Governor

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Governors Office of Health Policy and Finance
MaineCare Pharmacy Initiatives
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PDL

• Preferred Drugs
• By definition are usually Cost-Effective
• Provide the best clinical outcome for the least
  amount of money

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PDL What its not

• A PDL is not a Formulary
• Formulary is a limited list of drugs that are
  covered
• In a PDL all Drugs continue to be covered
• Members have access to Non-Preferred Drugs in a
  variety of ways
• By Prior Authorization
• By Step Therapy
• By Grandfathering in certain Drug Classes
• By Special Medical Conditions (Cancer)

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Antipsychotics

• Nearly 20 million (state federal) spent
  annually
• 11 of drug budget
• Over 12,000 users
• Presently, PDL only addresses high doses and
  duplicate therapy
• Can save over 1 million (state) by selecting
  first-line drugs that wont need PA
• 15 States currently PA in this Category

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PA for Some Atypicals

• Follow National Association of State Mental
  Health Directors Guidelines
• (see next 2 slides)
• Many choices in first line medications
• Established users not affected (about 50 over
  course of the year)
• Only affects new starters

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Antipsychotic PDL Ensuring Appropriate Access
and Efficient Utilization (NASMHD)

• All medications should be available.
• Not all medications need be available on a
  first-line basis.
• PA should be simple and flexible.
• Choices of first-line medications at a minimum
  must include
• Clozapine (any approved formulation)
  Treatment-resistance
• Risperidone or paliperidone Atypical with
  long-acting formulation
• Ziprasidone or aripiprazole Weight-neutral
  atypical
• Olanzapine or quetiapine Sedating atypical
• Haloperidol or fluphenazine high potency typical
  and long-acting formulation
• Perphenazine or thiothixene or other
  medium-potency typical
• Chlorpromazine or other low-potency typical.

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Antipsychotic PDL Ensuring Appropriate Access
and Efficient Utilization (NASMHD)

• Helps ensure that medications are prescribed
  according to manufacturer indications
• A prescription drug may be selected for prior
  authorization if one of the following
  characteristics apply
• Clinically appropriate
• High ingredient cost
• Use is within a narrow member population
• Drugs with a high potential for inappropriate use
  or abuse
• Agents that are best reserved for second or third
  line therapies

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What happens when a PA is needed?

• But the doctor has not completed the PA request
• There was a one time override the pharmacist
  could use to dispense a one month supply during
  the PDL implementation phase.
• The member always has access to a 96 hour
  emergency supply.
• Nearly 80 of PAs submitted are approved
• Completed PA receive a decision on average within
  3 hours of submission

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Draft PA Criteria

• Grandfather existing users
• Start of NP in Hospital setting will be
  grandfathered
• 3 week trial of an effective dose of a Preferred
  Drug will meet approval criteria for a NP Drug
• Documentation of good response to samples of NP
  Drug
• Documentation of significant side effects will
  meet approval criteria for NP Drug
• Doctor can always request a prior authorization
  without having to use Preferred Drug if medical
  necessity is documented

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What happens when a PA is not approved?

• Additional information documenting medical
  necessity for a re-determination may be
  submitted.
• A member can appeal the decision by requesting a
  Fair Hearing.

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Safety Net Protections

• Completed PAs acted on within 24 hours of
  submission
• Average time to review a completed PA is 3 hours
• 96 hour supply of drug is available on an
  emergency basis

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4 Brand Name Per Month Limit

• 1 Million savings (State)
• Only for MaineCare members who are
• Not a dual eligible
• Over 18 years of age
• Will not apply to
• Cancer medications
• HIV medications
• Antipsychotics
• Currently have 5 Brand limit for MaineCare
  members living in certain settings
• 17 States currently have limits in place