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10 October 2013 1. Follow-up to Previous Reviews Nystatin/Triamcinolone Combo DUR (re-run summer months to compare to previous, as well as potent steroid.

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Presentation on theme: "10 October 2013 1. Follow-up to Previous Reviews Nystatin/Triamcinolone Combo DUR (re-run summer months to compare to previous, as well as potent steroid."— Presentation transcript:

1 10 October 2013 1

2 Follow-up to Previous Reviews Nystatin/Triamcinolone Combo DUR (re-run summer months to compare to previous, as well as potent steroid combos – these fall in combo rule so no claims) Suboxone and Participants Paying Cash for Other Opioids Hepatitis C DUR GeoMapping Analysis Utilization of Narcotic Analgesics (HIC3 = H3A) 16YO+ 2

3 Nystatin/Triamcinolone Combo DUR What are the utilization numbers on the various nystatin/triamcinolone combo products? 3

4 Nystatin/Triamcinolone Combo DUR 4

5 5

6 Questions/Comments ??? 6

7 Suboxone and Participants Paying Cash for Other Opioids (includes Suboxone film, Suboxone tablets, buprenorphine/naloxone tablets, buprenorphine tablets) 7

8 Buprenorphine DUR Follow-Up Identified all participants with at least one claim paid for oral buprenorphine by Idaho Medicaid between 6/1/13 and 8/31/13. n=201 Ran Board of Pharmacy report for all of these participants to identify anyone who had received any other opioid with overlapping days of service and noted payment method (cash, Idaho Medicaid, other insurance). 8

9 Buprenorphine DUR Follow-Up 9

10 10 Note: Adds up to more than 27 as some patients paid cash for multiple opioids.

11 Buprenorphine DUR Follow-Up 2 patients had both Suboxone and another opioid prescribed by the same doctor. The other 25 patients had different prescriber(s) for the other opioids. 11

12 Buprenorphine DUR Follow-Up 12

13 Buprenorphine DUR Follow-Up Case Study: Patient identified during DUR done the previous quarter and payment was blocked for Suboxone after it was filled in June. Between June through August 2013, patient filled hydrocodone 18 times, oxycodone 4 times, and codeine once. This patient obtained prescriptions from 9 different prescribers and used 9 different pharmacies during this three month period. Letters were sent to all 9 prescribers and she is in the process of being enrolled into the lock-in program. Prescribers included two ER physicians, 2 internal medicine physicians, 2 family medicine physicians, an orthopedic surgeon, an otolaryngologist, and a physicians assistant. At this time, Idaho Medicaid has blocked payment for Suboxone as well as other opioids. She is paying cash for all of these drugs and is getting medication filled every several days. 13

14 Buprenorphine DUR Follow-Up Called Suboxone Prescribers Was prescriber aware of other opioids paid for with cash? What was the consequence to the patient? 14

15 Buprenorphine DUR Follow-Up 15

16 Buprenorphine DUR Follow-Up 16

17 Buprenorphine DUR Follow-Up 17

18 Buprenorphine DUR Follow-Up 18

19 Buprenorphine DUR Follow-Up 19 Unable to contact one prescriber (n=2) Left three voicemail messages and sent letters on two of his patients that had paid fills for hydrocodone as well as Suboxone. Blocking payment to Suboxone one week after letters sent.

20 Buprenorphine DUR Follow-Up 20 All prescribers were appreciative of the information Idaho Medicaid provided to them. Future Plans The department plans on running routine board of pharmacy reports every 3 to 6 months on all Suboxone patients.

21 Hepatitis C DUR Total Medicaid patients who received HepC treatment: 53 (36 Incivek, 17 Victrelis) Letters were sent to prescribers in June 2013 and for those who did not respond sent again August 2013 Requested information returned from prescribers: 46 (29 Incivek, 17 Victrelis) (13% no response from provider) 21

22 Hepatitis C DUR 1A-10, 1B-10, Type 1 unspecified-9 1A-10, 1B-3, Type 1 unspecified-4 22

23 Hepatitis C DUR 23

24 Hepatitis C DUR All patients from both groups who reported back underwent triple therapy with Pegylated Interferon and Ribavirin No patients who reported back had an HIV co- infection Initial Viral Loads Lowest – 18,029, Highest – 69,000,000, Average – 5,777,694 Info not received for 5 patients (11%) 24

25 Hepatitis C DUR 25

26 Hepatitis C DUR 26

27 Hepatitis C DUR Yes-9, No- 6 d/t SEs & 1 d/t Non-response, In progress-9, Info not provided-4 Yes-3, No-3 d/t SEs & 1 d/t infection, In progress-4, Info not provided-6 27

28 Hepatitis C DUR 28

29 Hepatitis C DUR Non-responder-1, Side effects-6, Co-Morbid Condition-0 Non-responder-0, Side effects-3, Co-Morbid Condition-1 29

30 Hepatitis C DUR Question/comments ??? 30

31 Prepared by MMA 6/13/2013 originally Age specific prepared by MMA 8/5/2013 Please refer to handout in Packet 31

32 Current Interventions/Outcomes Studies Use of Psychotropic Medications in Foster Children – Next Steps 2012 Data Analysis Update Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 32

33 Current Interventions/Outcomes Studies Non-Preferred Growth Hormone Levofloxacin Oral ketoconazole Imitrex Pens 33

34 34

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51 Use of Psychotropic Medications in Foster Children: Next Steps 51

52 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior authorization criteria instituted 01-01-13 for immune globulin (intravenous and subcutaneous) on both the medical side (J-code medical claims) and on the pharmacy side. 52

53 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Therapeutic criteria 1. FDA approved indications such as hypogammaglobulinemia (require laboratory confirmation of diagnosis plus follow-up IgG levels while on therapy) and inflammatory demyelinating polyradiculoneuropathy. 2. Other indications that have evidence to support their usage (e.g. Guillain- Barré syndrome). 3. Use ideal body weight or adjusted body weight (ideal body weight plus 50% of the difference between actual body weight and ideal body weight) in obese patients. 4. Round dosages to +/- 5% (note: literature states up to +/- 10%) to use whole vials and reasonable dosages. We discovered during 2012 DUR project that some pharmacies were using many vial sizes to give exact dose – examples would be 57.5gm using two 200ml vials, one 100ml vial, one 50ml vial, one 20ml vial, ½ of 10ml vial. 53

54 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical Claims J1459Privigen J1557Gammaplex J1559Hizentra J1561Gamunex-C or Gammaked J1566Immune Globulin Intravenous J1568Octagam J1569Gammagard 54

55 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 55

56 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 56

57 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 57

58 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical Claims Annualized Cost Savings since prior authorization implementation: $192,794 67% reduction in claims 60% reduction in number of unique patients 65% reduction in expenditure 58

59 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical Claims 20 Patients with Medical Claims in 2012 5 of these patients continued on IVIG in 2013 All 5 patients had immunodeficiency diagnoses 15 of these patients with no paid medical claims (or pharmacy claims) in 2013 59

60 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 60

61 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical Claims – Prior Authorization Issue Unbeknownst to us until July 2013, prior authorization for medical claims was only instituted for drugs administered in physician offices and not for drugs administered in outpatient settings such as an infusion clinic where the majority of patients would receive this drug. 61

62 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical Claims – Prior Authorization Issue Only 1 out of 8 patients who received immune globulin as a medical claim between January – June 2013 had a prior authorization request submitted. Patient descriptions of the 7 patients without prior authorization requests who still had paid claims in 2013: CVID – 5 patients infantile spasms – 1 patient pregnant – 1 patient (dont know indication for IVIG) None of these patients are currently receiving any more IVIG so their prescribers were not contacted for additional information. 62

63 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical Claims – Prior Authorization Issue Even though medical claims would still have paid at medical clinics without prior authorization, the number of patients and number of claims dropped substantially from 2012 to 2013 most likely due to the notification to providers that prior authorization was going to be required effective 01-01-2013. 63

64 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 64

65 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 65

66 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 66

67 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Pharmacy Claims No individual patient had claims paid as both medical and pharmacy claims. 9 of 11 patients who received IVIG in 2012 continued therapy in 2013 with prior authorization approval. One patient on IVIG in 2012 died in 2012. Another patient on IVIG in 2012 switched over to Medicare in December 2012. 67

68 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Pharmacy Claims 17% reduction in claims 18% increase in number of unique patients (two more patients) 13% reduction in expenditure 68

69 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 69

70 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 70

71 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project 71

72 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Medical and Pharmacy Claims Combined 40% reduction in claims 32% reduction in number of unique patients 31% reduction in expenditure Annualized cost savings since prior authorization requirement instituted January 1, 2013: $271,116 72

73 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior Authorization Requests Received Between January – June 2013 Total of 26 requests – 25 were approved. The one denial was for IVIG weekly for a child with encephalitis – no evidence provided to support efficacy for this indication. 14 approvals with paid claims (medical and pharmacy) 13 approvals – paid pharmacy claims 1 approval – paid medical claims 11 approvals with no paid claims 73

74 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior authorization approvals with no paid claims Idaho Medicaid no longer payor: 2 Just approved June 2013 with no paid claims yet as of 6-30-13: 2 Requested prn low IgG levels (ITP, s/p liver transplant) with no paid claims: 2 Requested for hypogammaglobulinemia but no paid claims: 3 Single dose approved for ITP but never billed to Medicaid: 1 Myasthenia gravis patient - 1 74

75 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior Authorization Example - #1 Specialty Pharmacy insisting on using exact mg dose of 1000mg/kg in an obese patient with dose being adjusted every month as patient was gaining weight. The supporting documentation that the pharmacy provided stated that adjusted body weight should be used (ideal body weight plus 50% of the difference between actual and ideal body weight if patient was obese) and that doses could be rounded +/- 10% to use whole vials. Physician was contacted by phone and agreed to using both adjusted body weight and rounding dose to whole vials. 75

76 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Example - Rounding doses in obese patients Ideal body weight = 60kg Actual body weight = 100kg Adjusted body weight = 80kg Cost savings when using adjusted body weight for 1gm/kg/dose monthly: $29,114 per year per patient. Total cost of therapy is still $116,448 per year per patient. 76

77 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior Authorization Example - #2 N.P. prescribing high dose IVIG (500mg/kg/daily for 4 days every 4 weeks) and wanting to shorten frequency to every 3 weeks in myasthenia gravis patient who was very symptomatic. N.P. agreed to decrease IVIG dose to usual dose of 500mg/kg monthly and increase oral medications instead. Prescribers rationale for wanting to increase IVIG was that patient had a Staph infection and was having difficulty walking. Patient was also on a contra-indicated drug (beta blocker) for a myasthenia gravis patient as well as on lots of sedating medications that could affect walking (methadone, oxycodone, diazepam, diphenhydramine, and carisoprodol). 77

78 Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Questions/Comments ??? 78

79 Non-Preferred Growth Hormone 79 Preferred Growth Hormones Norditropin, Nutropin, Nutropin AQ Non-Preferred Growth Hormones Genotropin, Humatrope, Omnitrope, Saizen, Serostim, Tev-Tropin, Zorbtive

80 Non-Preferred Growth Hormone 80 * preferred products

81 Non-Preferred Growth Hormone 81

82 Non-Preferred Growth Hormone Each endocrinologist prescribes multiple different growth hormone products so his/her office is familiar with multiple product lines and devices from the different pharmaceutical companies. The actual growth hormone medication is exactly the same. 82

83 Non-Preferred Growth Hormone Potential Cost Savings Substantial cost savings will be achieved by Idaho Medicaid when patients previously on non-preferred growth hormone products are switched over to preferred growth hormone products. 83

84 Non-Preferred Growth Hormone Reviewed profiles of 16 patients on non-preferred growth hormone products. 9* – growth hormone product was preferred when first approved; grandfathered ever since 2 - Medicaid is secondary insurance and only paying a small co-pay 84

85 Non-Preferred Growth Hormone Reviewed profiles of 16 patients on non-preferred growth hormone products. 2* – Started on a preferred agent but then switched to a non-preferred agent (stinging noted with one, cant call up the old faxes on the other one for the details of why switched) 1 – database error so claim paid for a non-preferred agent even though prior authorization for the medication had been denied 85

86 Non-Preferred Growth Hormone Reviewed profiles of 16 patients on non-preferred growth hormone products. 2 – no clear notes on why started a non-preferred agent; drug has been grandfathered for years (one patient started therapy in 2003 and the other in 2004*). Not sending a letter to the patient who started therapy in 2003 as medication is up for renewal in October 2013 so will deal with this issue then (and anticipate that growth hormone therapy may be discontinued soon due to patients age). 86

87 Non-Preferred Growth Hormone Letter sent to prescribers of grandfathered non- preferred growth hormone patients. Please refer to packet for a copy of the letter sent to the prescribers 87

88 Non-Preferred Growth Hormone 9* – growth hormone product was preferred when first approved; grandfathered ever since Switched to preferred agent –4 Renewal request received for non-preferred agent – sent back fax to prescriber stating that growth hormone would be approved but patient needed to be switched to a preferred agent; still waiting for response back – 2 NO response yet to letter asking prescriber to switch – 3 No response back from all other letters sent 88

89 Non-Preferred Growth Hormone Questions or Comments ??? 89

90 Levofloxacin DUR Based on the recommendations from the DUR Board at the August 2012 meeting, the minimum age was changed from 16 years down to zero on 11/1/2012 for levofloxacin. 90

91 Levofloxacin DUR 91

92 Levofloxacin DUR 92

93 Levofloxacin DUR While the number of claims and number of patients has increased somewhat since the age restriction was removed, claims for children < 16 years old remain a very small percentage of total paid claims for levofloxacin. 27 paid claims for 22 unique patients aged 0-15 years between 1-01-2013 and 6-30-2013 Diagnoses on following slides 93

94 Levofloxacin DUR Diagnoses Pneumonia – 4 patients 15 year old, only antibiotic prescribed 2 year old with trache, one previous antibiotic tried 9 year old, three previous antibiotics tried 2 year old with trache, only antibiotic prescribed CF – 3 patients (one with 4 paid claims) Tracheitis – 3 patients with CLD with tracheostomies (one with 3 paid claims) 94

95 Levofloxacin DUR Diagnoses Bronchitis – 2 patients (15 year old; 10 year old with chronic lung disease s/p Augmentin) URI – 2 patients (13 year old s/p other antibiotic; 4 year old s/p other antibiotic) UTI – 2 patients (11 years old, chronic kidney disease, s/p other antibiotics; 15 years old, s/p other antibiotic) Pharyngitis – 1 patient (11 years old) Typhoid fever – 1 patient (12 years old) 95

96 Levofloxacin DUR Diagnoses Orchitis – 1 patient (15 years old) Open wound/fracture – 1 patient (15 years old) Sinusitis – 1 patient (12 years old, s/p 3 other antibiotics tried) Otitis media – 1 patient (1 year old, s/p 3 other antibiotics tried) 96

97 Levofloxacin DUR Questions or comments??? 97

98 Oral Ketoconazole DUR On July 26, 2013 the U.S. Food and Drug Administration (FDA) released a safety announcement regarding the safe use of oral ketoconazole tablets due to potentially fatal liver injuries, adrenal problems, or drug interactions. A copy of the Drug Safety Communication handout is available in your packet. 98 http://www.fda.gov/downloads/Drugs/DrugSafety/UCM362444.pdf

99 Oral Ketoconazole DUR A report of the paid pharmacy claims for Idaho Medicaid was run for the time period of 4/26/2013 to 7/26/2013 for oral ketoconazole tablets. Results 31 patients 33 claims (one patient had 3 paid claims) 99

100 Oral Ketoconazole DUR Only 3 patients currently on oral ketoconazole as of 7/26/13 1. 9 year old male who has been on ketoconazole continuously since January 2011. Diagnosis in electronic profile is unspecified immunity deficiency. His prescriber was sent a letter asking for diagnosis and therapeutic justification for the medication. A copy of the FDA Safety Announcement was included with the letter. Continued on next slide 100

101 Oral Ketoconazole DUR 1. 9 year old male: Did not receive a response to DUR letter. However, received a prior authorization request on 8-16-13 which was approved in error by a pharmacy technician as a renewal as patient had been on the medication. This error was caught in September 2013 when reviewing patient profiles for this DUR project. Prior authorization for this medication has now been denied with new information faxed back to prescriber and dispensing pharmacy (claim did pay for this medication in September 2013). 101

102 Oral Ketoconazole DUR 1. 9 Year old male: The information that was on the 8-16-13 prior authorization request stated the diagnosis as GI candidiasis for a patient with low NK cell and abnormal hyper-sensitivity. There has been no response to the September prior authorization denial. 102

103 Oral Ketoconazole DUR 2. 2 year old patient who had a paid claim for 28 days of oral ketoconazole on 7/2/2013 who also had a paid claim for topical ketoconazole on the same day. Not sending a letter as assuming for a topical infection and therapy should be completed soon. No more claims run for oral ketoconazole. 3. 12 year old with a paid claim for 30 days of oral ketoconazole on 7/16/2013. No diagnoses in electronic profile corresponding to oral ketoconazole. Not sending a letter. Will wait and see if prescription is refilled. No more claims run for oral ketoconazole. 103

104 Oral Ketoconazole DUR The other 28 patients had a single claim paid for oral ketoconazole with days of service ranging from 2 to 30. 1-7 days:13 patients 8-14 days:7 patients 15 days:8 patients 104

105 Oral Ketoconazole DUR Instituted prior authorization requirement on 8/2/2013. Prior to this date, claims would just pay at the pharmacy. Will track how many prior authorization requests received and how many approved vs. denied 105

106 Oral Ketoconazole DUR 106

107 Oral Ketoconazole DUR Denied Prior Authorization Requests 1. Tinea corporis with failure of prednisone and cephalexin 2. Onychomycosis with failure of nystatin cream 107

108 Oral Ketoconazole DUR 108 *one claim initially ran as Qty #4 for 4 day supply and claim denied for PA, pharmacy then ran through with emergency override codes and a qty#4 for 3 day supply

109 Oral Ketoconazole DUR Questions or Comments ??? 109

110 Imitrex Pens DUR 110

111 Imitrex Pens DUR 111 Paid Claims for injectable Imitrex (sumatriptan) between 2/1/2013 – 7/31/2013 56 unique patients 165 total claims $82,597 paid at POS

112 Imitrex Pens DUR 112

113 Imitrex Pens DUR 113

114 Imitrex Pens DUR 114

115 Imitrex Pens DUR 115 Letters were sent out to pharmacies filling pens more than once in six months. A copy of the letter is included in the packet Questions or comments ???

116 Proposed Studies for Next Quarter: P&T Committee Narcotic Analgesic Studies – Next Steps Use of Psychotropic Medications in Foster Children – Next Steps Tamiflu/Influenza Vaccine DUR Uloric and Colcrys DUR Antipsychotic Indication Evaluation- Hold for Future 116

117 P&T Committee Narcotic Analgesic Studies – Next Steps 117

118 Use of Psychotropic Medications in Foster Children The U.S. Government Accountability Office released the results from a study that they performed examining the rates of psychotropic medications for foster and nonfoster children in 2008. It was determined that HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions. 118

119 7/18/2013 119

120 Red Flags Five (5) or more psychotropic medications prescribed concomitantly (reviewed August 2012) Two (2) or more concomitant antidepressants (reviewed October 2013) Two (2) or more concomitant antipsychotic medications (current) Two(2) or more concomitant stimulant medications long-acting plus short-acting ok Three (3) or more concomitant mood stabilizer medications Psychotropic polypharmacy (2 or more agents) for a given mental disorder prescribed before utilizing psychotropic monotherapy 120

121 Implementation of Red Flags Retroactive Evaluation Identify outliers Profile Review DUR Board Intervention Targeted education Re- evaluation individuals overall Further Action Point of service edits Informational (soft) – pharmacist override Hard Stop 121

122 122

123 123

124 Use of Psychotropic Medications in Foster Children: Next Steps 124

125 Tamiflu/Influenza Vaccine DUR 125

126 Uloric and Colcrys DUR 126

127 Antipsychotic Indication Evaluation- Hold for Future 127

128 Prospective DUR Report History Errors: DD – drug-to-drug PG – drug to pregnancy TD – therapeutic duplication ER – early refill MC – drug-to-disease Non-History Errors: PA – drug-to-age HD – high dose LD – low dose SX – drug-to-gender 128

129 Prospective DUR Report Idaho Medicaid Program ProDUR Message Report August-13 ProDUR Message SeverityCountAmount Drug To Drug11,618$515,012.15 214,344$2,509,235.49 372,191$14,625,291.32 Drug To Gender1177$33,523.42 22,530$318,273.49 Drug To Known Disease172,327$11,171,612.78 2255,198$50,785,564.33 3313,531$59,952,053.52 Drug To Pregnancy129$260.80 26$445.83 A3$34.95 B69$5939.85 C124$9849.41 D6$37.46 X2$43.89 Duplicate Therapy0115,769$26,336,886.92 Min Max030,794$4,989,431.70 Too Soon Clinical021,579$7,832,898.27 ALL 900,297$179,086,395.58 Total Number of Claims with Messages 216,998 Average ProDUR Message Per Claim 4.15 129

130 DUR Fall Newsletter Copy of Summer Newsletter in packet Brainstorm for new topics 130

131 Medicaid Update 131


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