Seniors and Persons with Disabilities Transitioning Pharmacy Benefits from FFS Medi-Cal to Managed Medi-Cal for Seniors and Persons with Disabilities (SPDs) - PowerPoint PPT Presentation

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Seniors and Persons with Disabilities Transitioning Pharmacy Benefits from FFS Medi-Cal to Managed Medi-Cal for Seniors and Persons with Disabilities (SPDs)

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Seniors and Persons with Disabilities Transitioning Pharmacy Benefits from FFS Medi-Cal to Managed Medi-Cal for Seniors and Persons with Disabilities (SPDs) – PowerPoint PPT presentation

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Title: Seniors and Persons with Disabilities Transitioning Pharmacy Benefits from FFS Medi-Cal to Managed Medi-Cal for Seniors and Persons with Disabilities (SPDs)


1
Seniors and Persons with Disabilities
Transitioning Pharmacy Benefits from FFS
Medi-Cal to Managed Medi-Cal for Seniors and
Persons with Disabilities (SPDs)
2
Agenda
  • Overview of FFS Medi-Cal vs. Managed Medi-Cal
  • What do we know about our new members?
  • Transition from FFS Medi-Cal to SFHP formulary
  • Overview of major formulary differences
  • Conversion from non-formulary to formulary long
    acting opiates
  • Prior authorization process for NF medications
  • Questions, Concerns and Feedback

3
Fee For Service Medi-Cal vs. Managed Medi-Cal
4
Medi-Cal Options Fee For Service vs. Managed
Care
  • In San Francisco, there are 2 models for
    delivering Medi-Cal benefits
  • 1) Fee For Service (FFS) Medi-Cal
  • SPDs who also have Medicare will stay in FFS
    (unless they voluntarily enroll in managed care)
  • Administered by the State of California.
  • Beneficiaries can self-refer to any Medi-Cal
    provider.
  • 2) Managed Medi-Cal
  • Kids and families are mandatorily enrolled into
    one of two plans
  • San Francisco Health Plan Managed Medi-Cal
  • Anthem Blue Cross Managed Medi-Cal
  • Effective June 1, 2011, SPDs will be mandatorily
    enrolled on the month after their birthday.
  • Care is managed by PCP within a medical group and
    care outside the medical group requires
    authorization

5
What do we know about our potential members?
6
What do we know about our potential members?
  • SFHP expects to enroll over 1,100 new SPD members
    per month.
  • SFHP expects to enroll over 14,000 new members by
    May 2012.
  • The cost of each member per month for SPD members
    is substantially higher than the cost for non-SPD
    MediCal members.

7
What do we know about the cost for our potential
members?
  • SFHP current pharmacy expenditures average about
    17 PMPM for non-SPD MediCal members.
  • The current cost per member per month (PMPM) is
    211 for the SPD members in FFS
  • The cost PMPM needs to be closer to 130 to be
    sustainable for our network.
  • Every dollar spent on pharmacy cannot be invested
    back into primary care.

8
Top Diagnoses in SPD Population
Hypertension
HIV
Diabetes
Respiratory Conditions (Asthma, COPD)
Musculoskeletal problems including back pain
Chronic Kidney Disease
9
Transition to SFHP Formulary
10
Information to Members and Providers
  • Communicating to members and providers about the
    transition to the SFHP formulary is a top
    priority.
  • Webinars and provider site visits will be
    utilized to share information regarding
    differences in the FFS Medi-Cal formulary and the
    SFHP formulary.

11
Information to Members and Providers
  • SFHP will allow a 90 day transition period.
    After 90 days, a prior authorization request will
    need to be submitted for any non-formulary
    medication.
  • Letters will be sent to members and physicians
    when members need to be transitioned to a SFHP
    formulary medication.
  • Key Pharmacy Carve-Outs (Medi-Cal services not
    paid by Health Plans)
  • Psychotropic drugs
  • AIDS drugs

12
Resources
  • SFHP formulary will be published online.
  • Epocrates.com
  • Short Formulary on SFHP website (www.sfhp.org)
  • Full formulary with drug use criteria will be on
    the SFHP website by November 2011.
  • SFHP will share relevant patient-specific data
    with providers to improve care coordination.

13
Overview of Major Formulary Differences
14
Differences in Five Major Therapeutic Categories
  • PPIs
  • Lipid Lowering Agents
  • SSRIs/SNRIs
  • NSAIDs
  • Long Acting Opioids

15
Proton Pump Inhibitors
Medications Not on SFHP Formulary Average Cost per 30 Day RX SFHP Cost-Effective Alternatives Average Cost per 30 Day Rx
Dexlansoprazole (Dexilant) 164 Omeprazole (Prilosec) 26
Esomeprazole (Nexium) 164 Omeprazole (Prilosec) 26
Lansoprazole (Prevacid) 164 Omeprazole (Prilosec) 26
Pantoprazole (Protonix) 164 Omeprazole (Prilosec) 26
16
Lipid-Lowering Agents
Medications Not on SFHP Formulary Average Cost per 30 Day RX SFHP Cost-Effective Alternatives Average Cost per 30 Day Rx
Atorvastatin (Lipitor) Rosuvastatin (Crestor) Colesevelam (Welchol) Colestipol (Colestid) Ezetimibe (Zetia) Omega-3-FA (Lovaza) Niacin ER (Niaspan)   153 Fluvastatin (Lescol) Lovastatin (Mevacor) Pravastatin (Pravachol) Simvastatin (Zocor) Cholestyramine (Questran) Fenofibrate (Tricor) Fenofibrate micronized (Lofibra) Gemfibrozil (Lopid) Niacin CR 42
17
SSRIs and SNRIs
Medications Not on SFHP Formulary Average Cost per 30 Day RX SFHP Cost-Effective Alternatives Average Cost per 30 Day Rx
Lexapro 109 Fluoxetine 24
Lexapro 109 Citalopram 24
Lexapro 109 Paroxetine 24
Lexapro 109 Sertraline 24
Venlafaxine Cymbalta 114 160 Must try and fail 2 SSRIs. Venlafaxine is preferred agent. Must try and fail 2 SSRIs. Venlafaxine is preferred agent.
18
Cox-2 Inhibitors/Non-Selective NSAIDS
Medications Not on SFHP Formulary Average Cost per 30 Day RX SFHP Cost-Effective Alternatives Average Cost per 30 Day Rx
Celecoxib (Celebrex) Ketorolac (Toradol) Meloxicam (Mobic)   124 Diclofenac (Voltaren) Etodolac (Lodine) Fenoprofen (Nalfon) Flurbiprofen (Ansaid) Ibuprofen (Motrin) Indomethacin(Indocin) Nabumetone(Relafen) Naproxen (Naprosyn) Oxaprozin (Daypro) Piroxicam (Feldene) Sulindac (Clinoril) 44
19
Long-Acting Opioids
Medications Not on SFHP Formulary Average Cost per 30 Day RX SFHP Cost-Effective Alternatives Average Cost per 30 Day Rx
Oxycontin (40mg BID) 462 Methadone 5mg TID MS Contin 60mg BID   54 180  
Fentanyl Transdermal Patches 50mcg (10) 260 Methadone 5mg TID MS Contin 60mg BID   54 180  
 Kadian 120mg/day  545 Methadone 5mg TID MS Contin 60mg BID   54 180  
20
Conversion from Oxycontin to SFHP formulary agent
  • Analgesia is more dependent on dose than drug.
  • In a patient taking chronic, high doses some
    recommend tapering the original opioid while
    initiating the new to avoid over-dosing or
    under-dosing.
  • Decrease original opioid by 50 and begin new
    opioid at 50 of the calculated projected dose.

21
Conversion - continued
  • Short-acting opioids can be used to manage pain
    during transition
  • Gradually increase or decrease the dose over
    several days based on patient tolerability, e.g.
    25 increments per week.
  • Once an adequate level of analgesia is attained,
    discontinue the old opioid.

22
Information on Methadone
  • Methadone requires slow, careful dose titration.
  • Methadones potency increases with increasing
    prior opioid exposure.
  • Patients who have been on higher doses are
    converted differently than those who have been on
    lower doses.

23
Prior Authorization Request for Non-formulary
Medications
  • All non-formulary medications require prior
    authorization.
  • Prior authorization may also be required for
    quantity limits.
  • Prior authorizations are first reviewed by the
    SFHP Pharmacy Benefits Manager (PBM) based on
    approved criteria.
  • If the PBM is unable to make a decision based on
    criteria, the request is sent to SFHP for review.

24
Prior Authorization Request for Non-formulary
Medications
  • The provider or providers representative will
    complete a prior authorization request which will
    contain
  • Diagnosis
  • Other relevant medications tried and failed
  • Clinical justification for the request including
    reason your patient cannot use a SFHP formulary
    medication.

25
Prior Authorization Request for Non-formulary
Medications
  • SFHP pharmacy will review prior authorization
    request and will take the following action
  • Approve as requested
  • Modify to a formulary medication
  • Deny request
  • SFHP will send letter to member and provider if a
    medication is modified or denied.

26
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