Upload
amy-rich
View
217
Download
0
Tags:
Embed Size (px)
Citation preview
Status Report: Medicaid Preferred Drug List Program
Presentation to the:
Joint Commission on Health Care
Behavioral Health Subcommittee
Patrick W. Finnerty, DirectorDepartment of Medical Assistance Services
August 4, 2004Richmond, Virginia
2
Presentation Outline
Background of PDL Development
Current Status
Review of Antidepressants
3
2003 Appropriations Act Required DMAS to Implement A PDL
Item 325(ZZ.1) of the 2003 Appropriations Act directed DMAS to:– Implement PDL program no later than Jan. 1, 2004– Seek input from physicians, pharmacists, pharmaceutical
manufacturers, patient advocates, and others– Form a Pharmacy & Therapeutics (P&T) Committee– Ensure drugs on the PDL are safe and clinically effective
before considering cost effectiveness– Include several key provisions: 72-hour emergency supply;
24-hour prior authorization process; expedited review of denials; and consumer/provider training and education
– Report to General Assembly on main design components
4
What is a PreferredDrug List (PDL) Program?
PDL is a prior authorization program that divides Medicaid covered prescription drugs into two categories:– (1) Those that are available with no prior authorization,
known as “preferred” drugs that are selected based on safety and clinical efficacy first, then on cost-effectiveness.
– (2) Those that are available with prior authorization, known as “nonpreferred” drugs.
Virginia Medicaid’s PDL applies only to the fee-for-service program; MCOs have their own PDLs or formularies
5
Pharmacy & Therapeutics Committee
Member Background Randy Axelrod (MD) (Chairman) Anthem Chief Medical Officer Roy Beveridge (MD) Oncologist/Patient
Advocate Avtar Dhillon (MD) Psychiatrist (CSB) James Reinhard (MD) Psychiatrist (DMHMRSAS) Arthur Garson, Jr (MD) Dean, UVA Med. School Mariann Johnson (MD) Family Practice Eleanor (Sue) Cantrell (MD) Local Health District
Director Christine Tully (MD) Geriatrician, VCU/MCV Mark Szalwinski (Pharmacist) Sentara Health Care
(Vice Chairman) Gill Abernathy (Pharmacist) INOVA Health System Mark Oley (Pharmacist) Westwood Pharmacy Renita Warren (Pharmacist) Edloe’s Pharmacies
6
PDL Development Process
All Therapeutic Classes of Drugs
P&T Committee Reviews Certain Drug Classes For Possible Inclusion in PDL
For Those Classes Included in PDL, P&T Committee Recommends Drugs That Are Preferred/Non-Preferred
Based on Clinical Efficacy First
Preferred Drugs
NO PDL PA Required
Non-Preferred Drugs
Drug requires PA
Cost Consideration
7
Key Classes of Drugs Excluded from the PDL Program
Therapeutic Class Description Used in the Treatment of
Insulins Diabetes
Cholinesterase Inhibitors Alzheimers
Platelet Aggregation Inhibitors Clotting Disorders
Antivirals for HIV HIV/AIDS
Cancer Chemo. Agents Cancer
Anti-convulsants Seizure Disorders, Mental Health
Immunosupressants Transplant rejections, Arthritis
Antiemetics Nausea in cancer patients, Aging
Anti-psychotics, Atypical and Typicals
Serious Mental Illness
8
13 Drug Classes Were Included in the PDL Program for January 2004
Therapeutic Class Description Proton Pump Inhibitors (PPIs)
H2 Antagonists
Nasal Steroids
Second Generation Antihistamines
Selective Cox-2 Inhibitors
HMG CoA Reductase Inhibitors (Statins)
Sedative Hypnotics
Beta Adrenergics
Inhaled Corticosteroids
ACE Inhibitors
Angiotensin II Receptor Blockers (ARBs)
Calcium Channel Blockers (CCBs)
Beta Blockers
Used in the Treatment of: Gastrointestinal Disorders
Gastrointestinal Disorders
Allergies, Asthma, Other Respiratory Illness
Allergic Conditions
Inflammatory Conditions
High Cholesterol and Dyslipidemia
Insomnia
Asthma and Other Respiratory Illness
Asthma and Other Respiratory Illness
Hypertension/Other Cardiovascular Illness
Hypertension/Other Cardiovascular Illness
Hypertension/Other Cardiovascular Illness
Hypertension/Other Cardiovascular Illness
9
Drug Classes Added to PDL Program in April 2004
Therapeutic Class Description
Oral Hypoglycemics
Leukotriene Modifiers
Bisphosphonates
Traditional NSAIDs
Serotonin Receptor Agonists
Oral Antifungals
Used in The Treatment of:
Diabetes
Allergic Conditions/Asthma
Osteoporosis
Inflammatory Conditions
Migraine Headache
Nail Fungal Infections
10
Drug Classes Added to PDL Program in July 2004
Therapeutic Class Description
Carbonic Anhydrase Inhibitors
Alpha 2 Adrenergics
Beta-blockers
Prostaglandin Inhibitors
Antihyperkinesis/CNS Stimulants
Macrolides - Adult
Macrolides - Pediatrics
2nd Generation Quinolones - Systemic
3rd Generation Quinolones - Systemic
2nd Generation Cephalosporins
3rd Generation Cephalosporins
Used in the Treatment of:
Ophthalmic
Ophthalmic
Ophthalmic
Ophthalmic
ADD/ADHD
Antibiotics
Antibiotics
Antibiotics
Antibiotics
Antibiotics
Antibiotics
11
Critical Steps Taken in Implementation Process
Met with more than 40 interested parties to solicit input into design of PDL program.
Formed PDL Implementation Advisory Group
Provided broad access to all PDL information through dedicated web site (www.dmas.virginia.gov) and e-mail ([email protected])
Conducted extensive beta-site testing with independent, chain and long-term care pharmacies.
Phased-in drug classes – “soft edits” for a period, then “hard edits”
12
Critical Steps Taken in Implementation Process
Developed an extensive education program– Memorandum and reminder postcard sent to providers– Information (English & Spanish) sent to all recipients– Regional and targeted training programs for
pharmacists, health systems, and provider associations– Personal contact made with high volume Medicaid
prescribers and pharmacists
Effective September 1, providers can download the PDL to their handheld personal assistants through eProcates
13
Presentation Outline
Background of PDL Development
Current Status
Review of Antidepressants
14
Implementation Has Gone Very Smoothly
All clinical decisions regarding the PDL and prior authorization process are made by DMAS’ Pharmacy and Therapeutics (P&T) Committee.
PDL compliance rate is high and most changes to “preferred” drugs are being made voluntarily
Patients are getting the drugs they need– There have been 26 “technical” denials but in these cases,
the patients still received their drugs– There have been no appeals – 7 of every 10 requests for a PA are approved; in other
cases, provider agrees to switch to the preferred drug
15
Implementation Has Gone Very Smoothly
Call Center is operating extremely well
Very few complaints from providers or clients
In terms of savings, actual Medicaid expenditures are significantly below DMAS’ official forecast. Preliminary savings analysis indicates DMAS is on pace to meet its required savings
16
Compliance Is High; Rates Do Not Vary Greatly By Drug Class
89% 89% 92%
84%
93% 93%
83%
90%
TotalGastrointestinal
Medications LipotropicsAnti-
HistaminesHypotensive
ACE BlockersHypotensive
ReceptorsAnti-
InflammatoryBeta
Blockers
85% Compliance Level Needed For Budgeted Savings
17
First Health Call Center Staff Are Answering Calls In Less Than 30
Seconds
0:16
2:46
Average Speed to Answer
Average Length of Call
Average
January February May
0:30
2:39
March April
0:00:00
0:28:48
0:57:36
1:26:24
1:55:12
2:24:00
2:52:48
3:21:36
3:50:24
18
DMAS Will Conduct A Comprehensive Evaluation of PDL Program
Evaluation will address the following key issues:
– Has the PDL program been implemented in a way to ensure a high rate of compliance without adversely affecting patient access/care?
– What impact has the PDL program had on Medicaid pharmaceutical spending?
– Has the PDL program impacted patient health outcomes for Medicaid clients?
19
Presentation Outline
Background of PDL Development
Current Status
Review of Antidepressants
20
Antidepressants (SSRIs) & Antianxiety Drugs
Medicaid spent approximately $29.5 million in total funds (net of rebates) on SSRIs ($15.8), anti-anxiety drugs ($6.9), and new generation antidepressants ($6.8) in FY 2003
The SSRI drug class is the third highest in expenditures
Excluding the SSRIs, anti-anxiety drugs and new generation antidepressants from the PDL would cost approximately $5 million (total funds) annually; a “grandfather” provision would cost roughly half of this amount
21
2004 Appropriations Act Provides Direction on Review of
Antidepressants Item 326 BB 7
– If DMAS does not exempt antidepressants and antianxiety medications used for the treatment of mental illness from the PDL, it should defer inclusion from PDL until July 1, 2005
– Prior to including these drug classes in the PDL, DMAS shall provide a plan that stipulates mechanisms to: minimize adverse impacts on consumers; ensure appropriate provider education; and ensure inclusion is evidence-based, clinically efficacious and cost-effective
– DMAS shall report such plan to the Governor, and Chairman of the House Appropriations and Senate Finance Committees and the Joint Commission on Health Care by January 1, 2005
22
DMAS/P&T Committee Approach
Antidepressants and antianxiety drug classes will be reviewed by the P&T Committee on October 6, 2004
In addition to receiving testimony on scientific evidence from manufacturers, clinicians and others, the P&T Committee also will receive public comments from other interested parties
If the P&T Committee recommends including these drug classes in the PDL, a report will be prepared and submitted as required by the 2004 Appropriations Act.– If recommended for inclusion in the PDL, the effective
date would be no earlier than July 1, 2005