Status Report on Development of a Medicaid Preferred Drug List Program

1
Status Report on Development of a Medicaid
Preferred Drug List Program

• Presentation to
• The Joint Commission on Health Care

Patrick W. Finnerty Department of Medical
Assistance Services
May 6, 2003 Richmond, Virginia
2
Presentation Outline
Background Actions Taken Thus Far Next Steps
3
2003 Appropriations Act Preferred Drug List
(PDL) Program

• Item 325(ZZ.1) of the 2003 Appropriations Act
  directs 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 (PT) 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
• Program must generate savings of 9 million GF in
  FY 2004, and 18 million GF in subsequent fiscal
  years.

4
2003 Appropriations Act PT Committee
Responsibilities

• The PT Committee shall recommend to the
  Department
• therapeutic classes of drugs to be subject to the
  PDL and prior authorization requirements
• specific drugs within each class to be included
  on the PDL
• appropriate exclusions for medications, including
  atypical anti-psychotics, used for the treatment
  of serious mental illnesses such as bi-polar
  disorders, schizophrenia, and depression
• appropriate exclusions for medications used for
  the treatment of brain disorders, cancer, and
  HIV-related conditions
• other appropriate exclusions and grandfather
  clauses

5
PDL Development Process
6
Overview of PDL With Reference Pricing and
Supplemental Rebates
70
Non-Participating Manuf. Drug Available through
P.A.
56
38
29
11
27
27
27
22
Source DMAS Staff Illustration
7
Presentation Outline
Background Actions Taken Thus Far Next Steps
8
Actions Taken Thus Far

• Met with 30 different interested parties on PDL
  issues
• pharmaceutical manufacturers, physicians,
  pharmacists, hospitals, nursing homes, advocacy
  groups and others
• Submitted status report to General Assembly on
  April 1
• Solicited nominations from provider associations
  for physicians and pharmacists to serve on the
  PT Committee
• Solicited public comments on a draft Request for
  Proposals (RFP) to select a PDL contract
  administrator RFP issued on May 1
• Established a pharmacy web page at DMAS internet
  site and e-mail address for PDL comments/input
• pdlinput_at_dmas.state.va.us

9
Members of PT Committee Have Been Selected

• Member Background
• Randy Axelrod (MD) Anthem Chief Medical Officer
• Roy Beveridge (MD) Oncologist
• Randall Dalton (MD) Ear, Nose Throat
• 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
• Gill Abernathy (Pharmacist) INOVA Health System
• Mark Oley (Pharmacist) Westwood Pharmacy
• Renita Warren (Pharmacist) Edloes Pharmacies

10
An Initial List of Key Classes of Drugs to be
Excluded from the PDL Program Has Been Developed

• 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

11
Presentation Outline
Background Actions Taken Thus Far Next Steps
12
Next Steps

• Procure PDL contractor services
• Develop emergency regulations and submit State
  Plan amendment to Centers for Medicare Medicaid
  Services
• Provide status reports to the General Assembly at
  key points in development process
• Schedule initial PT Committee meeting
• Continue to receive input from interested parties

13
Next Steps(continued)

• Incorporate other pharmacy-related prior
  authorization requirements
• prior authorization for more than 9 unique
  prescriptions in 180 days (non-institutionalized
  patients) or 30 days (institutionalized patients)
• Modify Medicaid Management Information System
  (MMIS) to process PDL and prior
  authorization-related transactions
• Develop provider/consumer education and training
  program
• PDL contractor will have major responsibilities