Follow-up to Previous Reviews

21 January 2016 1

Follow-up to Previous Reviews Patients Receiving > 1 Long-Acting Opioid Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Multiple Dosage Forms of Oral Paliperidone Prescribed Concomitantly Buprenorphine and benzodiazepine 2

1/21/2016 3

Chronic Pain Management Standard Practice Long-acting opioid for primary throughout the day pain relief Short-acting opioid as needed for acute/breakthrough pain Duplication of long-acting may result in overdose and/or increase in side-effects 4

Patient Medication Profile Review 7 Patients identified who were receiving > 1 Long- Acting Opioid for > 2 months Letters sent on July 27 to prescribers for those 7 patients Included Patient Medication Profile Prescription Monitoring Program (PMP) Report 5

Letter Key Points Part of an overall opioid analgesic prescribing improvement project November 1, 2015 a hard edit for therapeutic duplication would be put into effect Need to consolidate to one agent OR Request prior authorization with justification and plan Described future initiatives > 1 short-acting Disallowing long-term short acting without long acting MED < or = to 120 mg/day 6

Patient # 1 At time of Intervention: LAO: Morphine ER + Fentanyl Short- Acting: None Total MED: 105 Prescriber Response to Intervention: 7/31 submitted PA for Fentanyl. Denied as 2 nd LAO Currently (10/1 through 12/31/2015) LAO: Morphine ER Short-Acting: None Total MED: 45 7

Patient # 2 At time of Intervention: LAO: Methadone + Morphine ER Short- Acting: Hydromorphone + Hydrocodone/APAP Total MED: 398 Prescriber Response to Intervention: Follow-up with patient on 11/4, to send chart notes (none received) Currently (10/1 through 12/31/2015) LAO: Methadone + Morphine ER Short-Acting: Hydromorphone + Hydrocodone/APAP (in December received additional Oxycodone/APAP) Total MED: 398 (Dec = 600) 8

Patient # 3 At time of Intervention: LAO: OxyContin + Fentanyl Short- Acting: oxycodone Total MED: 360 Prescriber Response to Intervention: to follow-up with patient on 10/5 Currently (10/1 through 12/31/2015) LAO: OxyContin discontinued. Fentanyl increased from 25 mcg to 50 mcg Short-Acting: oxycodone plus additional Hydrocodone/APAP in November Total MED: 300 (November 360) 9

Patient # 4 At time of Intervention: LAO: Morphine ER + Fentanyl Short- Acting: oxycodone Total MED: 600 Prescriber Response to Intervention: Patient transferred to St. Luke s Pain Institute Currently (10/1 through 12/31/2015) LAO: Morphine ER + Fentanyl Short-Acting: oxycodone Total MED: 600 10

Patient # 5 At time of Intervention: LAO: Morphine ER + Methadone Short- Acting: Morphine IR Total MED: 420 Prescriber Response to Intervention: 9/12/2015 letter to Medicaid indicating working on multimodal therapy and plan to wean patient off of methadone Currently (10/1 through 12/31/2015) LAO: Morphine ER + Methadone (but methadone dose decreased) Short-Acting: Morphine IR Total MED: 260 11

Patient # 6 At time of Intervention: LAO: Methadone + Morphine ER Short- Acting: Hydrocodone/APAP Total MED: 190 Prescriber Response to Intervention: 8/20 sent in a PA for methadone. Was denied, but since preferred agent and duplication edit not in place has continued to receive. Currently (10/1 through 12/31/2015) LAO: Methadone + Morphine ER Short-Acting: Hydrocodone/APAP Total MED: 190 12

Patient # 7 At time of Intervention: LAO: OxyContin + Morphine ER Short-Acting: None Total MED: 360 Prescriber Response to Intervention: 9/19 chart note to discontinue OxyContin, Increase Morphine ER to tid and add Morphine IR 10/3 did not reflect this change but ended up being last OxyContin fill Currently (10/1 through 12/31/2015) LAO: Morphine ER Short-Acting: Morphine IR Total MED: 270 13

Summary Action: PA for Second LAO 2 (approved = 0) Second LAO discontinued 2 Weaning off of 2 nd LAO 1 No Action 2 Change in MED: Decrease in Daily MED 4 > 120 daily Med prior = 6 post = 6 14

Next Steps Therapeutic Duplication Edit Description: Hard stop with 2 nd LAO within current LAO days supply denied (i.e. no overlap) Implementation: within the next 30 days 15

Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Usual maximum FDA approved daily dose for aripiprazole (Abilify) is 30mg. Tablets available in the following strengths: 2, 5, 10, 15, 20, and 30mg Discmelt tablets available in the following strengths: 10, 15mg 16

Multiple Dosage Forms of Atypical Antipsychotics Prescribed Concomitantly Olanzapine 10/19/13 1/19/2014 Ziprasidone 9/1/14 11/30/14 Aripiprazole 3/1/15 5/31/15 2837 claims 869 unique recipients $246,340 1409 claims 473 unique recipients $96,063 5554 claims 2252 unique recipients $4,540,782 17

Multiple Dosage Forms of Atypical Antipsychotics Prescribed Concomitantly 6000 5000 Claims 5554 4000 3000 2837 2000 1000 0 1409 Olanzapine 10/19/13-1/19/14 Ziprasidone 9/1/14-11/30/14 Aripiprazole 3/1/15-5/31/15 18

Multiple Dosage Forms of Atypical Antipsychotics Prescribed Concomitantly 2500 2000 Recipients 2252 1500 1000 869 500 476 0 Olanzapine 10/19/13-1/19/14 Ziprasidone 9/1/14-11/30/14 Aripiprazole 3/1/15-5/31/15 19

Multiple Dosage Forms of Atypical Antipsychotics Prescribed Concomitantly $5,000,000 $4,500,000 $4,000,000 $3,500,000 $3,000,000 $2,500,000 $2,000,000 $1,500,000 $1,000,000 $500,000 $0 Total $ Paid $4,540,782 $246,340 $96,063 Olanzapine 10/19/13-1/19/14 Ziprasidone 9/1/14-11/30/14 Aripiprazole 3/1/15-5/31/15 20

Multiple Dosage Forms of Atypical Antipsychotics Prescribed Concomitantly 80 70 60 50 40 30 20 10 0 Greater than FDA approved daily dose 70 19 12 Olanzapine 10/19/13-1/19/14 Ziprasidone 9/1/14-11/30/14 Aripiprazole 3/1/15-5/31/15 21

Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Baseline Paid claims for oral aripiprazole between 3/1/2015 and 5/31/2015 were evaluated. 74 patients identified with two or more fills for two or more tablet strengths 62 (84%) on 30mg daily 12 (16%) on > 30mg daily 22

Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Patients receiving 30mg aripiprazole using multiple tablet strengths (n=62) 3 7 Contacting prescriber to round dose to one tablet daily Already changed to only one tablet strength 14 38 No longer on aripiprazole No longer eligible for Medicaid 23

Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Plan: A letter with the following paragraph along with a Qty Override Form and Member Rx Profile was sent to prescribers of 10 members on 7/7/2015: The maximum FDA approved dose for aripiprazole is 30mg/day because safety and efficacy have not been established for higher doses. The DUR board is reviewing Idaho Medicaid participants who are receiving more than 30mg/day of aripiprazole using multiple tablet strengths. As of 8/12/2015, multiple strengths of aripiprazole tablets will no longer pay at the pharmacy without prior authorization. During a recent review it was noted that your patient, $MEMBER NAME, has been receiving more than 30 mg/day of aripiprazole using multiple tablet strengths. If you feel that it is clinically justified for your patient to remain on multiple strengths of aripiprazole tablets, please submit a quantity override prior authorization request for review by the department. A copy of this form is enclosed for your convenience. 24

Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Of the ten letters that went out only five were returned; however, no additional comments were written on the response form. 25

Multiple Dosage Forms of Aripiprazole Prescribed Concomitantly Questions/Comments??? 26

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly Tablets available in the following strengths: 1.5mg 3mg 6mg 9mg Designed for once daily dosing (extended release formulation). Maximum FDA approved daily dose for paliperidone (Invega) is 12mg. Generics just became available September 2015 So far three manufacturers of generic: Actavis, Mylan, Patriot 27

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly WAC(wholesale acquisition cost) prices of drug Brand Generic 1.5mg $28.33 $24.45 3mg $28.33 $24.45 6mg $28.33 $24.45 9mg $42.49 $36.71 28

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly 210 patients identified with at least one paid claim for oral Invega (claims evaluated from 7/1/15-9/30/15) 15 on only one tablet strength on two different tablet strengths 195 29

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly 12 10 10 8 6 4 Patients 2 2 2 1 0 1.5mg + 6mg tablets 3mg + 6mg tablets 3mg + 9mg tablets 6mg + 9mg tablets 30

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly Monthly WAC drug cost for 30 day supply of 12mg/day dose Using two 6mg tablets: $1835 Using one 3mg plus one 9mg tablet: $2125 Plus have two monthly dispensing fees when using two different tablet strengths. Annual cost savings with using two 6mg tablets rather than one 3mg and one 9mg tablet (assuming $11.51 dispensing fee): $3616 31

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly For 1.5mg plus 6mg tablets (7.5mg daily dose) Cost savings $5239 annually if round dose up to 9mg tablet once daily For 3mg plus 6mg tablet daily (9mg daily dose) Cost savings $5239 annually if use one 9mg tablet instead For 6mg plus 9mg tablets (15mg daily) Will need therapeutic justification for exceeding maximum FDA approved daily dose of 12mg 32

Multiple Dosage Forms of Paliperidone (Invega) Prescribed Concomitantly A letter with the following paragraph along with a Member Rx Profile was sent to prescribers of 11 members on 11/5/2015: You are receiving this letter as you have a patient(s) receiving multiple strengths of oral Invega (paliperidone). Effective 12-15-2015, prior authorization will be required for a patient to receive multiple strengths of oral Invega (paliperidone) concomitantly. Oral Invega (paliperidone) is an extended release tablet designed for once daily dosing. For the maximum FDA approved daily dose of 12mg, please use two 6mg tablets rather than one 3mg and one 9mg tablet (more cost effective). For 9mg daily dose, please use one 9mg tablet rather than one 3mg and one 6mg tablet; for patients currently on 7.5mg daily (one 1.5mg and one 6mg tablet), please consider rounding dose up to one 9mg tablet instead. 33

Multiple Dosage Forms of Paliperidone (Invega) Prescribed Concomitantly Of the eleven letters that went out only one was returned; however, no additional comments were written on the response form. 34

Multiple Dosage Forms of Oral Paliperidone (Invega) Prescribed Concomitantly Questions/Comments??? 35

Buprenorphine DUR 300 250 200 200 201 210 223 222 211 212 223 241 251 265 150 100 50 26 27 23 20 36 31 20 31 35 40 0 2/1/13-4/30/13 6/1/13-8/31/13 9/1/13-11/30/13 12/1/13-2/28/14 3/1/14-5/31/14 6/1/14-8/31/14 9/1/14-11/30/14 Total # of participants on oral buprenorphine 12/1/14-2/28/15 3/1/15-5/31/15 4/1/15-8/31/15 Participants who paid cash for an opioid while on oral buprenorphine 9/1/15-11/30/2015 36

Buprenorphine and Benzodiazepine DUR Suboxone Package Insert Buprenorphine in combination with benzodiazepines or other CNS depressants including alcohol has been associated with significant respiratory depression and death. Patients should be warned of the potential of selfadministration of benzodiazepines or other depressants while under treatment with Suboxone. 37

Buprenorphine and Benzodiazepine DUR March 1 May 31, 2015 57 Buprenorphine AND benzos Buprenorphine (no benzos) 184 38

Buprenorphine and Benzodiazepine DUR March 1 May 31, 2015 50 45 40 35 30 25 20 15 10 5 0 44 12 1 One Benzo Two Benzos Three Benzos Number of Patients (Total = 57) 39

Buprenorphine and Benzodiazepine DUR DUR letter sent out on 7/2/2015 40

Buprenorphine and Benzodiazepine DUR 55 letters were sent out to Prescribers and a total of 31 came back as of 1/12/2016. Response Description No Response 13 I have reviewed the informationand do not believe an adjustment to the current therapy is necessary I attemptedto modify the therapy, but the patient response was not favorable Extremely useful to my practice 4 Somewhat useful to my practice 4 Not useful to my practice 2 1 2 Responses 41

Buprenorphine and Benzodiazepine DUR Some additional written responses since last DUR Meeting 6 responses came back with this specific written response: I have received correspondence concerning your concerns about the possibility of respiratory depression in patients who use buprenorphine and benzodiazepines. This concern has primarily been generated because people who were illicitly using buprenorphine and alprazolam and injecting them together, in Europe, were dying from repository failure. My buprenorphine patients have often had anxiety as trigger for opiate addiction. Also many have significant ongoing anxiety for which they would smoke marijuana. Therefore, I have given patients ongoing benzodiazepines and counseled them about the importance of not taking any doses beyond what is prescribed because of the presumed possibility of respiratory depression. I have been a buprenorphine provider as long as the program has been legal. It's not clear why you are suddenly sending letters of concern about this potential problem when this has been known a problem for a long time. 42

Buprenorphine and Benzodiazepine DUR Written Responses Treating both addictions He has been counseled to not use Benzo with Suboxone. Went to the ER with panic attack. He is not to use any benzo or other CNS depressant. Has entered formal IOP treatment and complicated GAD. As always I appreciate any help with patient not being compliant. He has GAD but is not to use SSRI or SNRito control rather than any benzo. Sometimes patients have more than one addiction. I am weaning the benzodiazepine. 43

Buprenorphine and Benzodiazepine DUR Questions/Comments??? 44

Ongoing Reviews Narcotic Prescribing Improvement Project Top 150 Utilizers Methadone Utilization Hepatitis C Update 45

Narcotic Prescribing Improvement Project Top 150 Utilizers 46

Idaho Medicaid Participants 2015 Study 47

Profile Review Generated profiles for the top 150 recipients by total narcotic claim count from the recipients who had at least one narcotic claim in each of the 24 months of the period ending August 31, 2015 Time Period: March 1, 2015 through August 31, 2015 Last study period: October 1, 2012 through March 31, 2013 All profiles were hand reviewed by Idaho Medicaid Pharmacists 7 patients had cancer diagnoses, but were kept in evaluation as all but one patient also had chronic nonmalignant pain unrelated to cancer diagnosis 48

Review Focus Demographics - age and gender Health and Welfare regional variation Pain Related Diagnoses Drug and/or alcohol abuse history Lock-in Status Opioids with cash payments Number of Prescribers Average Daily Morphine Equivalent Dose over 6 months (MED) Focus criteria (next page) 49

Focus Criteria Using more than one long-acting opioid concurrently for greater than 2 months Using more than one short-acting opioid concurrently for greater than 2 months Use of short-acting opioids only without long-acting opioid for greater than 2 months Short-acting opioid total daily morphine equivalents > 50% of total daily morphine equivalents Daily morphine equivalents > 120 mg Concurrent chronic benzodiazepine use If concurrent benzodiazepine use whether prescribed by same or different prescriber of opioids 50

2015 Results Top 150 Narcotic Utilizers 100 90 80 70 60 50 40 30 20 10 0 7 41 5 9 48 35 35 91 82 54 51 45 51

Results 2015 % 2012 Cancer Diagnosis 7 5% 8 Abuse Diagnosis 41 27% 66 Lock In 5 3% 5 > 1 Long-Acting 9 6% not done > 1 Short-Acting 48 32% not done Short-acting without Long-acting 35 23% not done Short Acting> 50% total Daily MED 35 23% not done MED > 120 91 61% not done Concurrent Benzodiazepine 82 55% not done Benzo same prescriber as Opioids 54 66% not done Opioids Paid Outside of Medicaid (Cash) 51 34% 34 Patients also in 2012 Study 45 30% NA 52

Focus Criteria Using more than one long-acting opioid concurrently for greater than 2 months Using more than one short-acting opioid concurrently for greater than 2 months Use of short-acting opioids only without long-acting opioid for greater than 2 months Short-acting opioid total daily morphine equivalents > 50% of total daily morphine equivalents Daily morphine equivalents > 120 mg Concurrent chronic benzodiazepine use 53

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Demographics Age Range 23-69 20-29 years 8 30-39 years 23 40-49 years 57 60+ years 30 Gender Male 38 (25%) Female 112 (75%) 55

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Regional Variation 24 11 35 11 30 18 10 57

Diagnosis/Indications Most patients had multiples diagnoses Diagnosis Number of Participants (incidence) Lumbago; unspecified disorder of back; back pain 90 chronic pain; chronic pain syndrome; other chronic pain 100 intevertebral disc disorder; lumbar disc degeneration; cervical disc 65 degeneration; cervicalgia; sciatica; disc degeneration; spondylosis knee injury; shoulder injury; pain in limb; lower leg pain; neck injury; 19 hip and thigh injury; wrist injury hand joint pain; osteoarthritis; rheumatoid arthritis; pain in joint of 79 ankle and foot; ankylosing spondylitis; other disorders of synovium tendon and bursa headache; migraine 11 disorders of muscle ligament and fascia; other disease of bone and 12 cartilage; myalgia abdominal pain; generalized pain 12 peripheral neuropathy; diabetic peripheral neuropathy 3 chronic pancreatitis 2 58

Daily Morphine Equivalents Range 15 2244 mg Average 260 mg > 1000 mg 501-1000 mg 8 9 301-500 mg 18 121-300 mg < 120 mg 56 59 0 50 100 Number of Patients 59

Patients with > 1000 Daily Morphine Equivalents Patient 38 1110 MED (changed to Medicare Sept. 15) Patient 98 1173 MED Patient 119 1279 MED Patient 141 1470 MED Patient 110 1589 MED Patient 61 1611 MED Patient 96 2082 MED Patient 45 2244 MED 60

High Utilizer Patient # 96 See handout Average daily MED over 6 months = 2082 mg 61

High Utilizer Patient # 45 See handout Average daily MED over 6 months = 2244 mg 62

More Than 1 Long-Acting Opioid Concurrently 5 of 9 identified in previous study Combinations Methadone plus Fentanyl 1 Methadone plus Morphine ER 5 OxyContin plus Morphine ER 1 Fentanyl plus Morphine ER 1 OxyContin plus Fentanyl 1 63

Cash Paying Example See Handout. Patient # 69 All prescriptions filled at same pharmacy Majority by same prescriber Both prescribers in same practice location 64

Next Steps Medicaid Pharmacy Proposed Educational Intervention specific to problem areas identified with patient New CDC Guidelines and other Best Practice Guidelines Continue toward goals of 120 MED max Focus on benzodiazepines and opioid concurrent use Short-acting with inadequate or no long-acting DUR Board Additional Suggestions 65

Narcotic Prescribing Improvement Project Methadone Utilization 66

October-December 2015 67

Methadone Growing Public Health Concern More than 16,500 people in the United States die each year from opioid-related prescription drug overdoses. Methadone is responsible for nearly 1/3 of these deaths but accounts for only 2% of opioid pain reliever prescription. Preferred pain reliever for most state Medicaid programs. Idaho Medicaid removed Methadone preferred status in October 2015 Centers for Disease Control and Prevention. Opioids Drive Continued Increase in Drug Overdose Deaths (2013). http://www.cdc.gov/media/relases/2013/p0220_drug_overdose_deaths.html. 68

Methadone Reviewing methadone utilization Determine number of active patients. Identify patients prescribed more than 40mg of methadone/day. Initiate prior authorization criteria to limit inappropriate use of methadone for chronic pain. 69

Methadone Demographic Data October-December 2015 Total Claims=927 Total Unique Patients=306 Total Unique Prescribers=226 Females: 188 (age: 45) Range: 20-66 y/o Males: 118 (age: 49) Range: 23-72 y/o 70

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Methadone 72

Methadone 73

Methadone 74

Methadone Dosing Patients taking more than 40mg/day 40mg=320 Morphine Equivalents Daily (MED) Average #tablets/day=6.8 Range: 5-16 tablets/day (50mg-160mg/day) 75

MED for Methadone Chronic Methadone Dose. Approximate Conversion Factors to Morphine Equivalent* Up to 20 mg per day 4 21 to 40 mg per day 8 41 to 60 mg per day 10 >60 mg per day 12 *Adapted from Ayonrinde2000. Equi-analgesic dose ratios between methadone and other opioids are complex. Methadone exhibits a non-linear relationship due to the long half-life and accumulation with chronic dosing. Because methadone pharmacokinetics are variable across patient populations, these conversion factors are approximate and doses around the cutoff can have huge differences in calculated MED. 76

Methadone 77

Methadone Next Steps: Communicate CDC concerns of methadone for chronic pain. Letter to providers with patients on doses greater than 40mg/day. Prescription Painkiller Overdose Vitalsigns July 2012 Newsletter Prior authorization for initiating methadone. Prior authorization for continuing methadone. 78

Methadone Questions/Comments? 79

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4 th Quarter 2015 81

Hepatitis-C 82

Hepatitis-C 83

Hepatitis-C 84

Hepatitis-C 85

Hepatitis-C 86

Hepatitis-C 87

Hepatitis-C 88

Hepatitis-C 89

Hepatitis-C 90

Hepatitis-C 91

Hepatitis-C 92

Hepatitis-C 93

Hepatitis-C Emerging Trends for Hepatitis-C Agents Merck: Grazoprevir/elbasvir Once daily Genotype 1,4, 6 (12 weeks therapy) Gilead: Sofosbuvir/velpatasvir Once daily Genotype 1 thru 6 (12 weeks therapy) 94

Hepatitis-C Emerging Trends for Hepatitis-C Agents BMS: Daclatasvir/sofosbuvir/ribavirin Once daily Genotype 1 thru 4 for advanced cirrhosis (12 weeks therapy) Genotype 1 thru 6 for Post-Liver Transplant (12 weeks therapy) Gilead: Sofosbuvir/ledipasvir(Harvoni) Broader indications for treatment in patients with decompensated cirrhosis for pre/post-transplant. 95

Questions?/Comments? Hepatitis-C 96

Current Interventions/Outcomes Studies Albuterol MDI DUR 97

Albuterol MDI DUR High usage of short-acting beta 2 -agonists is a risk factor for asthma exacerbations; furthermore excessive usage (more than 200 doses/month) is a risk factor for asthma-related death. 98

Albuterol MDI DUR Profiles reviewed for patients who filled > 9 albuterol MDI s over the six month time period from May 1 Oct 31, 2015. Total of 109 patients identified. Majority of patients were on ProAir (preferred bronchodilator) contains 200 actuations/canister. Some patients were on Proventil (preferred), Ventolin (nonpreferred), and Xopenex (non-preferred) all contain 200 actuations per canister. 99

Albuterol MDI DUR Patients on 9 inhalers / 6months, 109, 1% Patients on < 9 inhalers / 6months, 15,546, 99% 100

Albuterol MDI DUR 4 Patient Age 26 32 < 18 years 18-29 30-49 50-64 15 65 32 101

Albuterol MDI DUR 90 80 70 60 50 40 30 20 10 0 83 Asthma Diagnosis 26 COPD 102

Albuterol MDI DUR Taxonomy of albuterol MDI prescriber 60 50 48 40 30 20 10 0 5 1 4 18 3 17 10 3 103

Albuterol MDI DUR 60 50 50 Concomitant inhaled steroid 40 35 30 20 24 10 0 None 1-3 fills in 6 months 4 fills in 6 months 104

Albuterol MDI DUR 60 50 40 30 20 10 0 5 48 25 18 17 9 1 1 4 0 1 3 1 10 6 7 3 0 Taxonomy of albuterol MDI prescriber Taxonomy of prescriber with NO inhaled steroid 105

Albuterol MDI DUR Asthma (83 patients total) no inhaled steroid 39 1-3 fills in 6 months 19 4 fills in 6 months 25 For the 39 asthma patients who were not on an inhaled steroid 5 were on montelukast 8 were also on nebulized albuterol 106

Albuterol MDI DUR 45 40 35 30 25 20 15 10 5 0 39 Asthma COPD 25 19 11 10 5 no inhaled steroid 1-3 fills in 6 months 4 fills in 6 months 107

Albuterol MDI DUR Recommendations 1. Should we mail DUR letter to prescribers of patients who received a) no inhaled steroid and/or b) < 4 fills of inhaled steroid in the last 6 months 2. Letter to dispensing pharmacies? 3. Other suggestions 108

Study Proposals for Upcoming Quarters: Opioid and benzodiazepine concomitant use Atypical Antipsychotics in children 6 years of age 109

Study Proposals for Upcoming Quarters: New CF Drugs Kalydeco and Orkambi Review overall cost of therapy (including all medications as well as hospitalizations and outpatient care costs) for CF patients now on Kalydeco or Orkambi Since 8/1/2015 we have 32 paid claims for 11 recipients for Orkambi and 7 paid claims for 3 recipients for Kalydeco totaling $647,284 110

Study Proposals for Upcoming Quarters: Multiple dosage forms of quetiapine prescribed concomitantly 111

Prospective DUR Report History Errors: DD drug-to-drug PG drug to pregnancy TD therapeutic duplication ER early refill MC drug-to-disease Non-History Errors: PA drug-to-age HD high dose LD low dose SX drug-to-gender 112

Prospective DUR Report Idaho Medicaid Program ProDUR Message Report December 2015 ProDUR ProDUR Message Message Message Severity Count Amount Drug To Drug 1 1,680 $723,063.65 2 16,779 $6,878,597.95 3 81,700 $18,364,437.75 9 3 $63.94 Drug To Gender 1 61 $54,583.40 2 2,214 $248,336.01 Drug To Known Disease 1 70,171 $12,774,790.79 2 255,072 $66,164,457.93 3 314,390 $74,216,899.71 Drug To Pregnancy 1 13 $162.72 2 8 $920.12 A 13 $353.31 B 83 $12,850.52 C 131 $11,398.31 D 8 $185.40 X 0 $0.00 Duplicate Therapy 0 121,857 $34,645,161.38 Min Max 0 27,647 $8,468,427.80 Too Soon Clinical 0 23,318 $6,449,519.70 ALL 915,148 $229,014,210.39 Total Number of Claims with Messages 226,818 Average ProDUR Message Per Claim 4.03 113

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DUR Board Meeting January 21, 2016 115