Virginia Medicaid ProDUR Program Update Presented to: PDLPA Implementation Advisory Group

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Virginia Medicaid ProDUR Program
UpdatePresented toPDL/PA- Implementation
Advisory Group


Javier Menendez, Pharmacy Manager Department of
Medical Assistance Service
June 22, 2004 Richmond, Virginia
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Presentation Outline
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• Background on the ProDUR Program

• DUR Board

• ProDUR enhancements

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Background on the ProDUR Program

• ProDUR is a review by the pharmacist of the
  prescription medication order and the patients
  drug therapy before each prescription is filled.
  This review is for the health and safety of the
  Medicaid patient.
• The review includes an examination of the
  patients profile to determine the possibility of
  potential drug therapy problems due to
  therapeutic duplication, drug-disease
  contraindications, drug-drug interactions,
  drug-allergy interactions, drug dosage or
  duration of drug treatment.
• ProDUR is used by commercial carriers, Medicaid
  managed care organizations and DMAS. This is in
  compliance of state regulations 12 VAC 30-130-280
  through 130-410 and The Omnibus Reconciliation
  Act of 1990.

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Presentation Outline

• Background on the ProDUR Program

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• DUR Board

• ProDUR enhancements

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DUR Board

• 5 Physicians
• 2 Nurses
• 6 Pharmacists

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Members of DUR Board

• Member Background
• Geneva Briggs (PharmD) (Chairman) DUR Board
• Kelly Goode (PharmD) Virginia Pharmacist Assoc.
• Sandra Dawson (Rph) VaPha-Consultant Pharmacist
• Mark Johnson (PharmD) Shenandoah University
• Bill Rock (PharmD) VA Hospital
• Jennifer Edwards (PharmD) Va. Assoc. Chain Drugs
• Jane Settle (NP) Virginia Nurses
  Association
• Elaine Ferray (MS) Virginia Nurses Association
• Thomas Moffatt (MD) Medical Society of Virginia
• Robert O Friedel (MD) Medical Society of
  Virginia
• Matthew Goodman (MD) UVA School of Medicine
• Catherine Kelso (MD) MCV
• Jason Lynam (MD) UVA School of Medicine

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DUR Board Quarterly Meetings

• August 7th 2003
• November 6, 2003
• February 5th, 2004
• May 6, 2004

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Presentation Outline

• Background on the ProDUR Program

• DUR Board

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• ProDUR enhancements

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ProDUR Enhancements

• February 1st, 2004, certain edits enhanced from
• Message Only to Provider Level Override.
• DD(drug-drug), MC(drug-disease), PG(pregnancy)
  and TD (therapeutic duplication)now require
  intervention and outcome codes.
• FHSC has complete prescription history for all
  recipients, many recipients use multiple
  providers for prescription services

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11 Drug Classes Deny for Therapeutic Duplication

• Anti-Ulcer Agents
• Ace Inhibitors
• Angiotensin II Receptor Blockers
• Antidepressants
• Benzodiazepine
• NSAIDS

• Calcium Channel Blockers
• Narcotics
• Thiazide Diuretics
• Loop Diuretics
• Potassium-Sparing Diuretics

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ProDUR Enhancements

• June 14th, 2004, ER (early refill) edits
  enhanced from Provider Level Override With
  Intervention and Outcome Codes, to required
  telephone call.
• The Early Refill (ER) alerts occur when the
  prescription is presented for refill before 75
  of the medication is used in compliance with the
  directions and quantity (days supply).
• Requires POS/RPH to call FHSC for PA
• FHSC has complete prescription history for all
  recipients

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Early Refills

• 30 days x .75 23
  days
• 23 days / 365 days 15.8
  scripts/year
• An Extra 3 scripts at 55/script (avg. Rx ) for
  10 of the FFS population (23,000)
  would equal 3,795,000.00

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Why enhance ER edit to telephone call required?

• From January 2004 through May 2004 DMAS has
  made gt 3,500,000.00 in override payments.
• Most state Medicaid plans require a telephone
  call for this override (Tennessee, South
  Carolina, Missouri, Massachusetts, Maryland,
  Michigan, Ohio, Iowa, Alabama)
• Most MCOs have this as standard including
  Sentara, Anthem, VA Premier, Unicare and CareNet.
• Most commercial plans have this as standard (
  Aetna, BCBS, Cigna, United Healthcare )

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