Virginia Medicaid Preferred Drug List and Other Pharmacy Programs: What You Need To Know Presented b

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Virginia Medicaid Preferred Drug List and Other
Pharmacy ProgramsWhat You Need To
KnowPresented byDepartment of Medical
Assistance Servicesand First Health Services
Corporation


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Goal Virginia Medicaid Preferred Drug List

• Provision of
• Safe drug therapy
• Effective drug therapy
• Appropriate drug therapy
• To Fee for Service/MEDALLION Enrollees
• At A reasonable cost to the Medicaid program
• The assistance from prescribers and pharmacists
  is key to the success of the program

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How Does This Affect You

• Prescribers should proactively change their
  Medicaid enrollees, as appropriate, to drugs
  included on the PDL (proactive PA).
• For new drug therapy, prescribers should
  prescribe drugs, as appropriate, that are
  included on the PDL.
• In the event that a non-preferred drug is
  medically necessary, the prescriber must contact
  the FHSC Call Center to request PA before giving
  a prescription to an enrollee.
• Pharmacy providers should notify prescribers when
  prescriptions for non-preferred drugs are
  received and request changes to preferred drugs.
• Pharmacy providers should instruct prescribers to
  request PA from FHSC Call Center if they are
  unwilling to change to preferred drugs.

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Summary of PDL Development Process
Preferred Drugs NO PDL PA Required
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PDL Program Phase-In

• The goal of this phased-in transition process
  is to minimize the impact of the program on
  enrollees and providers.
• New classes of drugs with approved preferred
  drugs are to be implemented quarterly January,
  April, July 2004
• Soft edits (messages that future PA will be
  required) precede hard edits (PA required).
• All affected Medicaid enrollees will be notified
  by mail of the PDL program.
• All Medicaid providers will receive a Medicaid
  Memo announcing the PDL program including a copy
  of the PDL and instructions for requesting PA for
  non-preferred drugs.
• Presentations will be offered to Medicaid
  providers to introduce the program and to explain
  operational procedure.

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Initial Drug Classes 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
• AngiotensinII 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

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Drug Classes Proposed for Implementation in April
2004

• Therapeutic Class Description Used for
  Treatment of
• Oral Hypoglycemics
  Diabetes
• Leukotriene Modifiers
  Allergic Conditions/Asthma
• Bisphosphonates Osteoporosis
• Traditional NSAIDs
  Inflammatory Conditions
• Serotonin Receptor Agonists
  Migraine Headache
• Oral Antifungals Nail Fungal
  Infections
• NOTE Additional classes of drugs to be
  implemented quarterly at the recommendation of
  the PT Committee.

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Classes of Drugs Excludedfrom the PDL Program

• Therapeutic Class Description
• Insulins
• Cholinesterase Inhibitors
• Platelet Aggregation Inhibitors
• Antivirals for HIV
• Cancer Chemo. Agents
• Anti-convulsants
• Immunosupressants
• Antiemetics
• Anti-psychotics, Atypical and Typicals

• Used in the Treatment of
• Diabetes
• Alzheimers
• Clotting Disorders
• HIV/AIDS
• Cancer
• Seizure Disorders, Mental Health
• Transplant Rejections, Arthritis
• Nausea in Cancer Patients, Aging
• Serious Mental Illness

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What is the Prescribers Responsibility

• Prescribers should prescribe drugs on the
  preferred drug list.
• New therapy should be initiated on a preferred
  drug unless a non-preferred drug is medically
  necessary.
• Prescribers should review the therapy of their
  Medicaid enrollees for utilization of
  non-preferred drugsand wherever medically
  appropriate, change patients to preferred
  drugs.
• Therapy review and modification should begin
  immediately, during December and January.
• In situations where non-preferred drugs are
  medically necessary, prescribers should initiate
  PA requests by phone, fax or mail to the FHSC
  Call Center.

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What is the Pharmacists Responsibility

• During the soft edit phase of the PDL program
  implementation, messages will alert pharmacy
  providers when a non-preferred drug claim is
  submitted
• Pharmacy providers should call the prescriber
  with a request to change the drug to a preferred
  drug within the same therapeutic class
• If the prescriber does not feel it is medically
  appropriate to change to a preferred drug, the
  pharmacy provider should instruct the prescriber
  to call or fax FHSC with a PA request for the
  non-preferred drug.
• When hard edits begin, if the pharmacy provider
  deems that the patients medical condition
  warrants it, he/she can call FHSC for a 72hr
  supply of medication.

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Prescribing and Dispensing Drugs in the Virginia
Medicaid PDL Program

• Scenario 1
• Prescriber writes a prescription for a preferred
  drug
• Enrollee takes the prescription to the pharmacy
  and receives the medication, pays the 1 or 3
  co-pay, if applicable

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Prescribing and Dispensing Drugs in the Virginia
Medicaid PDL Program

• Scenario 2
• Prescriber writes a prescription for a
  non-preferred drug
• Prescriber faxes or calls a PA Request to the
  FHSC Call Center BEFORE giving the prescription
  to the enrollee
• Prescriber either changes the prescription to a
  preferred drug or gets a PA approval for the
  non-preferred drug
• Enrollee takes the prescription to the pharmacy
  and receives the medication, pays the 1 or 3
  co-pay, if applicable

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Prescribing and Dispensing Drugs in the Virginia
Medicaid PDL Program

• Scenario 3
• Prescriber writes a prescription for a
  non-preferred drug and enrollee takes the
  prescription to the pharmacy
• Pharmacy provider gets a message and denial that
  a PA is required for a non-preferred drug
• Pharmacy provider calls the prescriber by phone
• Prescriber changes the prescription to a
  preferred drug and medication is dispensed, or
• Prescriber told to call FHSC to request a PA for
  a non-preferred drug
• If pharmacy provider deems the patients medical
  condition warrants it, he/she calls FHSC for a
  72-hour supply of medication
• Prescriber calls FHSC to request a PA for a
  non-preferred drug
• Prescriber changes prescription to a preferred
  drug and medication is dispensed, or
• Prescriber receives PA approval for
  non-preferred drug and medication is dispensed,
  or
• PA request is denied and appeals options are
  offered

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FHSC Prior Authorization/Call Center Information

• Methods to Request Prior Authorization
• Telephone Call
• Faxed PA Request Form
• Mailed PA Request Form
• Prescriber/Pharmacy Call Center 800-932-6648
• Fax [phone]
• Mailing Address First Health Services
  Corporation 4300 Cox Rd.
  Glen Allen, VA 23060 Attn MAP
• Enrollee Call Center 800-932-3923
• TYY/TDD 800-855-1155

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PA Request Required Information

• Enrollee Name, Medicaid ID, Date of Birth,
  Diagnosis
• Name of Drug and Strength, Quantity per Day
• Documentation of Previous Drug Therapy for the
  Indicated Diagnosis
• Clinical Evidence That a Preferred Drug Will
  Not Provide Adequate Benefit
• Physician Name, Signature
• Physician Phone and Fax
• Date

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Turnaround Time PA Request

• Phone PA Requests will be processed on the
  initial call.
• Certified pharmacy technicians will respond
  initially. If prior authorization cannot be
  determined, the call will be transferred to a
  clinical pharmacist for further review.
• If necessary, further review can be requested
  from a lead clinical pharmacist and finally, a
  physician.
• Fax PA Requests and Mailed PA Requests will be
  processed within 24 hours of receipt.
• Once a PA Request is approved, it is entered into
  the system for immediate claim adjudication.
• If a PA Request is denied, there is an appeals
  process.

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Denials and Appeals

• FHSC mails a denial letter to both the prescriber
  and the enrollee outlining the Right to Appeal.
• The prescriber and/or the enrollee decides to
  complete the appeals paperwork and submits to
  DMAS Appeals Division.
• Department of Medical Assistance Services
• Appeals Division
• 600 E. Broad Street
• Richmond, Virginia 23219
• Appeals Hearing is conducted with the support of
  FHSC to provide background information related to
  the PA request denial and to be available to
  attend the hearing.

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Quality Initiatives

• Prospective Drug Utilization Review (ProDUR)
  related to possible serious drug/drug
  interactions, pregnancy contraindications and
  therapeutic duplication and early refill requests
  that may compromise quality of care will require
  PA.
• Clinical edits will be implemented related to the
  cost-effective use of medications that are
  frequently overused or misused.
• Retrospective Drug Utilization Review (RetroDUR)
  related to polypharmacy through established
  threshold limits for number of utilized
  medications will occur.
• Prescribers will receive letters, requiring
  response, as indicated by clinical review of
  enrollee medication profiles.
• Medications determined to be inappropriate will
  be prevented from further adjudication until PA
  is requested by the prescriber and approved.

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Pharmacy Contact/Information Sites

• Provider Call Center 800-932-6648
• Enrollee Call Center 800-932-3923
• Fax [phone]
• E-mail for Comments pdlinput_at_dmas.virginia.gov
• Web Sites www.dmas.state.va.us
• http//virginia.fhsc.com