PharmaSuitables October Rich Price, MD Zach Kareus, Pharm.D. Steve Nolan, Pharm.D.

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1 PharmaSuitables October 2017 Rich Price, MD Zach Kareus, Pharm.D. Steve Nolan, Pharm.D.

2 Disclosures Rich, Zach, and Steve work for Rocky Mountain Health Plans. We do not have any financial interest in the medications we are discussing today. We have no intention to malign any person, business or product.

3 Question When treating ADHD, have you contemplated the need for an ODT methylphenidate formulation? A. Yes B. No C. Sounds like another Me too drug just got approved

4 Cotempla XR ODT (methylphenidate ER)

5 Approved June 19 th, Made by Neos Therapeutics Cost: $384/30 tabs (all strengths) Max dose 51.8mg = $768/30 days First ODT formulation of methylphenidate Cotempla XR is a methylphenidate base (like Daytrana patch) Not interchangeable Comes in 8.6mg *(10mg), 17.3mg *(20mg), and 25.9mg *(30mg) *(HCl equivalent)

6 Indication ADHD in pediatric patients 6 to 17 years of age Clinical studies Run in phase 4 week, open label, doseoptimization, N = 87 Initial dose = 17.3mg Titrate up weekly to 51.8mg (max dose) 1 week randomized, double blind, parallel group with optimized dose or placebo Used SKAMP Combined rating scale to evaluate efficacy

10 Mydayis (mixed amphetamine salts)

11 Approved June 20 th, Made by Shire pharmaceuticals Cost: $325/30 capsules 50mg max dosing (17+) = $325 25mg max dosing (13 17) = $325 7 th long acting amphetamine product on the market Extended duration of action 16 hours versus 12 hours Can be opened and sprinkled on apple sauce

12 Indication ADHD in children 13 years of age and older Clinical Studies Total of 5 studies All 4 week trials with total N = adult groups 2 pediatric groups

14 Question When is the next DEA drug take back day? A. November 3 rd B. Some time next year C. What is this? D. This Saturday (Oct 28 th ) from 10 2 with drop off location at the V.A. hospital

15 Drug Safety Program (DSP) from Rocky Mountain Health Plans Zach Kareus, Pharm.D. Clinical Pharmacist RMHP Carla Garcia RN, MSN, CARN AP Nurse Case Manager RMHP

16 DSP statistic 2015 rebranding Formerly called Single Source 206 of members currently enrolled DSP: 106 member DSP OUD: 100 members Stratification High Medium Low Maintenance

17 What is the RMHP Drug Safety Program? A multidisciplinary approach to make chronic opioid use more safe, predictable and effective Collaboration between RMHP, our members, providers, and pharmacies Promotes safe and appropriate opioid utilization Enhanced care coordination and communication addressing multiple aspect of patient care

18 Goal To reduce abuse and overdose of opioids and other controlled prescription drugs while ensuring members with pain are safely and effectively treated. Support to providers and pharmacies in treating difficult to manage individuals who may exhibit aberrant behaviors and/or require assistance with care coordination

19 Benefits to Providers Provide support in managing the patient s prescription regimen while promoting safety and appropriate care Facilitate safe use of medications Restricting payment for claims from other prescribers Support providers with tools Provider packet Case manager specializing in addiction

20 Benefits to Providers RMHP Case Manager can help: Facilitate utilization of resources Reinforce adherence to treatment plan Identify gaps in care Provide support and education based on member s needs Serve as a liaison between the health plan, provider, pharmacy and other health care team members

21 Hub and Spoke Model RMHP Care Coordinator Member Designated Provider Pharmacy Other prescribers

22 Building a Foundation of Safety Layers of oversight One prescriber One pharmacy Claims history ER utilization Relationship with pharmacy and prescriber Changing the stigmatism From dependency/abuse to safety

23 Who s eligible Commercial and Medicaid Multiple prescribers 3 or more Multiple pharmacies 3 or more High ER utilization Often lack primary care Concern for aberrant behaviors Combination of medications Opioids/benzodiazepine Opioids/benzodiazepines/Soma (carisoprodol)

24 Following a Referral Clinical Pharmacist reviews available data Claims history QHN Cannot access PDMP at this time Medical Directors review for approval and reach out to providers Dr. Betsy Longenecker Dr. Richard Price

25 Pharmacy Detailing Visited area pharmacies Discussed DSP program Support Importance of limiting cash fills Encouraged increased communication Clinical Decision Program is not intended to interfere or restrict clinical decisions

26 Referring a member Contact Pharmacy Help Desk Call Carla Garcia

27 Best Practice Drug toxicology screens At least every 6 months Check PDMP With every controlled script or at least quarterly Pain contracts Functional assessments Taper schedule Random pill counts Screening for abuse potential Behavior health consultation

28 Drug Toxicology Screens

31 Question What is the least expensive 30 day prescription drug commonly prescribed? A. Simvastatin B. Alendronate C. Lisinopril D. Metformin E. Forteo

32 Top 30 by Script Count

33 Top 30 by Cost/30 day Rx Rank Drug Name Average Day Supply Number of Scripts Avg Cost per 30 Days 1 HUMIRA PEN CROHNS DISEASE 28 2 $14, CIMZIA STARTER KIT 30 1 $10, COSENTYX SENSOREADY PEN $6, REMICADE 30 1 $6, STELARA $5, TALTZ $5, ENBREL $5, HUMIRA PEN $5, ENBREL SURECLICK $5, HUMIRA $4, COSENTYX 28 5 $4, ENBREL 28 3 $4, HUMIRA $4, SIMPONI $4, CIMZIA $4,156.10

34 Top 30 by Cost/30 day Rx Rank Drug Name Average Day Number of Avg Cost per Supply Scripts 30 Days 16 ORENCIA $4, ORENCIA CLICKJECT 28 6 $4, ACTEMRA $3, CIMZIA $3, XELJANZ XR 30 1 $3, XELJANZ 30 7 $3, OTEZLA $3, FORTEO $3, HUMULIN R U 500 KWIKPEN 34 6 $2, XIFAXAN $2, HUMULIN R U $1, TOPAMAX $1, LATUDA $1, VORICONAZOLE 30 6 $1, REPATHA SURECLICK 28 7 $1,202.94

35 Top 30 Breakdown Select ADHD Drugs Number of Scripts Select ADHD Drugs Cost Rank Drug Name Average Day Supply Number of Scripts Avg Cost per 30 Days Rank Drug Name Average Day Supply Number Avg Cost per of Scripts 30 Days 1 AMPHETAMINE/DEXTROAMPHETA 29 1,730 $ METHYLPHENIDATE HCL ER $ VYVANSE $ DEXTROAMPHETAMINE SULFATE $ CONCERTA $ RITALIN LA 44 9 $ DEXMETHYLPHENIDATE HCL ER 30 5 $ ADDERALL XR 30 4 $ METHYLPHENIDATE HCL 30 4 $ AMPHETAMINE/DEXTROAMPHETA 29 1,730 $ METHYLPHENIDATE HCL 30 4 $ DEXMETHYLPHENIDATE HCL ER 30 5 $ DEXTROAMPHETAMINE SULFATE $ METHYLPHENIDATE HCL ER $ VYVANSE $ ADDERALL XR 30 4 $ CONCERTA $ RITALIN LA 44 9 $415.24

36 Top 30 Breakdown Insulin Number of Scripts Insulin Cost Rank Drug Name Average Day Supply Number of Scripts Avg Cost per 30 Days Rank Drug Name Average Day Supply Number of Scripts Avg Cost per 30 Days 1 LANTUS SOLOSTAR $ HUMALOG $ LEVEMIR FLEXTOUCH $ HUMALOG KWIKPEN $ TRESIBA FLEXTOUCH $ HUMULIN 70/30 KWIKPEN $ HUMULIN R U $1, HUMALOG MIX 50/50 KWIKPEN $ BASAGLAR KWIKPEN 60 9 $ TOUJEO SOLOSTAR 52 9 $ HUMULIN R U 500 KWIKPEN 34 6 $2, HUMALOG MIX 50/ $ BASAGLAR KWIKPEN 60 9 $ TOUJEO SOLOSTAR 52 9 $ HUMALOG MIX 50/50 KWIKPEN $ LANTUS SOLOSTAR $ LEVEMIR FLEXTOUCH $ HUMALOG KWIKPEN $ HUMALOG $ HUMULIN 70/30 KWIKPEN $ TRESIBA FLEXTOUCH $ HUMALOG MIX 50/ $ HUMULIN R U $1, HUMULIN R U 500 KWIKPEN 34 6 $2,968.41

37 Top 30 Breakdown Inhalers Inhalers Rank Drug Name Average Days Supply Number of Scripts Avg Cost per 30 Days Rank Drug Name Average Days Supply Number of Scripts Avg Cost per 30 Days 1 PROAIR HFA 20 2,738 $ VENTOLIN HFA 20 1,275 $ ADVAIR DISKUS 32 1,014 $ SYMBICORT $ FLOVENT HFA $ SPIRIVA HANDIHALER $ DULERA $ BREO ELLIPTA $ ADVAIR HFA $ PROVENTIL HFA $ STIOLTO RESPIMAT $ ANORO ELLIPTA $ INCRUSE ELLIPTA $ ASMANEX HFA $ PROAIR RESPICLICK 24 7 $ FLUTICASONE PROPIONATE/SA 60 2 $ BEVESPI AEROSPHERE 30 2 $ PROAIR RESPICLICK 24 7 $ VENTOLIN HFA 20 1,275 $ FLUTICASONE PROPIONATE/SA 60 2 $ PROAIR HFA 20 2,738 $ PROVENTIL HFA $ ASMANEX HFA $ FLOVENT HFA $ SYMBICORT $ DULERA $ BREO ELLIPTA $ INCRUSE ELLIPTA $ ADVAIR HFA $ BEVESPI AEROSPHERE 30 2 $ STIOLTO RESPIMAT $ ANORO ELLIPTA $ ADVAIR DISKUS 32 1,014 $ SPIRIVA HANDIHALER $368.15

38 Top 30 Breakdown Rank Non Insulin Antidiabetic Drugs Number of Scripts Drug Name Average Days Supply Number of Scripts Avg Cost per 30 Days 10 METFORMIN HCL 34 3,335 $ METFORMIN HCL ER $ GLIPIZIDE $ GLYBURIDE $ JANUVIA $ VICTOZA $ GLIMEPIRIDE $ PIOGLITAZONE HCL $ TRADJENTA $ TRULICITY $ JARDIANCE $ FARXIGA $ BYDUREON PEN $ BYETTA $ INVOKANA $ TANZEUM 28 8 $ Rank Non Insulin Antidiabetic Drugs Cost Drug Name Average Days Supply Number of Scripts Avg Cost per 30 Days 10 METFORMIN HCL 34 3,335 $ GLIPIZIDE $ GLIMEPIRIDE $ PIOGLITAZONE HCL $ GLYBURIDE $ METFORMIN HCL ER $ FARXIGA $ TRADJENTA $ JANUVIA $ INVOKANA $ JARDIANCE $ TANZEUM 28 8 $ BYDUREON PEN $ VICTOZA $ BYETTA $ TRULICITY $690.10

39 Top 30 Breakdown Rank Drug Name Opioids Average Days Supply Number of Scripts Avg Cost per 30 Days 1 HYDROCODONE/ACETAMINOPHEN 11 5,851 $ OXYCODONE/ACETAMINOPHEN 9 4,119 $ TRAMADOL HCL 18 2,670 $ OXYCODONE HCL 15 1,992 $ MORPHINE SULFATE ER $ OXYCONTIN $ HYDROMORPHONE HCL $ FENTANYL $ MORPHINE SULFATE $ HYDROCODONE/IBUPROFEN $ OXYMORPHONE HYDROCHLORIDE $ CODEINE SULFATE 16 6 $78.64 Rank Drug Name Opioids Average Days Supply Number of Scripts Avg Cost per 30 Days 1 TRAMADOL HCL 18 2,670 $ HYDROCODONE/ACETAMINOPHEN 11 5,851 $ OXYCODONE HCL 15 1,992 $ MORPHINE SULFATE $ HYDROCODONE/IBUPROFEN $ HYDROMORPHONE HCL $ OXYCODONE/ACETAMINOPHEN 9 4,119 $ CODEINE SULFATE 16 6 $ MORPHINE SULFATE ER $ FENTANYL $ OXYMORPHONE HYDROCHLORIDE $ OXYCONTIN $415.08

40 Bottom 30 by Cost/30 day Rx Rank Network Drug Name Average Days Supply Number of Scripts Total Allowed Amount Total Per Script Avg Cost per Day Avg Cost per 30 Days 1 ME SIMVASTATIN 43 1,781 $6, $3.43 $0.08 $ ME HYDROCHLOROTHIAZIDE 41 2,132 $7, $3.59 $0.09 $ ME VITAMIN D $1, $3.02 $0.09 $ ME FOLIC ACID $1, $3.36 $0.10 $ ME ATENOLOL $3, $4.76 $0.12 $ ME LOVASTATIN $1, $5.61 $0.12 $ ME LISINOPRIL 38 5,267 $25, $4.91 $0.13 $ ME MELOXICAM $3, $4.05 $0.13 $ ME FUROSEMIDE 33 1,047 $4, $4.34 $0.13 $ ME ALENDRONATE SODIUM $1, $5.17 $0.14 $ ME ZOLPIDEM TARTRATE 31 2,006 $9, $4.49 $0.14 $ ME AMLODIPINE BESYLATE 39 1,540 $8, $5.69 $0.15 $ ME CITALOPRAM HYDROBROMIDE 35 2,552 $13, $5.14 $0.15 $ ME LISINOPRIL/HYDROCHLOROTHI 37 1,060 $6, $5.73 $0.15 $ ME METFORMIN HCL 34 3,335 $18, $5.42 $0.16 $4.78

41 Bottom 30 by Cost/30 day Rx Rank Network Drug Name Average Days Supply Number of Scripts Total Allowed Amount Total Per Script Avg Cost per Day Avg Cost per 30 Days 16 ME BENAZEPRIL HCL $ $5.44 $0.16 $ ME LOSARTAN POTASSIUM 40 1,199 $7, $6.55 $0.16 $ MECP OMEPRAZOLE 37 1,414 $8, $6.09 $0.16 $ ME GLIPIZIDE $1, $5.45 $0.17 $ MECP METOPROLOL TARTRATE $2, $7.75 $0.17 $ ME RAMIPRIL $ $10.42 $0.20 $ MECP ATORVASTATIN CALCIUM 45 1,092 $9, $9.11 $0.20 $ ME TERAZOSIN HCL $ $7.61 $0.21 $ ME CLOPIDOGREL $3, $7.48 $0.21 $ ME PANTOPRAZOLE SODIUM 34 2,194 $15, $7.21 $0.21 $ MECP FAMOTIDINE $ $6.94 $0.22 $ ME BISOPROLOL FUMARATE/HYDRO $ $10.96 $0.23 $ ME SERTRALINE HCL 33 4,024 $30, $7.70 $0.23 $ ME CARVEDILOL $4, $7.71 $0.23 $ ME ANASTROZOLE $ $9.71 $0.24 $7.11

42 12.00% 10.00% 8.00% 6.00% 4.00% Medicaid Private Pay 2.00% 0.00% 2017 Q Q Q Q Q Q Q Q Q Q Q Q Q Q Q 4

43 Top 6 opioids 25.0% HYDROCO/APAP TAB 5 325MG 20.0% OXYCOD/APAP TAB 5 325MG 15.0% TRAMADOL HCL TAB 50MG OXYCODONE TAB 5MG 10.0% HYDROCO/APAP TAB M 5.0% 3.7% 3.4% 3.0% OXYCOD/APAP TAB M 0.0%

44 Top 5 extended release opioids 1.6% 1.4% 1.2% Morphine Sulf 15mg ER Oxycontin 10mg Oxycontin 20mg Morphine 30mg ER Fentanyl Patch 50 mcg/hr 1.0% 0.8% 0.6% 0.4% 0.2% 0.0%

45 Opioid/benzo/carisoprodol The perfect storm the triple threat and known as The Holy Trinity in substance abuse circles Carisoprodol is metabolized extensively by the liver and is a substrate for the CYP450 2C19. The prevalence of CYP 2C19 ultra rapid metabolizers is about 16 21% in Caucasians and African Americans and 3% in Asians. Can lead to 4X increase in AUC Meprobamate is a major metabolite, and has a half life of about 10 hours (carisoprodol itself has a half life of approximately 2.4 hours) Meprobamate has anxiolytic and sedative properties resembling benzodiazepines. But, from a toxicity standpoint, it more closely resembles the properties of barbiturates

46 Opioid/benzo/carisoprodol Drug ingestions reported to the Texas Poison Center between 1998 and 2009 found that 1,295 cases overdosed on the drug combination of three different drugs: Hydrocodone (Vicodin, Lortab, Norco, Lorcet) Carisoprodol (Soma) Alprazolam (Xanax) ~42+ RMHP members statewide are on all three drugs ~17 of these are on the Western Slope

47 The Pharmacology and Toxicology of the 'Holy Trinity'. Horsfall JT 1, Sprague JE 2. Abstract Combining opioids with benzodiazepines and skeletal muscle relaxants ('The Holy Trinity') has been reported to potentiate the 'high'. Through unique interactions with co localized μ opioid and GABA A receptors, the combined use of these agents induces a synergistic increase in dopamine in the nucleus accumbens (NAc) and depression of respiration. The inhibition of GABA release mediated by μ 1 opioid receptor activation results in a subsequent increase in dopamine in the NAc. Benzodiazepines activate the GABA A R to suppress respiration in the medullary respiratory centres. The skeletal muscle relaxant, carisoprodol, appears to bind to a unique binding domain within the GABA A R to further enhance the respiratory depressant effects of the benzodiazepines. Therefore, the opioids, the benzodiazepines and carisoprodol alone or in combination are capable of inducing respiratory depression. Current guidelines for opioid prescribing recommend against the concomitant use of benzodiazepines but do not recognize the potential risk associated with the addition of skeletal muscle relaxants. Basic Clin Pharmacol Toxicol Feb;120(2): doi: /bcpt

THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM

THERAPEUTIC AREA NAME STRENGTH DOSAGE FORM Value Based Tier Drugs are selected for the management of Asthma, Diabetes, Hypertension and Hyperlipidemia. These drugs are covered at no charge or at a reduced cost share. Medications are under continual