TennCare Drug Utilization Advisory Board. October 1, 2013

Transcription

1 TennCare Drug Utilization Advisory Board October 1, 2013

2 Agenda Call to Order Introductions Approval of Previous Minutes / Additions to the Agenda TennCare Update David Collier, MD Old Business ProDUR Max Dose Analysis Katie Lockhart, MA Medication Therapy Management Denise Barker, PharmD Blocking Outlier Prescribers Standing Business TennCare Drug Utilization Data RetroDUR and Provider Practice Activity Review Pharmacy Lock-In Review New Business Adjournment

3 Review of Minutes July 9, 2013

4 Old Business ProDUR Max Dose Analysis Katie Lockhart, MA Senior Healthcare Analyst

5 Background Currently, the Prospective DUR Maximum Dose Edit is set at 225% The general consensus amongst the DUR Board was that the limit was exceedingly high No concrete recommendations have been offered at this time due to the ambiguity surrounding the ramifications from changing the limit. The goal of this analysis is to present relevant data to assist in determining which adjustment should be made to the ProDUR Max Dose edit, if any

6 Executive Summary Approximately 3% of claims a month exceed the FDB recommended max dose which account for 3.3% of total spend for the month. Only 0.1% of claims a month meet or exceed 225% of the FDB recommended max dose which account for 0.14% of total spend for the month. At 100% or below the FDB recommended max dose 60% or more of the claims belong to adults.

7 Data Assumptions Report encompasses data from July 1 st to July 31 st Adult max dose was applied to children. Final Status of a claim was used for this analysis. Medications could be unpaid based on criteria outside of max dose.

8 Potential Impact 40,000 35,000 30,000 25,000 20,000 15,000 10,000 Over FDB Max Dose 25% and over 50% and over 100% and over 150% and over 225% and over 5,000 0 # of claims # of distinct Patients # of Adult Claims # of Adult Patients # of Ped Claims # of Ped Patients

9 Potential Impact by Percentage 12.00% 10.00% 8.00% 6.00% 4.00% Over FDB Max Dose 25% and over 50% and over 100% and over 150% and over 225% and over 2.00% 0.00% % of claims % of distinct Patients % of Adult Claims % of Adult Patients % of Ped Claims % of Ped Patients % of Total Paid % of Total Paid Adult % of Total Paid Kid

10 Age Distribution of Children 700 Number of Kids with a claim over FDB Max Dose Total

11 Paid Percentages

12 Current Paid Percentage 90% 80% 70% 60% Paid Percentage 50% 40% % Paid All % Paid Adults % Paid Kids 30% 20% 10% 0% Over FDB Max Dose 25% Above Max 50% Above Max 100% Above 150% Above 225% Above

13 Tennessee Compared to Other States High Dose ProDUR Edit Analysis Piad Percentage (Bar) % of Total Claims (Line) State 1 (5%) State 2(15%) State 3(100%) Hard Edit Tennessee State 0 Paid Percentage % of claims

14 Next Steps and Recommendations

15 Conservative Scenario Change Max dose limit to 150% of FDB Considerations: Edit may be considered more clinically relevant Paid percentage <50% Less impact at point of sale versus other limits Potentially double (~1.8x) the impact vs current edit May not be very significant overall versus other limits

16 Aggressive Scenario Change Max dose limit to 25% above FDB Max Considerations: Impacting more than 10x current number of claims for current edit Point of sale impact may/may not over-burden pharmacists based upon claim volume (1.79%) Not alerting on claims at FDB max and may allow prescribers a dose titration above the max dose

17 Very Aggressive Scenario Change limit to 100% FDB Max dose as a hard edit Considerations: Hard edit would need to be overridden by PA Prescribers would be allowed a dose titration above FDB Max Relative significant increased impact Implementation strategy may be needed due to strain on call center Potentially more PA calls per day

18 Evolution of Pharmacist-Provided Clinical Services

19 Medication Therapy Management is a distinct service or group of services that optimize therapeutic outcomes for individual patients. Medication Therapy Management services are independent of, but can occur in conjunction with, the provision of a medication product. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model: Version March 2008

20 Med Therapy Reviews Immunizations Pharmacotherapy Consults Health, Wellness, Public Health Disease Management Coach / Support Med Safety Surveillance Pharmacogenomics Application Other Clinical Services Anticoagulation Management Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model: Version

21 A group of new services which have been offered by pharmacists for many years Reimbursable by Medicare, some state Medicaids, and some Private Payers

22 Sheet.pdf

23 MTM s Role in Health System Acute Care / Hospital Long-Term Care Ambulatory Care Accountable Care Organizations and Patient-Centered Medical Homes

24 Pharmacists Payers/ Insurers Patients Health Care Providers Employers

25 Have multiple chronic diseases Take multiple Part D drugs Incur annual costs for covered Part D drugs that exceed a predetermined level

26 Plan sponsors must offer all the following MTM services to eligible beneficiaries: Beneficiary and prescriber Interventions Comprehensive medication review (CMR) Annual Targeted medication review (TMR) Quarterly Follow-up interventions when necessary

27 Components of an MTM Service: Medication Therapy Review Personal Medication Record Medication-related Action Plan Intervention and/or Referral Documentation and follow-up Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model: Version March 2008

28 One-on-one session with individual patient (also Service delivered face-to-face, by telephone, or through other telehealth mechanisms Session may include patient s caregiver and family member(s) Full review of all medications and medication history Rx, OTC, vitamins, herbals, immunizations, etc. Review of past medical history and diseases Develop and Implement Medication-related Action Plan in collaboration with patient and primary care provider(s) Develop and Deliver Personal Medication Record to Patient May be Prompted or Requested

29 Plans work with documentation platforms to generate specific recommendations Recommendations based on Medicare criteria Overuse/underuse Suboptimal drug selection Omission of therapy Adverse side effects Patient profiles screened quarterly for Medicare plans Results in Irregular distribution to providers

30 MTM Services routinely provided by pharmacists Identifying gaps in medications and care Reducing medicationrelated adverse events Providing OTC medication recommendations Administering immunizations Educating patients on proper administration Increasing patient adherence to medications Managing Cost Effectiveness of medications Evaluating Underuse/Overuse Minimizing drug interactions Maximizing patient health outcomes And much more

31 Medicare PartD/MA-PD Platforms Mirixa OutcomesMTM PharmMD Solutions SOCRxATES Various private companies

32 Sheet.pdf

33 In 2012, 18 state Medicaid programs had some form of MTM program in place States: CA, CO, FL, IA, MN, MS, MO, MT, NM, NY, NC, OH, OR, UT, VT, VA, WI, WY Services range in scope from limited to broad Eligibility of beneficiaries ranges from small, specialized populations to all patients

34 Two Examples of Success Iowa: 31% of 3,037 eligible patients met with pharmacists 2.6 medication-related problems per patient 52% recommended new medication 31% recommended discontinuing medication Minnesota: 14% increase in meeting patient s goals 31% reduction in total health expenditures per patient (from $11,965 to $8,197) Savings exceeded cost by more than 12 to 1

35 Credentialed MTM Specialist Pharmacists Additional Services Offered by Plans to Patients Immunization Review and Administration Medication Adherence Consultations Disease Management Services Anticoagulation services, diabetes management, hypertension, hyperlipidemia, bone health, respiratory illness, mental health, etc. CLIA-Waived Testing Ex: Lipid Panels, A1C monitoring, INR monitoring, Genetic testing

36

37 Blocking Outlier Prescribers High Opiate Prescribers Ray McIntire, DPh

38 Background TennCare currently pays for prescriptions from all prescribers, regardless of their participation or network status. In 2011, TennCare pharmacy began to use a formal process to no longer pay for prescriptions from non-participating prescribers when they were found to be outliers in their prescribing habits. Process begins with identifying top narcotic prescribers, or the process has also began with a referral / complaint or when a prescriber has been in the media for being arrested or having their license disciplined.

39 Background In 2012, TennCare pharmacy moved away from the use of a list of high prescribers based on volume of opiates prescribed and percent of opiates prescribed. A new algorithm, which is still being evaluated for ways to improve, is intended to identify prescribers who: Prescribe many of the same types of opiates for many different patients, and appear to not evaluate each patient based on their own unique pain relief needs. Prescribe larger quantities of high-dose short-acting pure opiates compared with combination products and long-acting opiates Prescribe on average, more morphine equivalents than others All specialists and Suboxone prescribers are removed from the analysis

40 Background Once the top prescribers are identified, and candidates for blocking are chosen, TennCare s MCO s are notified. Once the MCO s verify that the prescriber is not needed for their network and agree to proceed, each prescriber is presented to TennCare s DUR Board, with blinded data for a final vote for either blocking or retaining. Prescribers are notified if blocked, and have 30 days to appeal. If the prescriber appeals, the DUR Board makes a final decision at the next quarterly meeting. All enrollees are notified that TennCare will no longer pay for prescriptions from their provider, and prescribers are referred to the State Board of Medical Examiners.

41 Candidates for Blocking TennCare pharmacy analyzed the opiate prescribing data for all prescribers with more than 50 opiate prescriptions in the 2 nd quarter of prescribers were analyzed The average number of opiate prescriptions per prescriber is 137. The highest number of opiate prescriptions was Four candidates selected for blocking were listed in the Top 100, and each prescriber has already been involuntary terminated from the MCO s due to their billing practices. Since they were already terminated by the MCO s it was not necessary to first refer these prescribers to the MCO s for signoff.

42 Prescriber#1 Both Prescriber#1, who is an Advance Practice Nurse, and the prescriber s Medical Director have been terminated from the MCO s for their billing practices. Prescriber#1 is not high volume, but is ranked #11 in the algorithm, and is an outlier in the following categories: Ratio of C-II to C-III opiates Ratio of Pure short-acting opiate to Combination products Average Morphine equivalents per patient per day. From TennCare claims the average MEQ per patient per day is 127mg. When claims from the CSDB are added, the total average MEQ per patient per day equals mg.

43 Prescriber#2 and Prescriber#3 Both Prescriber#2, who is an Advance Practice Nurse, and the prescriber s Medical Director (Prescriber#3) have been terminated from the MCO s for their billing practices. Prescriber#3, who is at least 80 years old, has claims in the TennCare paid algorithm, but all claims in the CSDB show up in Prescriber#2 s name. Prescriber#3 is #19 ranked in the algorithm, Prescriber#2 is #26 Due to data integrity issues, with pharmacies submitting different information to TennCare and to the CSDB, we are submitting both Prescriber#2 and Prescriber#3 for blocking. Prescriber#3 s License Verification with the State of TN shows Missionary Overseas

44 Prescriber#2 and Prescriber#3 Prescriber#2 has a higher volume and is an outlier in the following categories: Number of opiate prescriptions Average Morphine equivalents per patient per day. From TennCare claims the average MEQ per patient per day is 43.4mg. When claims from the CSDB are added, the total average MEQ per patient per day equals 95.88mg. For the 2 nd quarter, 330 additional prescriptions for CNS depressants were found on the CSMD, not found in TennCare claims.

45 Prescriber#2 and Prescriber#3 When looking at all claims, Prescriber#2 is commonly prescribing the cocktail for many patients, which is a combination of: Opiate analgesic Benzodiazepine Carisoprodol All non-opiate CNS depressants can be converted to diazepam equivalents. In addition to 96mg of MEQ per person per day, Prescriber#2 s patients also take on average 23.3mg of Diazepam equivalents per day.

46 Prescriber#4 Prescriber#4, is an Advance Practice Nurse, who has been terminated from the MCO s for because of billing practices. Prescriber#4 is high volume, and has a significantly lower percent of controlled substances to all paid claims (probably due to prescribing in a Family Practice and in a Pain Clinc), and is an outlier in the following categories: Number of Opiates Average Morphine equivalents per patient per day. From TennCare claims the average MEQ per patient per day is 91.32mg. When claims from the CSDB are added, the total average MEQ per patient per day equals mg.

47 Prescriber#4 When looking at all claims, Prescriber#4 is commonly prescribing the cocktail for many patients (opiate, benzodiazepine, carisoprodol). In addition to 216mg of MEQ per person per day, Prescriber#4 s patients also take on average 16.2mg of Diazepam equivalents per day.

48 Prescriber#5 Prescriber#5, is an Advance Practice Nurse, who has been terminated from the MCO s for because of billing practices. Prescriber#5 has a low volume of TennCare paid claims and claims on the CSMD, is ranked #85 in the algorithm and is an outlier only in the following category (borderline at that): Average Morphine equivalents per patient per day. From TennCare claims the average MEQ per patient per day is 54.95mg. When claims from the CSDB are added, the total average MEQ per patient per day equals 96.1mg. Our recommendation is to not block at this time, but to continue to monitor prescribing and utilization.

49 Standing Business

50 TennCare Pharmacy Data TennCare Statistics Utilization Data Population 2Q13 vs. 2Q12 vs. 1Q13 TennCare Utilizing members Generic Drug Utilization 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

51 Overall Population Statistics Utilizing Members 14.6% YOY reduction in Non-dual Adults without Rx Limit 5.2% YOY reduction in Utilizing members per month & 10.3% QOQ reduction in Utilizing members per month 3.8% reduction in Total amount paid / month

52 TennCare Population Eligibility 2Q2013 1Q2013 2Q2012 %Change (Quarter/ Quarter) %Change (Year/ Year) Average Total TennCare Population 1,202,313 1,204,740 1,200, % 0.2% Non-Dual Children 736, , , % -1.5% Non-Dual Adults with Rx Limit 327, , , % 1.7% Non-Dual Adults without Rx Limit 6,056 6,194 6, % -14.6% Dual Eligible Children % 13.4% Dual Eligible Adults 129, , , % -1.4% Average Pharmacy Utilizing Members per Month < 21 (Children) Average Pharmacy Utilizing Members per Month 21 (Adults) 191, , , % -13.1% 181, , , % -5.7%

53 TennCare Utilizing Members 2Q2013 1Q2013 2Q2012 % Change (Quarter/ Quarter) % Change (Year/Year) # Utilizing Members / Month 359, , , % -5.2% # Prescriptions / Month 1,048,260 1,109,823 1,063, % -1.4% Total Amount Paid / Month $63,997,773 $66,511,776 $66,514, % -3.8% Average # of Rx / Utilizing Member/ Month % 4.3% Average Amount Paid / Claim $61.05 $59.92 $ % -2.4% Average Amount Paid / Utilizing Member $ $ $ % 1.6% Average Amount Paid / Eligible Member $53.23 $55.21 $ % -3.9%

54 Utilization Data Total Population

55 Overall Utilization Highlights 1Q2013 Narcotic payment amount: ~17% QOQ ADHD payment amount: ~33% YOY PPI claims: ~40% YOY & ~35% QOQ Dexlansoprazole payment amount: ~19% YOY Adult Population Narcotic claims: ~15% YOY Narcotic payment amount:~27% YOY ( Oxymorphone payment amount 44% QOQ) Atypical payment amount: 21.5% YOY Hepatitis C Protease Inhibitors payment amount: ~33% YOY 22.7% increase payment amount QOQ ( 19% Telapravir QOQ) Child Population Antihemophilic Factors: ~60% QOQ ( ~57% Factor VII payment amount QOQ) *all percentages reported as per member per month

56 Top 10 Therapeutic Classes by Claim Volume Rank Therapeutic Class # of Claims (2Q13) Rank 2Q13 # of Claims (1Q13) Rank 2Q12 # of Claims (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Narcotic Analgesics 256, , , % -9.3% 2 Anticonvulsants 149, , , % 4.2% 3 2 nd Gen Antihistamines 125, , , % 1.2% 4 Penicillins 110, , , % -4.5% 5 NSAIDS/COX Inhibitors 107, , , % -7.7% 6 SSRIs 104, , , % -4.5% 7 Beta-Adrenergic Agents 94, , , % -6.3% 8 1 st Gen Antihistamines 83, , , % -5.2% 9 PPIs 97, , , % 40.3% 10 Adrenergics 66, , , % 3.0%

57 Top 10 Therapeutic Classes by Payment Amount Rank Therapeutic Class $ Paid (1Q13) Rank 1Q13 $ Paid (1Q13) Rank 2Q12 $ Paid (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Atypical Antipsychotics $20,199,935 1 $19,518,741 1 $23,924, % -15.7% 2 Adrenergics $10,528,225 2 $18,719,079 2 $10,594, % -0.8% 3 Anticonvulsants $10,292,067 4 $10,186,600 3 $10,503, % -2.2% 4 Insulins $8,886,280 8 $8,541,039 6 $7,884, % 12.5% 5 Narcotic Analgesics $7,767,908 5 $9,368,331 5 $8,154, % -4.9% 6 ADHD treatment $6,388,943 7 $6,738,725 4 $9,558, % -33.3% 7 PPIs $6,220, $5,731,548 9 $5,371, % 15.6% 8 Beta-Adrenergic Agents $5,591,741 8 $6,151, $5,280, % 5.7% 9 Antihemophilic Factors $5,417,520 3 $13,161,063 8 $6,248, % -13.5% 10 Inhaled Glucocorticoids $4,602, $5,825, $4,540, % 1.2%

58 Top 10 Drugs by Claim Volume Rank Drug # of Claims (1Q13) Rank 1Q13 # of Claims (1Q13) Rank 2Q12 # of Claims (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Hydrocodone/APAP 152, , , % -11.5% 2 Albuterol 91, , , % -4.8% 3 Cetirizine 82, , , % 6.0% 4 Amoxicillin 69, , , % -4.4% 5 Montelukast 61, , , % -4.0% 6 Lisinopril 53, , , % -0.9% 7 Gabapentin 50, , , % 17.7% 8 Ibuprofen 50, , , % -5.2% 9 Azithromycin 45, , , % -17.9% 10 Fluticasone Propionate 44, , , % 7.4%

59 Top 10 Drugs by Payment Amount Rank Drug $ Paid (2Q13) Rank 1Q13 $ Paid (1Q13) Rank 2Q12 $ Paid (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Aripiprazole $10,528,225 1 $10,037,678 2 $9,724, % 8.1% 2 Amphetamine Salts $6,321,383 2 $6,743,034 3 $6,243, % 1.1% 3 Albuterol $4,790,067 3 $4,891,523 6 $4,066, % 17.6% 4 Lisdexamfetamine $4,733,738 5 $4,977,443 5 $4,194, % 12.7% 5 Dexlansoprazole $4,610,172 8 $4,228,565 7 $3,877, % 18.7% 6 Methylphenidate $3,826,532 9 $4,043,633 1 $4,303, % -11.2% 7 Blood Sugar Diagnostic $3,465, $3,447,607 9 $3,165, % 9.3% 8 Telapravir $2,961, $2,597, $2,864, % 3.2% 9 Quetiapine $2,925, $2,929, $2,785, % 4.9% 10 Insulin Glargine $2,839, $2,662, $2,422, % 17.0%

60 Utilization Data Adult Population (Ages 21 and Older)

61 Top 10 Therapeutic Classes by Claim Volume - Adults Rank Therapeutic Class # of Claims (2Q13) Rank 1Q13 # of Claims (1Q13) Rank 2Q12 # of Claims (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Narcotic Analgesics 224, , , % -15.1% 2 Anticonvulsants 113, , , % 10.0% 3 SSRIs 81, , , % -1.5% 4 NSAIDS/COX Inhibitors 77, , , % -0.8% 5 ACE Inhibitors 63, , , % 0.0% 6 PPIs 61, , , % 11.7% 7 Skeletal Muscle Relaxants 55, , , % -0.3% 8 Statins 54, , , % 1.1% 9 Beta-Adrengic Agents 44, , , % -6.3% 10 Beta-Blocking Agents 43, , , % -2.8%

62 Top 10 Therapeutic Classes by Payment Amount - Adults Rank Therapeutic Class $ Paid (2Q13) Rank 1Q13 $ Paid (1Q13) Rank 2Q12 $ Paid (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Atypical Antipsychotics $13,198,953 1 $12,753,622 1 $16,790, % -21.5% 2 Narcotic Analgesics $7,546,391 2 $9,126,212 2 $10,295, % -26.8% 3 Insulins $7,437,488 3 $7,105,915 4 $6,383, % 16.3% 4 Anticonvulsants $6,844,910 4 $6,715,646 3 $6,761, % 1.1% 5 PPIs $5,101,463 5 $4,718,497 5 $4,215, % 20.8% 6 Hepatitis C Protease Inh $3,202, $2,616,412 6 $4,787, % -33.2% 7 Blood Sugar Diagnostics $2,786,583 8 $2,734,354 7 $2,527, % 10.1% 8 Narcotic Withdrawal Agents $2,688, $2,569,432 9 $2,326, % 15.3% 9 Multiple Sclerosis Agents $2,681,388 9 $2,676,493 8 $2,513, % 6.5% 10 Beta-Adrenergic Agents $2,525, $2,406, $2,193, % 14.9%

63 Top 10 Drugs by Claim Volume - Adults Rank Drug # of Claims (2Q13) Rank 1Q13 # of Claims (1Q13) Rank 2Q12 # of Claims (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Hydrocodone/APAP 129, , , % -10.7% 2 Lisinopril 52, , , % -0.8% 3 Gabapentin 49, , , % 18.1% 4 Albuterol 43, , , % -5.9% 5 Oxycodone/APAP 37, , , % -5.9% 6 Metformin 32, , , % -2.6% 7 Omeprazole 32, , , % 14.5% 8 Levothyroxine 29, , , % -2.7% 9 Amlodipine 29, , , % 2.3% 10 Citalopram 28, , , % -10.7%

64 Top 10 Drugs by Payment Amount - Adults Rank Drug $ Paid (2Q13) Rank 1Q13 $ Paid (1Q13) Rank 2Q12 $ Paid (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Aripiprazole $5,267,052 1 $4,994,818 1 $5,153, % 2.0% 2 Dexlansoprazole $4,299,043 2 $3,931,200 2 $3,581, % 19.8% 3 Telaprevir $2,900,543 6 $2,439,763 4 $2,696, % 7.4% 4 Blood Sugar Diagnostic $2,754,586 4 $2,730,968 5 $2,523, % 8.9% 5 Buprenorphine/Naloxone $2,547,557 5 $2,461,758 7 $2,227, % 14.2% 6 Inslulin Glargine $2,487,129 8 $2,349,573 8 $2,121, % 17.0% 7 Quetiapine $2,410,134 7 $2,401,451 6 $2,270, % 6.0% 8 Albuterol $2,352,689 9 $2,223, $1,998, % 17.5% 9 Oxymorphone $1,922,626 3 $3,465,591 8 $2,039, % -5.9% 10 Emtricitabine/Tenofovir $1,757, $1,725, $1,697, % 3.4%

65 Utilization Data Child Population (Ages 0 through 20)

66 Top 10 Therapeutic Classes by Claim Volume - Children Rank Therapeutic Class # of Claims (2Q13) Rank 1Q13 # of Claims (1Q13) Rank 2Q12 # of Claims (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 2 nd Generation Antihistamines 100, , , % 2.1% 2 Penicillins 81, , , % -5.5% 3 Leukotriene Receptor Antagonists 54, , , % -6.4% 4 Adrenergics 52, , , % 4.4% 5 Beta-Adrenergic Agents 50, , , % -6.3% 6 1 st Generation Antihistamines 40, , , % -6.4% 7 ADHD Medications 39, , , % 3.3% 8 Anticonvulsants 35, , , % -2.1% 9 Topical Anti-inflammatory Agents 35, , , % -12.7% 10 Glucocorticoids 33, , , % -6.7%

67 Top 10 Therapeutic Classes by Payment Amount - Children Rank Therapeutic Class $ Paid (2Q13) Rank 1Q13 $ Paid (1Q13) Rank 2Q12 $ Paid (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Adrenergics $9,362,035 1 $15,189,767 2 $8,488, % 10.1% 2 ADHD Agents $8,473,878 3 $8,768,731 3 $7,929, % 6.7% 3 Atypical Antipsychotics $7,000,982 4 $6,765,118 4 $7,133, % -2.0% 4 Antihemophilic Factors $4,007,698 2 $10,035,730 5 $5,168, % -22.6% 5 Orally Inhaled Glucocorticoids $3,750,722 6 $4,728,834 7 $3,651, % 2.5% 6 Anticonvulsants $3,451,334 8 $3,470,953 6 $3,546, % -2.9% 7 Beta-Adrenergic Agents $3,065,859 7 $3,745,232 9 $3,086, % -0.8% 8 Growth Hormones $2,688, $2,895, $2,789, % -3.8% 9 3 rd Generation Cephalosporins $2,105,042 9 $3,041, $1,759, % 19.4% 10 Insulins $1,448, $1,435, $1,261, % 14.6%

68 Top 10 Drugs by Claim Volume - Children Rank Drug # of Claims (2Q13) Rank 1Q13 # of Claims (1Q13) Rank 2Q12 # of Claims (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Cetirizine 71, , , % 5.8% 2 Amoxicillin 56, , , % -4.8% 3 Montelukast 54, , , % -6.5% 4 Albuterol 47, , , % -3.8% 5 Fluticasone Propionate 29, , , % 9.0% 6 Loratadine 28, , , % -5.6% 7 Azithromycin 28, , , % -19.7% 8 Amphetamine Salts 26, , , % 3.7% 9 Lisdexamfetamine 25, , , % 4.4% 10 Methylphenidate 24, , , % -1.8%

69 Top 10 Drugs by Payment Amount - Children Rank Drug $ Paid (2Q13) Rank 1Q13 $ Paid (1Q13) Rank 2Q12 $ Paid (2Q12) PMPM% (QOQ) PMPM% (YOY) 1 Aripiprazole $5,261,174 3 $5,042,860 3 $4,570, % 14.9% 2 Amphetamine Salts $4,890,213 2 $5,237,994 2 $4,596, % 6.2% 3 Lisdexamphetamine $4,280,427 4 $4,513,684 5 $3,782, % 13.0% 4 Methylphenidate $3,691,457 5 $3,924,025 4 $4,174, % -11.7% 5 Somatropin $2,688,465 7 $2,895,933 6 $2,789, % -3.8% 6 Albuterol $2,437,379 9 $2,667,643 7 $2,068, % 17.6% 7 Dexmethylphenidate $2,372, $2,500,728 8 $1,956, % 21.1% 8 Fluticasone Propionate $1,929, $1,814,074 9 $1,878, % 2.5% 9 Guanfacine $1,915, $1,906, $1,497, % 27.7% 10 Coagulation Factor VIIa $1,559,016 6 $3,637, $1,658, % -6.1%

70 Prospective Drug Utilization Review (ProDUR) 2 nd Quarter 2013

71 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.

72 ProDUR Review Top 10 Therapeutic Duplication Drug Name Total % Paid ALBUTEROL SULFATE 20, % HYDROCODONE BIT/ACETAMINOPHEN 18, % LISINOPRIL 17, % AMLODIPINE BESYLATE 14, % GABAPENTIN 12, % TRAZODONE HCL 11, % OXYCODONE HCL 11, % OXYCODONE HCL/ACETAMINOPHEN 10, % MORPHINE SULFATE 10, % DEXTROAMPHETAMINE/AMPHETAMINE 10, %

73 ProDUR Review Top 10 Early Refill Drug #Edits HYDROCODONE BIT/ACETAMINOPHEN 2,613 GABAPENTIN 1,335 LISINOPRIL 1,258 ALBUTEROL SULFATE 1,175 DEXTROAMPHETAMINE/AMPHETAMINE 1,063 CETIRIZINE HCL 994 MONTELUKAST SODIUM 969 CLONIDINE HCL 967 CITALOPRAM HYDROBROMIDE 914 BUPRENORPHINE HCL/NALOXONE HCL 854

74 ProDUR Review Top 10 Max Dose Drug Total Paid% HYDROCODONE BIT/ACETAMINOPHEN 8, % CEFDINIR 7, % POLYETHYLENE GLYCOL , % PROMETHAZINE HCL 4, % AMOXICILLIN/POTASSIUM CLAV 3, % IBUPROFEN 2, % CETIRIZINE HCL 1, % OXYCODONE HCL/ACETAMINOPHEN 1, % CYCLOBENZAPRINE HCL 1, % DEXTROAMPHETAMINE/AMPHETAMINE 1, %

75 ProDUR Review Top 10 Drug to Inferred Diagnosis Pregnancy Drug Total %Paid HYDROCODONE BIT/ACETAMINOPHEN 1, % PROMETHAZINE HCL 1, % IBUPROFEN 1, % OXYCODONE HCL/ACETAMINOPHEN % METRONIDAZOLE % AZITHROMYCIN % FLUCONAZOLE % NITROFURANTOIN MONOHYDRATE % ALBUTEROL SULFATE % BUPRENORPHINE HCL %

76 ProDUR Review Top 10 Drug to Gender Drug Total Paid% ZOLPIDEM TARTRATE 3, % EMTRICITABINE/TENOFOVIR % RIZATRIPTAN BENZOATE % TAMSULOSIN HCL % SUMATRIPTAN SUCCINATE % RIBAVIRIN % EMTRICITAB/RILPIVIRINE/TENOFOV % ABACAVIR SULFATE/LAMIVUDINE % MEDROXYPROGESTERONE ACETATE % ELVITEGR/COBICIST/EMTRIC/TENOFOVIR %

77 ProDUR Review Top 10 Geriatric Precaution Drug Total % Paid AMLODIPINE BESYLATE % HYDROCODONE BIT/ACETAMINOPHEN % SIMVASTATIN % METFORMIN HCL % LEVOTHYROXINE SODIUM % LISINOPRIL % WARFARIN SODIUM % ATORVASTATIN CALCIUM % HYDROCHLOROTHIAZIDE % CITALOPRAM HYDROBROMIDE %

78 ProDUR Review Top 10 Pediatric Precaution Drug Total % Paid MONTELUKAST SODIUM 40, % CETIRIZINE HCL 15, % CLONIDINE HCL 15, % METHYLPHENIDATE HCL 13, % RISPERIDONE 11, % DEXTROAMPHETAMINE/AMPHETAMINE 11, % LISDEXAMFETAMINE DIMESYLATE 11, % IBUPROFEN 10, % HYDROCODONE BIT/ACETAMINOPHEN 10, % GUANFACINE HCL 9, %

79 Review of DUR Activities

80 RetroDUR Activities Not Done in 2Q13 Due to Transition of PBM

81 Ideas for future RetroDUR Activities?

82 Pharmacy Lock-In Program

83 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

84 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

85 Pharmacy Lock-In Monthly Totals Month 2013 Lock-In 2012 Lock-In January 29 0 February 38 0 March April May June July 55 August 84 September 73 October 50 November 44 December 50 TOTAL

86 2 nd Quarter 2013 Re-reviews Remain: 57 Removed Refer Other: 1 Removed: 23 No cash prescriptions for medications covered by TennCare Utilizing only 1 pharmacy Utilizing only 1 physician Escalated to PA 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 Refer to Mmb Svc: 1 Refer to MCO:2 Total Rereviewed: 100 Refer to OIG: 2 Remain PA Status: 7 Escalate: 12

87 Next Meeting December 17, 2013