Hospice High Dollar Medications and Possible Alternatives Ly M. Dang, PharmD LDang@HospicePharmacySolutions.com Director of Pharmacy Operations Hospice Pharmacy Solutions
Topics of Discussion Hospice Coverage per CMS Guidelines Buckets of Relatedness Evaluating for Medical Necessity Rescheduling of Hydrocodone combinations DEA Controlled Substance Prescribing/Dispensing Common High Dollar Drugs
Drugs and Biologicals Covered Under the Hospice Benefit Under Medicare Hospice Benefit, patients receive treatments and interventions to minimize symptoms, and maximize comfort and quality of life. By electing hospice, patients have chosen to move from a curative model of care to a holistic palliative model of care. Federal regulations at 42 CFR 418.202(f) hospice covers drugs and biologicals used primarily for the relief of pain and symptom control for the terminal illness and related conditions.
Hospice Responsibility Pay for ALL drugs related to the terminal illness and related conditions Conduct medication review during admission process and comprehensive assessment Develop a plan for discontinuing medications and communicating discontinuation decisions
Buckets of Relatedness
Rescheduling of Hydrocodone combinations Effective October 6, 2014 Hydrocodone combinations will be Schedule II Hydrocodone/apap ie. Vicodin, Lortab, Norco, etc Hydrocodone/IBU ie. Vicoprofen Hydrocodone cough suppressant ie Tussionex, Hycodan, etc Prescriptions written prior to October 6 th with refills are valid up until April 8, 2015
Required elements of a valid prescription Full name and address of the patient Drug name, strength, dosage form, quantity prescribed and directions Name, address and registration number of the practitioner Practitioner s signature Dated and signed on the day when issued
Fax CII Orders ONLY for residents in LTC or Medicare hospice program Prescription must state Hospice Patient
Oral Emergency CII Only in emergency situations. Immediate administration of the controlled drug is necessary for proper treatment of the intended ultimate user No appropriate alternative available Not reasonably possible for prescribing practitioner to provide written prescription Quantity prescribed and dispensed is limited to amount adequate to treat the patient during emergency period Prescriber must present written prescription to dispensing pharmacist within 7 days Written prescription must have date of oral order and Authorization for Emergency Dispensing If mailed, must be postmarked within 7 days If prescriber fails to comply, pharmacist is required to notify DEA If pharmacist fails to notify DEA, the pharmacist or pharmacy may lose license to dispense emergency orders
Reorders and Partial fill for CII Prescriber may issue multiple prescriptions for the same CII up to 90 day supply Include written instructions on each indicating earliest date to fill Partial Fills Only for LTC or terminally ill patients Prescription is valid for 60 days from date of issue
Evaluating for Medical Necessity Life expectancy Time until benefit Risk vs benefit ratios Goals of care Treatment targets
Appetite Stimulant Evaluate for any actual weight gain or increased appetite. Megace (megesterol) Consider discontinuation if not effective to reduce pill burden and potential side effects (ie DVT, edema). Symptomatic improvement in appetite may be seen in less than one week, but weight gain (which only occurs in one-fourth of treated patients) may take 6-12 weeks. Periactin (cyproheptadine) Consider discontinuation if not effective after ~4 weeks.
Supplements Evaluate multivitamins for any benefit in terms of survival, quality of life or symptom control versus the potential side effects of nausea or constipation. Iron supplements can cause gastric discomfort and constipation and these side effects may outweigh the benefits of iron supplementation at end of life. Calcium + D - evaluate the risk of fracture in this patient and consider discontinuing to reduce pill burden since the time needed to see a benefit may exceed the life expectancy of the patient.
Cholesterol Medications The time needed to see a benefit (usually measured in years) may exceed the life expectancy of the patient. Statins - The potential side effects such as muscle pain or confusion may outweigh any benefit at end of life. Fish Oil Supplements - The potential side effects such as diarrhea may outweigh any benefit at end of life. Fenofibrate - The potential side effects such as headache may outweigh any benefit at end of life. Cholestyramine Possibility of interference with the absorption of many other medications. Zetia Not actually proven to reduce stroke/heart attacks.
Cognitive Enhancers/Dementia Meds The American Geriatric Society recommends discontinuing cognitive enhancers when the FAST score = 7 if consistent with the goals of care. When possible consider tapering the medication gradually instead of stopping abruptly in case behavior issues develop. Evaluate the benefit of Namenda, Aricept, Exelon and Razadyne in end-stage, advanced dementia versus potential side effects such as anorexia, nausea, diarrhea and insomnia. Recent controlled trials do not demonstrate significant advantages to the combination of Namenda and Aricept to Aricept alone in patients with severe dementia. Evaluate the benefit of continuing Axona and Cerefolin in advanced dementia. According to the American Geriatric Society Axona has insufficient evidence to support its value in preventing or treating dementia and long-term effects are uncertain.
Pulmonary Medications Inhalers Inhaler technique is patient able to actuate the inhaler? Performance status is patient able to inhale deep enough to get medications to the lung? Daliresp - is indicated to prevent COPD exacerbations but doesn t actually treat any symptoms or help the patient breath better. The number of patients needed to treat (NNT) with Daliresp to prevent one moderate exacerbation per year was 5. The time needed to see a benefit from Daliresp may exceed the life expectancy of the patient. Evaluate the benefit versus the risk of side effects such as nausea, diarrhea and weight loss and consider discontinuing Daliresp.
Pulmonary Beta Agonist Bronchodilator Short acting Proair/Ventolin HFA MDI $60 Albuterol Nebs $20 Xopenex (levalbuterol) Nebs $120 Xopenex HFA MDI $60 Long acting Foradil DPI $240 Serevent DPI $240 Brovana Nebs $620 Perforomist Nebs $610
Pulmonary Anticholinergic Bronchodilator Short acting anticholinergic Atrovent Nebs (ipratropium) $25 Atrovent HFA Respimat $280 Long acting anticholinergic Spiriva $330 Tudorza $300
Pulmonary Corticosteroids Corticosteroids Asmanex DPI $200 Flovent HFA MDI $200 Flovent Diskus DPI $120 Pulmicort INH DPI $200 Pulmicort (budesonide) Nebs $265
Pulmonary - combination Short acting Beta Agonist + Anticholinergic Duoneb (albuterol/ipratropium) Nebs $30 Combivent INH $300 Long acting Beta Agonist + Corticosteroids Advair $420 Symbicort $280 Dulera $260
Long Acting Opioids
Immediate Release Opioids Drug Morphine 20mg/ml Oxycodone 20mg/ml Hydromorphone Cost $30 for 30ml $200 for 30ml $15 for 30 tabs
Fentanyl Patches Fentanyl patch dose Cost per box of 5 Fentanyl 12mcg $120 Fentanyl 25mcg $50 Fentanyl 50mcg $70 Fentanyl 75mcg $90 Fentanyl 100mcg $110
Nausea and Vomiting Drug/dose/dosage form Cost per dose Prochlorperazine 10mg tabs $0.30 Prochlorperazine 25mg supp $8.00 Promethazine 25mg tabs $0.20 Promethazine 25mg supp $8.00 Ondansetron 4mg tab $0.30 Ondansetron 4mg ODT $2.00
Psychosis Zyprexa (olanzapine) Risperdal (risperidone) Seroquel (quetiapine) $0.75/5mg Zyprexa Zydis $1.25/5mg $0.25/1mg Risperdal M tabs $3.00/1mg $0.70/200mg Seroquel XR $25.00/400mg
Terminal Secretions Atropine drops Hyoscyamine Transderm Scop patch Robinul (glycopyrrolate) $20 per 5ml (20drops/ml) $1 per tab $20 per patch $1 per tab
Questions Ly M. Dang, PharmD LDang@HospicePharmacySolutions.com Director of Pharmacy Operations Hospice Pharmacy Solutions