dose) edits currently used by TennCare: Catamaran s system utilizes Medi-Span s Master Drug Data Base (MDDB) for drug data and DUR data In the MDDB, attached to each drug record, is the drug s MIN and MAX dose, assigned by Medi-Span Within each plan s setup, Catamaran assigns a specific multiplier, which taken times each drug s MAX dose, will result in either a hard or soft DUR reject. The current multiplier, 225%, of a drug s MAX dose results in a soft reject, unless other edits have been added with higher priority. SXC Health Solutions, Inc

33 Amphetamine Class Review Amphetamines with current Quantity Limits: MaxDose Dose per MaxDose TennCare MaxDose Max Poss Drug (units) unit (mg) (mg) Qty Limit x 225% w/o PA LISDEXAMFETAMINE DIMESYLATE CAP 20 MG LISDEXAMFETAMINE DIMESYLATE CAP 30 MG LISDEXAMFETAMINE DIMESYLATE CAP 40 MG LISDEXAMFETAMINE DIMESYLATE CAP 50 MG LISDEXAMFETAMINE DIMESYLATE CAP 60 MG LISDEXAMFETAMINE DIMESYLATE CAP 70 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 5 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 10 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 15 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 20 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 25 MG AMPHETAMINE-DEXTROAMPHETAMINE CAP SR 24HR 30 MG SXC Health Solutions, Inc

34 Amphetamine Class Review Amphetamines without current Quantity Limits: MaxDose (units) Dose per unit (mg) MaxDose (mg) MaxDose x 225% Max Poss w/o PA Drug DEXTROAMPHETAMINE SULFATE TAB 5 MG DEXTROAMPHETAMINE SULFATE TAB 10 MG DEXTROAMPHETAMINE SULFATE ORAL SOLUTION 5 MG/5ML DEXTROAMPHETAMINE SULFATE CAP SR 24HR 5 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 10 MG DEXTROAMPHETAMINE SULFATE CAP SR 24HR 15 MG METHAMPHETAMINE HCL TAB 5 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 5 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 7.5 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 10 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 12.5 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 15 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 20 MG AMPHETAMINE-DEXTROAMPHETAMINE TAB 30 MG SXC Health Solutions, Inc

35 Amphetamine Class Review Prospective DUR (MAX dose) edits currently used by TennCare: Because there have not been quantity limits added to several of the amphetamines, claims currently pay at 225% of the Medi-Span assigned MAX dose. Doses over 225% of the MAX dose currently result in a soft reject only, which can be overridden by pharmacy using PPS codes. Request that the Board review each product and assign an appropriate MAX dose, with a hard reject assigned for all doses over the MAX. SXC Health Solutions, Inc

36 Standing Business Catamaran

37 Population Highlights TennCare Population Stable at ~1.2 million members Non-Dual adults without Rx limits 8% Utilizing Members (3Q2012 vs. 3Q2011) Payment amount 5% Average Payment Per Claim/Utilizing member/ Eligible member, 6%, 5%, 4% Average Payment Per Claim $52.14 Catamaran

38 TennCare Pharmacy Data TennCare Statistics Utilization Data Population 3Q12 vs. 3Q11 TennCare Utilizing members Average Prescription Payments Total Population Drug class claim volume and payment amount Individual drug- claim volume and payment amount Adult Population (age 21 and above) Drug class claim volume and payment amount Individual drug- claim volume and payment amount Pediatric Population (ages 0 through 20) Drug class claim volume and payment amount Individual drug- claim volume and payment amount

39 TennCare Population Eligibility 3Q2012 3Q2011 %Change Non-Dual Children 739, ,184 (0.82) Non-Dual Adults with Rx Limit 325, , Non-Dual Adults without Rx Limit 6,446 7,036 (8.39) Dual Eligible Children (12.77) Dual Eligible Adults* 132, , Total TennCare Population 1,203,705 1,207,305 (0.30) Ave Pharmacy Utilizing Members per month < 21 (Children) 190,087 (25.7%) 188,208 (25.2%) 1.00 Ave Pharmacy Utilizing Members per month >= 21 (Adults) 188,454 (56.8%) 186,779 (56.6%).90 * No prescription benefits through TennCare

40 TennCare Utilizing Members 3Q2012 3Q2011 %Change # Utilizing Members / Month 379, , # Prescriptions / Month 1,066,657 1,048, Total Amount Paid / Month $62,757,825 $65,985,210 (4.89) Average # Rxs / Utilizing Member / Month Average Amount Paid / Claim $58.89 $62.91 (6.39) Average Amount Paid / Utilizing Member Average Amount Paid / Eligible Member $ $ (5.79) $52.14 $54.64 (4.57)

41 Average Prescription Payment 3Q2012 3Q % 0.25% Utilization Utilization 15.76% 0.31% 88.01% 83.93% Average Payment Brand: $ Brand Originator: $ Generic: $28.09 Average Payment Brand: $ Brand Originator: $ Generic: $25.47

42 42 Utilization Data Total Population Catamaran.

43 Utilization Highlights 3Q12 Narcotic Analgesic Claim Volume 3.42%PMPM Total population Hydrocodone 6.20% Adults 5.6%, Children Oxymorphone payment 30.36%PMPM Decrease utilization, secondary to drug shortage Hepatitis Agents payment amount 31.38% PMPM Incivek payment 33.64% Adults top drugs by claim volume 1 st line therapy for common medical conditions Hypertension, Diabetes, GERD Catamaran

44 Top 10 Therapeutic Classes By Claim Volume Rank Therapeutic Class 3Q12 # Claims 3Q12 Rank 2011 # Claims 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Narcotic Analgesics 313, ,375 (3.42) (0.32) 2 Anticonvulsants 138, , ADHD 121, , Sympathomimetics 117, , NSAIDs 114, , Penicillins 112, , (0.83) 7 Antihistamines 2nd Gen 109, , (7.56) 8 SSRI 104, ,288 (1.78) Atypical Antipsychotics 72, ,785 (0.37) (0.66) 10 Proton Pump Inhibitors 68, , SXC Health Solutions, Inc

45 Top 10 Therapeutic Classes By Payment Amount* Rank Therapeutic Class 3Q12 Payment 3Q12 Rank 2011 Payment 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 ADHD $21,149,539 2 $17,965, Atypical Antipsychotics $19,074,190 1 $29,126,698 (34.23) (16.28) 3 Narcotic Analgesics $11,060,448 3 $12,180,034 (8.80) Anticonvulsants $9,659,781 4 $9,861,333 (1.62) (0.95) 5 Antiretrovirals $8,128,946 6 $6,964, Sympathomimetics $8,072,168 7 $6,914, Insulin $8,063,700 8 $6,721, Antihemophilic products $6,357,246 9 $6,277, (16.41) 9 Proton Pump Inhibitors $5,647, $4,552, Steroid Inhalants $4,355, $3,833, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

46 Top 10 Drugs By Claim Volume Rank Drug 3Q12 # Claims 3Q12 Rank 2011 # Claims 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Hydrocodone/APAP 169, ,040 (6.20) (1.06) 2 Albuterol 99, , Amoxicillin 73, , Cetirizine 68, , (6.93) 5 Azithromycin 57, , Montelukast 57, , (5.78) 7 Ibuprofen 52, , Lisinopril 52, , (0.72) 9 Gabapentin 44, , Oxycodone/APAP 44, ,406 (0.16) (0.48) SXC Health Solutions, Inc

47 Top 10 Drugs By Payment Amount* Rank Drug 3Q12 Payment 3Q12 Rank 2011 Payment 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Aripiprazole $9,109,169 3 $8,259, (0.63) 2 Amphetamine Salts $6,682,385 4 $5,703, Albuterol Sulfate $4,452,091 8 $3,630, Lisdexamfetamine $4,317,219 7 $3,770, Montelukast $4,256,394 2 $8,464,000 (49.49) (55.68) 6 Methylphenidate $4,228,355 6 $4,066, (1.16) 7 Dexlansoprazole $4,162,931 9 $3,352, Somatropin $3,039, $2,915, Quetiapine $2,762,360 1 $8,842,598 (68.63) Buprenorphine/Naloxone $2,712, $3,323,086 (18.02) * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

48 48 Utilization Data Adult Population (Ages 21 and older) SXC Health Solutions, Inc.

49 Top 10 Therapeutic Classes By Claim Volume- Adults Rank Therapeutic Class 3Q12 # Claims 3Q12 Rank 2011 # Claims 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Narcotic Analgesics 265, ,129 (2.61) Anticonvulsants 105, , SSRIs 83, ,176 (3.53) NSAIDS 79, , ACEIs 63, , (1.01) 6 Proton Pump Inhibitors 56, , Sympathomimetics 56, , Skeletal Muscle Relaxants 55, , (0.30) 9 Statins 53, ,309 (0.29) (0.29) 10 Atypical Antipsychotics 44, ,404 (0.25) (0.64) SXC Health Solutions, Inc

50 Top 10 Therapeutic Classes By Payment Amount*- Adults Rank Therapeutic Class 3Q12 Payment 3Q12 Rank 2011 Payment 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Atypical Antipsychotics $12,722,958 1 $20,901,395 (39.41) (20.10) 2 Narcotic Analgesics $10,558,624 2 $11,625,106 (9.60) Antiretrovirals $7,740,531 4 $6,420, Anticonvulsants $6,767,360 3 $6,703, (0.23) 5 Insulins $6,743,519 5 $5,547, Proton Pump Inhibitors $4,615,203 7 $3,750, Sympathomimetics $4,175,473 8 $3,528, Hepatitis Agents $3,676,803 6 $5,333,350 (31.38) (23.43) 9 ADHD Agents $3,101, $2,286, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. 10 Multiple Sclerosis Agents $2,660, $2,253, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

51 Top 10 Drugs By Claim Volume- Adults Rank Drug 3Q12 # Claims 3Q12 Rank 2011 # Claims 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Hydrocodone/APAP 143, ,047 (5.61) (0.41) 2 Lisinopril 50, , (0.66) 3 Albuterol 44, , Gabapentin 42, , Oxycodone/APAP 39, , Metformin 31, , (0.41) 7 Citalopram 29, ,535 (11.65) (1.44) 8 Levothyroxine 28, , Omeprazole 28, , Amlodipine 27, , SXC Health Solutions, Inc

52 Top 10 Drugs By Payment Amount*- Adults Rank Drug 3Q12 Payment 3Q12 Rank 2011 Payment 3Q11 PMPM% Δ Year 3Q12-3Q11 PMPM% Δ Qtr 2Q12-3Q11 1 Aripiprazole $4,722,802 2 $4,253, (1.20) 2 Dexlansoprazole $3,852,802 6 $3,065, Buprenorphine/Naloxone $2,547,114 5 $3,171,425 (20.06) Quetiapine $2,231,309 1 $6,958,085 (68.08) Telaprevir $2,185,999 4 $3,278,807 (33.64) (15.33) 6 Insulin Glargine $2,135, $1,701, Albuterol $2,026, $1,678, Oxymorphone $1,830,649 7 $2,616,499 (30.36) (10.25) 9 Amphetamine Salts $1,694, $1,187, Emtricitabine/Tenofovir $1,694, $1,414, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

53 53 Utilization Data Child Population (Ages 0 through 20) SXC Health Solutions, Inc.

54 Top 10 Therapeutic Classes By Claim Volume- Chlidren Rank Therapeutic Class 3Q12 # Claims 3Q12 Rank 2011 # Claims 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 ADHD Agents 104, , Antihistamines, 2nd Gen 87, , (7.20) 3 Penicillins 83, , (1.51) 4 Sympathomimetics 61, , Leukotriene Modulators 52, , (6.08) 6 Narcotic Analgesics 48, ,154 (11.20) (2.58) 7 Macrolides 39, , Cephalosporins 37, , (6.03) 9 Glucocorticosteroids 35, , NSAIDS 34, , SXC Health Solutions, Inc

55 Top 10 Therapeutic Classes By Payment Amount*- Children Rank Therapeutic Class 3Q12 Payment 3Q12 Rank 2011 Payment 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 ADHD Agents $18,048,149 1 $15,682, Atypical Antipsychotics $6,351,233 2 $8,279,219 (22.65) (7.42) 3 Antihemophilic Factor $4,986,217 4 $4,811, (11.23) 4 Sympathomimetics $3,896,696 5 $3,397, Leukotriene Modulators $3,850,630 3 $7,741,698 (49.85) (56.21) 6 Steroid Inhalants $3,557,736 7 $3,147, Growth Hormones $2,965,210 8 $2,882, Anticonvulsants $2,892,421 6 $3,162,521 (7.78) (2.61) 9 Cephalosporins $1,800,217 9 $1,731, (10.74) 10 Insulin $1,320, $1,179, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

56 Top 10 Drugs By Claim Volume - Children Rank Drug 3Q12 # Claims 3Q12 Rank 2011 # Claims 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Cetirizine 59, , (6.69) 2 Amoxicillin 59, , Albuterol 54, , Montelukast 52, , (6.10) 5 Azithromycin 37, , Loratadine 26, ,417 (3.05) (8.27) 7 Amphetamine Salts 26, , Hydrocodone/APAP 25, ,993 (13.07) (4.51) 9 Ibuprofen 24, , (0.42) 10 Lisdexamfetamine 24, , SXC Health Solutions, Inc

57 Top 10 Drugs By Payment Amount* - Children Rank Drug 3Q12 Payment 3Q11 Rank 2011 Payment 3Q11 PMPM% Δ Year 3Q11-3Q12 PMPM% Δ Qtr 2Q12-3Q12 1 Amphetamine Salts $4,987,743 2 $4,515, Aripiprazole $4,389,329 3 $4,006, Methylphenidate $4,099,776 4 $3,949, (1.26) 4 Lisdexamfetamine $3,887,879 5 $3,446, Montelukast $3,850,087 1 $7,777,403 (50.08) (56.20) 6 Somatropin $2,965,210 6 $2,883, Albuterol $2,426,415 8 $1,952, Dexmethylphenidate $1,998, $1,624, Guanfacine HCL $1,577, $1,002, Coagulation Factor VIIA $1,457, $1,527,116 (3.75) (12.35) * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

58 58 Prospective Drug Utilization Review (ProDUR) 1 st Quarter 2012 SXC Health Solutions, Inc.

59 Definitions - Edits/Rejections ProDUR Edit A computer system review of the member s medication history Identifies potential drug therapy problems prior to dispensing the medication. Examples would include but not limited to: Therapeutic Duplication (TD), Early Refill (ER), Max Dose, Drug to Gender, Drug to Drug, Drug to Inferred Disease, Geriatric and Pediatric Warnings Types of Rejections: Hard Reject These edits will cause the claim to deny at the point of sale (POS) Soft Reject- These edits will cause the claim to deny at the point of sale. However, with appropriate documentation the pharmacy will be able to re-submit the rejected claim using Professional Pharmacy Service (PPS) codes Message These edits will cause an alert or warning message to be returned to the dispensing pharmacist to inform them of a potential problem. SXC Health Solutions, Inc. 59

60 Summary of ProDUR Edits Remains steady Drug Gender Edit New to the list: Revlimid SXC Health Solutions, Inc

61 Top 10 Therapeutic Duplication ProDUR Drug Name Conflict Drug Name Total % Paid Albuterol Albuterol 71, % Hydrocodone/APAP Hydrocodone/APAP 37, % Buprenorphine/Naloxone Buprenorphine/Naloxone 12, % Risperidone Risperidone 10, % Gabapentin Gabapentin 10, % Quetiapine Quetiapine 9, % Citalopram Citalopram 9, % Clonidine Clonidine 9, % Lisinopril Lisinopril 9, % Sertraline Sertraline 9, % SXC Health Solutions, Inc

62 Top 10 Early Refill ProDUR Edits* Drug #Edits Albuterol 10,604 Lisinopril 7,258 Gabapentin 6,944 Hydrocodone/APAP 5,251 Citalopram 5,210 Clonidine 5,138 Risperidone 4,450 Sertraline 4,243 Montelukast 4,043 Levothyroxine 3,917 *Hard reject at point of sale SXC Health Solutions, Inc

63 Top 10 Max Dose ProDUR Edits Drug Name Hydrocodone/APAP Polyethylene Glycol 3350 Cefdinir Promethazine Ibuprofen Amoxicillin/Clavulante Amphetamine Salts Oxycodone/ APAP Cyclobenzaprine Cetirizine Total % Soft Edits % Paid 16, % 83.6% 10, % 90.6% 7, % 97.6% 5, % 91.9% 4, % 96.2% 3, % 97.1% 3, % 90.2% 2, % 85.0% 2, % 89.9% 1, % 87.5% SXC Health Solutions, Inc

64 Top 10 Drug to Drug ProDUR Edits* Drug Name Conflict Drug Name Total % Paid Spironolactone Potassium 1, % Triamterene/HCTZ Potassium % Amiodarone Warfarin % Sulfamethoxazole/TMP Warfarin % Warfarin Tricor % Lithium Lisinopril/HCTZ % Lithium HCTZ % Sertraline Clozapine % Fluconazole Warfarin % Fluoxetine Clozapine % *Major severity / soft reject at point of sale

65 Top 10 Drug to Inferred Diagnosis Pregnancy Drug Name Total % Paid Hydrocodone/APAP Promethazine Ibuprofen Oxycodone/APAP Metronidazole Nitrofurantoin Fluconazole Azithromycin Albuterol Acetaminophen/Codeine 2, % 2, % 2, % 1, % % % % % % % SXC Health Solutions, Inc

66 Top 10 Drug to Gender ProDUR Edits Drug Name Total % Paid Emtricitabine/Tenofovir 1, % Ritzariptan % Ribavirin % Sumatriptan % Tamsulosin % Abacavir/Lamivudine % Emtricitabine/Rilpivirine/Tenofovir % Prenatal Vitamins* % Lenalidomide % Valganciclovir % *hard reject at point of sale SXC Health Solutions, Inc

67 Top 10 Geriatric Precaution ProDUR Warnings Drug Name Total % Paid Hydrocodone/APAP % Amlodipine % Simvastatin % Warfarin % Metformin % Citalopram % Hydrochlorothiazide % Quetiapine % Atorvastatin % Atenolol % *Medispan defines geriatric as 64 years of age SXC Health Solutions, Inc

68 Top 10 Pediatric Precaution ProDUR Warnings Drug Name Total % Paid Montelukast 31, % Clonidine 22, % Cetirizine 17, % Ibuprofen 15, % Risperidone 14, % Hydrocodone/APAP 14, % Dexmethylphenidate 12, % Methylphenidate 11, % Azithromycin 10, % Lisdexamfetamine 9, % *Soft reject at point of sale SXC Health Solutions, Inc

69 69 Review of DUR Activities SXC Health Solutions, Inc.

70 Review of RetroDUR Activities 3Q2012 July: Lithium Precautions Patient profiles reviewed: 1131 Provider letters sent: 405 Patients addressed: 791 August/September: Poly Pharmacy Patient profiles reviewed: 1600 Provider letters sent: 208 Patients addressed: 1180 Catamaran

71 Review of Provider Practice Analysis Activities 3Q2012 Top Narcotic Prescriber Short Acting Narcotic Initiative Prescribers Identified: 200 Prescribers Selected and Lettered Specialist: 78 Non-Specialist: 108 Dentist: 14 Prescribers Identified: 2,268 Prescriber Lettered: 800 Catamaran

72 Ideas for Future DUR Activities: (RetroDUR) Activities Non-Compliance with Antiretroviral Agents Potential Drug interaction between ACE-Inhibitor and NSAIDs Catamaran

73 Ideas for Future DUR Activities: Provider Practice Analysis Treatment of Atrial fibrillation Fraud and Abuse ACS and Antiplatelet Management Catamaran

74 Pharmacy Lock-In Program Catamaran 74

75 Member-Pharmacy Lock-In Criteria Criteria includes a review of the following in a 90 day period: Multiple controlled substances Multiple pharmacies Multiple prescribers Targeted pharmacies and prescribers Maximum Daily Dosage Use of buprenorphine for addiction treatment 75

76 Lock-In Criteria CRITERIA 1 CRITERIA 2 CRITERIA 3 CRITERIA 4 CRITERIA 5 3 controlled substances 2 controlled substances 2 controlled substances 2 controlled substances 2 controlled substances 3 pharmacies 2 pharmacies 1 targeted pharmacy(ies) 2 pharmacies 1 targeted pharmacy(ies) 3 prescribers 2 prescribers 2 targeted prescribers 1 targeted prescriber(s) 1 targeted prescriber(s) Percentage of Maximum Daily Dosage - N/A 100% of Maximum Daily Dosage 90% of Maximum Daily Dosage 90% of Maximum Daily Dosage 95% of Maximum Daily Dosage CRITERIA 6 Suboxone usage 76

77 Pharmacy Lock-In Monthly Totals Month 2012 Lock-In 2011 Lock-In January 0 40 February 0 43 March April May June July August September October 86 November 61 December 63 TOTAL Catamaran 77

78 3Q2012 Re-Reviews Escalation to PA Unlock Members meets 3 of the 4 following criteria over a 3 month period 3 cash prescriptions (verified by CSD) 2 Physicians 2 Pharmacies Concurrently using Suboxone with another narcotic No cash prescriptions for medications covered by TennCare Utilizing only 1 pharmacy Utilizing only 1 physician Not Locked-In Lock Now: 0 Remain on PA Status: 8 Escalate to PA Status: 21 Total enrollee profiles selected for re-review: 152 OIG Referrals: 1 Remove Lock-In: 39 Remain Locked-In: 83 Catamaran 78

79 3Q12 Lock-In Change Requests Number Changes Denied: 18 Total Lock-In Change Requests 3Q12: 143 Number Changes Approved: 125 Common Denial Reasons Wants pharmacy distance away when others are closer Doctor/Pharmacy shopping Claims recent move, but no address change and refuse to give new address Catamaran 79

80 Lock-In Pharmacy Change Requests Locked-In recipients are allowed 1 pharmacy change per calendar year. Exceptions: Pharmacy does not have medication in stock, verified by SXC call center (after hours) or TennCare during regular business hours Pharmacy is closed, and a clinical pharmacist at SXC call center, after a conversation with the pharmacist requesting an override, and after chart review, determines the situation is an emergency. Recipient has moved (verified by address entered in SXC s system) Recipient has been voluntarily dismissed by their pharmacy Candidates requesting 1 change during the year that is not deemed an emergency or medication remaining are not allowed an override. 80

81 81 Next Meeting: TBA Catamaran