Status Report: Medicaid Preferred Drug List Program

1
Status Report Medicaid Preferred Drug List
Program

• Presentation to the
• Joint Commission on Health Care
• Behavioral Health Subcommittee

Patrick W. Finnerty, Director Department of
Medical Assistance Services
August 4, 2004 Richmond, 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 (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

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 Medicaids 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) Edloes Pharmacies

6
PDL Development Process
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 (pdlinput_at_dmas.virginia.gov)
• 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 (PT) 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
85 Compliance Level Needed For Budgeted Savings
Gastrointestinal Medications
Anti-Histamines
Hypotensive ACE Blockers
Hypotensive Receptors
Anti-Inflammatory
Beta Blockers
Total
Lipotropics
93
93
92
89
90
89
84
83
17
First Health Call Center Staff Are Answering
Calls In Less Than 30 Seconds
35024
32136
246
Average Length of Call
239
25248
22400
15512
12624
05736
Average Speed to Answer
030
016
02848
00000
Average
January
February
May
March
April
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/PT Committee Approach

• Antidepressants and antianxiety drug classes will
  be reviewed by the PT Committee on October 6,
  2004
• In addition to receiving testimony on scientific
  evidence from manufacturers, clinicians and
  others, the PT Committee also will receive
  public comments from other interested parties
• If the PT 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