Presentation on theme: "Idaho Medicaid Drug Utilization Review Program"— Presentation transcript:
1Idaho Medicaid Drug Utilization Review Program 18 October 2012
2Follow-up to Previous Reviews CiprofloxacinSynagisGrowth Hormone
3Ciprofloxacin DURRationale for study: Idaho Medicaid was requested to look at why ciprofloxacin was prescribed for pediatric patients less than 16 years old. Currently ciprofloxacin will pay at the pharmacy with no age limitations while levofloxacin currently requires an age override prior authorization for pediatric patients less than 16 years old.
4Ciprofloxacin DUR Ciprofloxacin Package Insert: FDA approved for pediatric patients 1-17 years of age with complicated urinary tract infections and pyelonephritis due to E coli and for pediatric patients (age not specified) with inhalational anthrax.Levaquin Package Insert:FDA approved for pediatric patients (6 months of age and older) only for the prevention of inhalational anthrax (post-exposure) and for plague.
5Ciprofloxacin DURRetrospective DUR was done on patients less than 16 years of age with at least one paid claim between andN=77, mean age 10.3, std deviation 4.0 years.
6Ciprofloxacin DUROral Antibiotic Utilization through < 16 years of ageProductDistinct RecipientsTotal ClaimsTotal Reimbursement to PharmacyAverage cost per claimLevofloxacin89$827.62$91.96Ciprofloxacin*7986$2,772.86$32.24Amoxicillin14,15915,380$194,848.07$12.67Augmentin3,3263,620$119,378.31$32.98Azithromycin6,6207,157$140,062.90$19.57Bactrim1,8832,240$26,755.37$11.94* Report ran after original run to identify 77 recipients so 2 new recipients showed up on this report
7Ciprofloxacin DUR Summary Diagnosis Total # of recipients UTI or cystitis or pyelonephritis with at least one antibiotic tried before ciprofloxacin18UTI or cystitis or pyelonephritis with no other antibiotic tried before ciprofloxacin7CF Patients4Oncology Patients2Asthma/Respiratory Distress11Pneumonia/URI/bronchitis6Other16No Diagnosis Listed13
8Ciprofloxacin DUR Other n=16, mean age (standard deviation) 9.9 yrs (4.0), min=3, max=159 had prior antibiotics (Bactrim x 3, amox x 2, Augmentin x 1, cephalexin x 1, minocycline x 1, Bactrim/Augmentin x 1)13 had one fill of ciprofloxacin only; two had two fills and one had 5 fills (s/p liver transplant)
9Ciprofloxacin DURAmerican Academy of Pediatrics: The Use of Systemic and Topical Fluoroquinolones. John S. Bradley, Mary Anne Jackson and the Committee on Infectious Diseases. Pediatrics 2011;128;e1034-e1045.Quotes from the article:Use of fluoroquinolones in children should continue to be limited to treatment of infections for which no safe and effective alternative exists.Animal toxicology data available with the first quinolones compounds documented their propensity to create inflammation and subsequent destruction of weight-bearing joints in juvenile animals.No published reports exist of physician-diagnosed cartilage damage in children in the United States, either from controlled clinical trials of fluoroquinolones or from unsolicited reporting to the FDA or drug manufacturers.No reports of tendon rupture in pediatric patients exposed to any quinolone.
10Ciprofloxacin DURWorld Health Organization: What is the evidence of safety of quinolones use in children? International Child Health Review Collaboration. September 2, 2008.Summary Statement:Fluoroquinolones are efficacious antimicrobial agents with an important role in the treatment of a variety of pediatric infections. Ciprofloxacin is a particularly useful fluoroquinolone for dysentery and typhoid.There is grade A evidence to support both the overall safety of ciprofloxacin use in children and lack of joint toxicity.
11Ciprofloxacin DURRecommendations for prior authorization for age override for pediatric patients receiving ciprofloxacin and levofloxacin?Add age criteria to cipro and/or remove age criteria from levofloxacin?
12Synagis DUR Medical claims for 2011-2012 season: $274,881.27 Pharmacy claims for season: $1,362,626.70Grand Total for season: $1,637,507.97
13Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) 40 patients identified – ALL had prior authorization approvals.PA Request Marked as:Billing using CPT Code: 11Pharmacy billing for drug: 7Nothing specific marked on form: 22Future Question: Should we inform Idaho medical unit of all prior authorizations for Synagis as the doctors’ offices are not doing a good job of informing Medicaid if claim will be paid as a medical claim or as a pharmacy claim?
14Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) Potential billing errors and dosing inconsistencies were discussed at the August 2012 DUR meeting. The DUR Board recommended asking for administration records to verify what had actually been given.
15Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) Patient #30 – Billing ErrorFour doses were paid as pharmacy claims with an additional dose in January 2012 paid as a medical claim. The medical office was contacted via letter and documentation was sent that the patient received four doses with the drug being supplied by a pharmacy. The January dose was billed incorrectly by the doctor’s office for both an administration fee as well as the drug fee when the drug had been provided by a pharmacy and not purchased by the doctor’s office. The doctor’s office has been asked to reverse the drug fee ($ ).
16Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) Patient #38 – Billing ErrorApproved for up to 2 doses between 3/30/12 and 4/30/12. Doses were billed on 4/5/12 (which is fine) but also on 6/1/12 which is after the approval date as well as after the RSV season had ended. After being contacted by the Pharmacy Unit, the medical facility has stated that Synagis was not administered on 6/1/ The medical facility has been asked to reverse the 6/1/12 claim ($ ).
17Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) Patient #12 – Dose InconsistencyPaid for 150mg dose on 1/3/12 but for a lower 100mg dose on 1/30/12. Received administration records – using current weight at time of dosing, 1/3/12 dose was 109mg and 1/30/12 dose was 116mg so Idaho Medicaid was actually undercharged for the 1/30/12 dose. Patient has other primary insurance so Idaho Medicaid is secondary payor and is paying only part of the cost of the drug.
18Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) Patient #10 – Dose InconsistencyPaid for 150mg for doses #1,2,3,5 but 200mg for dose #4Based on current weight, doses were calculated correctly to be: 1– 145mg, 2– 145mg, 3– 150mg, 4– 154mg, 5 – 150mgBaby lost a little weight between dose 4 and 5 (but could have rounded dose #4 down to 150mg to avoid paying an extra $ for 4mg more, dose would have been 14.6mg/kg rather than 15mg/kg).
19Synagis DUR – Medical Claims Data from 10-1-2011 through 6-20-2012 (RSV 2011-2012 Season) As of , still waiting to hear back on four additional letters requesting administration records. Prescribers have been contacted by telephone, reminding them of request for additional information.
20Synagis - July 2012 AAP Red Book Updates for Synagis Prophylaxis Gestational Age 32 weeks, 0 days through 34 weeks, 6 days AND chronological age less than 90 daysSynagis prophylaxis (maximum of 3 monthly doses) may be considered for infants who have at least 1 of 2 risk factors:Infant attends child care, defined as home or facility where care is provided for any number of infants or young toddlers.One or more older siblings younger than 5 years of age or other children younger than 5 years of age lives permanently in the same household. Multiple births younger than 1 year of age do not qualify as fulfilling this risk factor.
21Synagis - July 2012 AAP Red Book Updates for Synagis Prophylaxis Infants with congenital abnormalities of the airway or neuromuscular diseaseImmunoprophylaxis may be considered for infants who have either congenital abnormalities of the airway or a neuromuscular condition that compromises handling of respiratory secretions. Infants and young children in this category should receive a maximum of 5 doses of palivizumab during the first year of life.
22Growth Hormone DURIdaho Medicaid’s Pharmacy & Therapeutics (P&T) Committee requested that the DUR Board look at the utilization numbers of the Growth Hormone class.The potential exists to save the State money should patients be switched from a non-preferred to a preferred agent. Previously patients have been grandfathered to allow them to remain on their current therapy.
25Current Interventions/Outcomes Studies P&T Committee Narcotic Analgesic StudiesPsychotropic Medications in Foster ChildrenUpdate (Washington DC Conference)Two (2) or more concomitant antidepressantsZometaLeukotrienes vs. inhaled corticosteroids in children with asthmaMigraine PreventionTopiramatePA, Medical Claim MismatchImmune Globulin (IV and SC)
28Idaho Current Management -1 Daily and monthly quantity limitsUse of preferred agentsLong-actingDocumented failure of at least a 30 day trial of a preferred agent within previous 6 monthsFentanyl transdermalInability to swallow capsules or pillsAllergy to morphine and/or methadoneFailure of a preferred agent
29Idaho Current Management -2 Short ActingNon-preferred only after documented failure of 3 preferred agents with at least a 7 day trial of each in the past 180 days (stated, but not operational)Fentanyl buccal/sublingual/transmucosalBreakthrough cancer pain in patients already receiving, and tolerant to opioid therapy
30Idaho In Process Changes-1 Fentanyl transdermal – additional requirementsManual reviewDose equivalent to preferred agent tried or documentation for increase or decreaseGood documentation for use over oral therapyOxycodone – additional requirementsDose equivalent or less than preferred agent tried or documentation for increase or decreaseGood documentation for use over other available narcotic analgesics
31Idaho In Process Changes- 2 ButransManual reviewNo history of opioid abuse or addictionICD-9 diagnosis of moderate or severe chronic painHistory of long-acting opioid within last 60 days at a dose less than 30 morphine equivalentsInability to take oral medications
32Other State Dispensing Restrictions: Limits on Number of Prescriptions New YorkTotal of 4 opioid prescriptions every 30 daysFloridaFour controlled substance prescriptions per monthGeorgia6 prescriptions/month (will go down to 5)Oklahoma13 prescriptions of hydrocodone per 12 months. To override need a PA and Pain Contract (in general OK has a 6 total, 2 brand per month limit on all drugs)
33Other State Dispensing Restrictions: Therapeutic Duplication Long-ActingShort-ActingArkansas(allows 1 long acting and 1 short acting from same provider)Reject if > 25% remains.Reject if > 25% remains. Includes injectables and nasal.Alaska1 long acting within a 19 day look back period1 short acting plus 1 combo within 19 day look back periodOklahoma1 long actingHard stop if received a prior prescription for a different strength of hydrocodone and new claim is within previous claim’s active periodMost programs exclude cancer, hospice and long-term care from these restrictions
34Other State Management Strategies Montana: Case management programOregon : Commissioned evidence-based review on treatment of low back painAlaska: Implementing a second opinion reviewer for high dose/duplicate opioid therapy requests
35Washington State Legislation “too many patients getting drugs at dosages that were too high for too long”Engrossed Substitute House Bill 2876In effect July 1 , 2011 for all except physicians and physician assistants – January 2, 2012Directs 5 boards and commissions to adopt rules concerning management of chronic non-cancer pain
37Key Points Elements for a patient evaluation A Dosing Threshold trigger for consultation with a pain specialistCriteria to be considered a pain specialistPeriodic review of a patient’s course of treatmentGuidance for episodic care practitionersConsultation exemptions for special circumstances and for the practitionerContinuing education requirements
38Example of Adopted Rules – Department of Health-Medical Quality Assurance Commission Patient evaluation – lists what should be in the initial evaluationTreatment PlanWrittenObjectives to determine treatment successOther treatment modalities or rehabilitation programPrescription must include ICD-9 indication
39Example of Adopted Rules – Department of Health-Medical Quality Assurance Commission Informed ConsentWritten agreement for treatmentPatient agrees to allow biological testingProtocol for lost prescriptions and early refillsSpells out what constitutes violation of agreementOne physician and one pharmacy (recommended)Agreement for release of agreement to local emergency departments, urgent care facilities and pharmacies
40Example of Adopted Rules – Department of Health-Medical Quality Assurance Commission Periodic ReviewAt least every 6 monthsAnnually if non-escalating daily dose of < 40 morphine equivalentsTaper or discontinueNo improvement in function or painEvidence of significant adverse effectsEvidence of misuse, addiction, or diversion
41Example of Adopted Rules – Department of Health-Medical Quality Assurance Commission Methadone prescribing requires four hours of continuing educationEpisodic Care (urgent/emergency care)review of tracking information (PMP)minimum amount to control pain until can see primary
42Example of Adopted Rules – Department of Health-Medical Quality Assurance Commission Mandatory Consultation with Pain SpecialistThreshold of 120 morphine equivalent dose per dayAllows for consultation between primary and specialistBoth primary and specialist must document consultPain Specialist qualifications are spelled out in rule
43Because Minds Matter: Collaborating to Strengthen Management of Psychotropic Medications for Children and Youth in Foster CareWashington DC August 27-28, 2012Six team members from each stateMedicaid (Dave Simnitt, Tami Eide)Child Welfare (Kathy Morris, Miren Unsworth)Mental Health (Kelly Palmer, Ken Kraft)Sponsored byAdministration for Children and FamiliesSubstance abuse and Mental Health Services AdministrationCenters for Medicare and Medicaid Services
44Purpose of Meeting Enhance cross-system efforts Showcase collaborative projects and initiativesOffer state-of-the art informationEncourage strategies for addressing mental health and trauma-related needs of foster children with evidence-based and evidence-informed interventionsFacilitate development and implementation of each State’s oversight plan
45Foster Children Psychotropic Drugs Red Flags 10/18/2012
46Red FlagsFive (5) or more psychotropic medications prescribed concomitantly (reviewed August 2012)Two (2) or more concomitant antidepressants (current)Two (2) or more concomitant antipsychotic medicationsTwo(2) or more concomitant stimulant medicationslong-acting plus short-acting okThree (3) or more concomitant mood stabilizer medicationsPsychotropic polypharmacy (2 or more agents) for a given mental disorder prescribed before utilizing psychotropic monotherapy
47Implementation of Red Flags Retroactive EvaluationIdentify outliersProfile ReviewDUR Board InterventionTargeted educationRe-evaluationindividualsoverallFurther ActionPoint of service editsInformational (soft) – pharmacist overrideHard Stop
48Foster Children with Two (2) or more concomitant antidepressants October 2012
51Study Parameters and Results Children in Foster Care ages 0-17Time Period 3/1/2012 through 8/31/2012Two or more antidepressants75 children met criteria66 had two concurrent6 had three concurrent2 had same drug with different strengths only1 had two with only a one week overlapTrazodone was the second drug in 63 children
52Number of Participants by Age and Sex Meeting Threshold
54Antidepressants in Foster Children Using Two or More Concurrently
55Zometa DURZometa (zoledronic acid) injection is a bisphosphonate that is FDA approved for:Hypercalcemia of malignancyPatients with multiple myeloma and patients with documented bone metastases from solid tumors in conjunction with standard antineoplastic therapy.Dosage is 4mg as an intravenous infusion over no less than 15 minutes. May repeat after a minimum of 7 days for hypercalcemia of malignancy or every 3-4 weeks for patients with multiple myeloma or bone metastases from solid tumors.
56Zometa DURMedical claims (J3487) were reviewed from 8/01/2011 through 7/31/2012 to determine if the Pharmacy Unit should prior authorize this medication requiring therapeutic criteria to be met.Number of claims: 169Number of patients: 50Cost per dose when Medicaid is the sole payer: $803.60Total annual expenditure: $107,266
57Zometa DUR Zometa is anticipated to go generic in March 2013. Eight pharmaceutical companies are planning on making generic zoledronic acid.Price is expected to drop significantly.
59Zometa DURSummaryAll patients had an FDA approved diagnosis for Zometa in their electronic profile. All patients with repeat doses had appropriate intervals between doses. All charges were for a 4mg dose.Recommendation: Prior authorization with therapeutic criteria is NOT needed at this time.
60Asthma DURMore than 25.7 million Americans are affected by the disease; 7 million under the age of 18Economic impact: $20.7 billion annuallyMortality: almost 4,000 deaths per year456,000 hospitalizations, 1.75 million ER visits annually10.5 million missed school days each year
62Asthma DUR Diagnosis and Management of Asthma Accurate Diagnosis Medical HistoryPhysical Exam – spirometry in all ≥ 5 years of ageRule out all other causesGoal is ControlReduce ImpairmentMaintain close to normal lung function and activity levelsReduce RiskPrevent exacerbations
63Asthma DUR Four Components of Asthma Care Assessment and Monitoring Education for a Partnership in CareControl Environmental Factors and Other ConditionsMedications
64Asthma DUR Medications Stepwise Approach (both up and down) Consideration must be given to both impairment and risksGeneral Principles for All AgesUse of all four components of asthma care for each stepInitiate therapy based on severityMonitor and adjust treatment based on asthma control (step up if needed and down if possible when asthma controlled for 3 months)
65Asthma DUR 2007 Asthma Treatment Guidelines Achieving and maintaining controlWhen stepping up treatment, combination therapy is often recommendedIntermittent Asthma (Step 1)Short Acting Beta Agonists (SABAs)Persistent Asthma (Steps 2-6)Inhaled Corticosteroids are the preferred treatment across all age groups
66Asthma DUR Leukotriene modifiers (LTRAs) Alternative, but not preferred, therapy for patients who require Step 2 (mild, persistent asthma) care.Can be used as adjunctive therapy with ICSs, but for patients > 12 years not preferred adjunctive therapy as compared to addition of LABAs.LTRAs can attenuate Exercise Induced Bronchospasm (EIB)
67Asthma DUR References http://www.acaai.com. Retrieved October 3, 2012.
68Leukotrienes vs. inhaled corticosteroids in children with asthma Number of recipients < 18 years of age with paid claim for leukotriene (HIC3=Z4B):Z4B = Leukotriene Receptor AntagonistsDate# of recipients7/1/2011 – 9/30/20113,2321/1/2012 – 3/31/20123,0007/1/2012 – 9/30/20123,253
69Leukotrienes vs. inhaled corticosteroids in children with asthma Number of recipients < 18 years of age with paid claim for inhaled corticosteroid (HIC3=B6M & J5G):B6M = orally inhaled glucocorticoids (individual)J5G = beta adrenergic and glucocorticoid combinationsLeukotrienes vs. inhaled corticosteroids in children with asthmaDate# of recipients7/1/2011 – 9/30/20111,8751/1/2012 – 3/31/20122,1437/1/2012 – 9/30/20122,012
70Leukotrienes vs. inhaled corticosteroids in children with asthma
71Leukotrienes vs. inhaled corticosteroids in children with asthma Total number of recipients less than 18 years of age that had a prescription of any medication filled between 7/1/2012 and 9/30/2012 that had an Asthma diagnosis on their profile:8,582
72Leukotrienes vs. inhaled corticosteroids in children with asthma
73Leukotrienes vs. inhaled corticosteroids in children with asthma
74Leukotrienes vs. inhaled corticosteroids in children with asthma
75Leukotrienes vs. inhaled corticosteroids in children with asthma
76Leukotrienes vs. inhaled corticosteroids in children with asthma Next Steps ???
77Migraine PreventionTopiramate use other than Seizure Disorder/Migraine HeadacheEvaluate the use of topiramate for non-FDA labeled indications.Off label use for weight lossOff label use as a mood stabilizer for Bipolar symptomsAll patients on topiramate were evaluated from 1/1/2012 thru 6/30/2012.1,222 patients on topiramate970 patients with approved criteria (ICD-9 code in Medical Profile) of Seizure Disorder/Migraine Headache252 (20.62%) of patients without approved criteria
78Migraine PreventionTopiramate use other than Seizure Disorder/Migraine Headache
80Migraine Prevention FDA approved indications for topiramate Monotherapy or adjunctive therapy for partial onset seizuresMonotherapy or adjunctive therapy for primary generalized tonic-clonic seizuresAdjunctive treatment of seizures associated with Lennox-Gastaut syndromeProphylaxis of migraine headache
81Migraine Prevention Off-label & Investigational uses for topiramate bipolar disorder **weight loss and obesity **alcohol dependence *binge eating disordercocaine dependencebulimia nervosacluster headacheschronic daily headacheinfantile spasms
82Migraine Prevention Off-label & Investigational uses for topiramate smoking cessationpost-traumatic stress disorder **neuropathic painsleep-related eating disorder (SRED) and nocturnal eating syndrome (NES)scar therapymigraine prevention in childrenpathologic gamblingpainful diabetic neuropathy
83Immune Globulin (IV and SC) Currently prior authorization is not needed for either an outpatient prescription (as long as cost per claim is less than $7500) or for a claim on the medical side.Also checked for paid claims for Immune Globulin Intramuscular between 8/1/2011 – 7/31/2012Only one paid claim on the medical side.No paid pharmacy claims.Therefore, did not include this route of administration in this DUR project.
84Immune Globulin (IV and SC) FDA Approved Indications for Immune Globulin (intravenous and subcutaneous):Primary immunodeficiency disordersKawasaki disease, for prevention of coronary aneurysmsImmune-medicated thrombocytopenia, to increase platelet countPediatric human immunodeficiency virus infection, for replacement therapySecondary immunodeficiency in B-cell chronic lymphocytic leukemiaBone marrow transplantationChronic inflammatory demyelinating polyneuropathy (CIDP)Multifocal motor neuropathyNote: not all IVIG/SCIG products are approved by the FDA for all indications
85Immune Globulin (IV and SC) Medical Claims Medical Claims between 8/1/2011 – 7/31/2012 for IVIG and SCIGJ1459 PrivigenJ GammaplexJ1559 HizentraJ1561 GamunexJ1566 Immune Globulin Intravenous, not otherwise specifiedJ1568 Octagam, intravenousJ1569 Gammagard LiquidBolded J-codes had paid claims during the study timeframe.
86Immune Globulin (IV and SC) Medical Claims Claims paid on medical side between 8/01/2011 and 7/31/2012$288,410116 claims24 patientsAverage cost per prescription: $2486
87Immune Globulin (IV and SC) Medical Claims 24 letters sent out between August , 2012 to the medical facilities that had paid claims for IVIG or SCIG requesting administration records and progress notes.By 9/21/2012, 10 responses.On 9/25/2012, an Idaho Medicaid pharmacy technician called the medical facilities that had not responded yet. As of 10/11/2012, there were 3 additional responses for a total response rate of 54% (13/24).
89Immune Globulin (IV and SC) Medical Claims Patient A33 year old maleDiagnosis listed as hypogammaglobulinemiaBaseline IgG level 557mg/dlIVIG ordered as 400mg/kg IV every six weeksOne dose given on 1/23/12 with follow-up IgG level ordered.No further doses of IVIG have been paid for by Idaho Medicaid.Question – did patient really have hypogammaglobulinemia? Do not have follow-up IgG level.
90Immune Globulin (IV and SC) Medical Claims Patient B52 year old maleNo diagnosis listed on administration records. In electronic profile, has diagnosis of optic neuritis listed from June 2012.Five doses IVIG paid for between 6/11/12 – 6/15/12 ($8638). Infusion Clinic has no record of these doses being administered.Two doses given 7/9/12 and 7/10/12. Administration records sent confirming that these two doses were given.
91Immune Globulin (IV and SC) Medical Claims Patient C14 year old maleSingle dose given 1/27/12.No diagnosis listed on administration record.In electronic profile – common variable immunodeficiency and selective IgA immunodeficiency.Question – only one dose IVIG needed ?
92Immune Globulin (IV and SC) Medical Claims Patient D10 year old maleNo diagnosis on administration records, but ITP listed in electronic profile.Received 60gm (given as two 30gm doses) – billed incorrectly as two 60gm doses.Patient E15 year old maleNo diagnosis on administration records but hypogammaglobulemia listed in electronic profile.Receiving IVIG approximately monthly. No baseline or follow-up IgG levels were provided in medical records. Patient’s weight was not provided to calculate mg/kg dosage.
93Immune Globulin (IV and SC) Medical Claims Patient F28 year old femaleCIDP – chronic inflammatory demyelinating polyneuropathyReceiving IVIG 400mg/kg for three consecutive days every 3 weeks ($69,054 annually)Patient states that she “feels better” on IVIG.IVIG is considered first line therapy for this diagnosis.Unfortunately, no specific criteria for when to continue or discontinue therapy.
94Immune Globulin (IV and SC) Medical Claims Patient G35 year old maleSingle 554mg/kg dose given on 2/17/12.Hypogammaglobulemia listed in electronic profile. No documentation provided why this single dose was ordered. No IgG levels listed in medical records that were sent.
95Immune Globulin (IV and SC) Medical Claims Patient H54 year old maleDiagnosis – immunodeficiency.Primary insurance is Medicare.Has been on IVIG therapy since 1995 per medical records. Therapy plan is to receive IVIG dose when IgG level falls <600mg/dl. However, dose given early (chart note stated “patient doesn’t really need it”) as patient spends the winter in Arizona and requested a dose prior to leaving Idaho. No doses paid for by Idaho Medicaid over the winter.
96Immune Globulin (IV and SC) Medical Claims Patient I52 year old female with CIDPReceived 400mg/kg/day x 5 days in May 2012 ($14,611) with plan being to receive 1000mg/kg monthly after that time but patient has not received any more IVIG. Administration records sent but no follow-up notes describing how patient is doing.Patient J7 year old femaleITP with mucosal bleeding, received IVIG 1000mg/kg x single dose.Platelet count improved from 6000 to 16,000 and bleeding resolved.
97Immune Globulin (IV and SC) Medical Claims Patient K55 year old maleCIDPReceived two IVIG doses (9/22/11, 10/27/11)Administration records received but no progress notes on how patient responded to therapy and why therapy was not continued.
98Immune Globulin (IV and SC) Medical Claims Patient L42 year old maleAgammaglobulinemiaReceived doses 1/5/12, 2/29/12, 5/12/12Administration records sent but no progress notes describing therapy plan or IgG levels.
99Immune Globulin (IV and SC) Medical Claims Patient M24 year old female pregnant patientNeonatal alloimmune thrombocytopeniaIVIG 2000mg/kg weekly ($154,784) from week 19 to Week 37 of pregnancy (10/06/11 – 2/08/12)54% of total medical claim chargesThird pregnancy – history of neonatal thrombocytopenia with second baby. Recurrence rate with subsequent pregnancies is over 80%.
100Immune Globulin (IV and SC) Medical Claims Patient M, continuedThe thrombocytopenia in the baby is often mild and may be asymptomatic, but potential exists for serious complications including intracranial hemorrhage which leads to fetal death in 10% and neurologic sequelae in 20% of cases.Usual dosage is 1000mg/kg weekly. Per progress notes submitted, plan of therapy was to give 2000mg/kg every two weeks but what was given was 2000mg/kg every one week.No information provided on baby (due date February 2012).
101Immune Globulin (IV and SC)Pharmacy Claims Reviewing outpatient prescription claims between 8/01/2011 and 7/31/2012$279,52779 claims14 patientsAverage cost per prescription: $3538
102Immune Globulin (IV and SC)Pharmacy Claims Sent letters to the prescribers of the seven patients still receiving IVIG/SCIG requesting chart notes and serum IgG levels.After four weeks, had received replies from three prescribers. An Idaho Medicaid pharmacy technician called the four remaining prescribers reminding them of the request for information.As of 10/11/12, one additional prescriber sent in the requested information.Total response rate: 57% (4/7)
103Immune Globulin (IV and SC)Pharmacy Claims Patient #1Diagnosis: CVID (chronic variable immunodeficiency)Receiving SCIV 20 gm weekly (weight not listed in chart notes so cannot calculate mg/kg dose).Very adherent to therapy.Still having multiple infections per chart notes. Has been on IVIG/SCIG therapy since No comparison made between rate of infections before and after IVIG/SCIG therapy began.Trough IgG level (2/06/2012) = 1108mg/dlAnnual cost of therapy: $129,794 (67% of pharmacy claims for this drug class)
104Immune Globulin (IV and SC)Pharmacy Claims Patient #2Diagnosis: hypogammaglobulinemia not otherwise specifiedIVIG 55gm every 4 weeks (469mg/kg)Documentation provided that the number of infections has decreased since on IVIG monthly.Trough IgG level (3/09/2012) 878mg/dl; next trough level scheduled to be drawn in October 2012 (follow-up prescriber visits with labs every 6 months).Annual cost of therapy: $77,251
105Immune Globulin (IV and SC)Pharmacy Claims Patient #4Diagnosis: CIDPChart note from 7/17/12 stated: “Pt has IVIG infusion scheduled for tomorrow but says she no longer feels this is beneficial and is considering taking a break from this Tx.”Subsequent phone call from pharmacy stating that patient decided to continue with the therapy.Has had multiple infusion reactions from IVIG and dose has been adjusted (both downward and upward) multiple times. Most recent dose is 60gm every 3 weekAnnual cost of therapy: $67,779
106Immune Globulin (IV and SC)Pharmacy Claims Patient #11Diagnosis: CIDPReceiving 1000mg/kg IVIG monthlyProblem: patient has very uncontrolled diabetes and has gained more than 100 pounds in the last year so dose keeps escalating higher.Chart notes state that he has had significant improvement of his neuropathy with IVIG monthly.Annual cost of therapy: $102,243 (21% of pharmacy claims for this drug class)
107Immune Globulin (IV and SC) What weight to use?Actual body weightIdeal body weightAdjusted body weightRounding DosagesIn reviewing dosages, there is potential for cost savings by rounding dosages to match single vial sizes.For example, no clinical difference between giving 120gm rather than 125gm.Pharmacies tend to automatically round dosages up.
108Immune Globulin (IV and SC) Total cost of therapy from 8/01/2011 – 7/31/2012:$567,937Total number of patients:37 (one patient had both medical and pharmacy claims)Number of patients receiving single dose of IVIG:14
109Immune Globulin (IV and SC) RecommendationRequire prior authorization for this expensive therapy.It is reasonable to check for an FDA approved diagnosis and to verify clinical benefit as well as monitoring periodic IgG levels (if applicable to diagnosis, such as hypogammaglobulinemia).Initial approval would be for 3-6 months with additional documentation required after that time period to renew the authorization.
110Proposed Studies for Next Quarter: P&T Committee Narcotic Analgesic Studies – Next StepsUse of Psychotropic Medications in Foster Children – Next StepsMigraine PreventionProphylaxis Utilization in Chronic Triptan UtilizersMultiple Strengths of AtypicalsAntipsychotic Indication Evaluation- Hold for FutureAAP and DVTs- Hold for future
111P&T Committee Narcotic Analgesic Studies – Next Steps
112Use 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.
113Use of Psychotropic Medications in Foster Children Medication Classes included in the reportADHD drugsAnti-anxietyAnticonvulsantAntidepressantsAnti-enuretic (just desmopressin acetate)AntiparkinsonAntipsychoticsCombination anti-anxiety and antidepressantHypnotic Mood stabilizer (just lithium)Sleep aid (just melatonin)
114Use of Psychotropic Medications in Foster Children: Next Steps Two (2) or more concomitant antipsychotic medications
115Migraine PreventionProphylaxis Utilization in Chronic Triptan UtilizersSee packet for summary handout
1192011 Annual DUR Report State name abbreviation: ID Medicaid Agency InformationTami Eide, Pharm.D., BCPSMagellan Medicaid AdministrationProspective DURComes from First Data BankDUR criteria approved by DUR BoardCurrently reviewing criteriaHow do pharmacists handle ProDur messages?Early Refills (Prior Authorizations)Non-controlled as well as Controlled
1212011 Annual DUR Report Physician Administered Drugs DUR Board Activity Deficit Reduction Act requires collection of NDC numbers for covered outpatient physician administered drugs. Has MMIS been designed to incorporate this data into DUR for both Prospective and Retrospective DUR?DUR Board ActivitySummary Report of activities/meetings (Attachment 4)DUR Board InvolvementDisease Management ProgramMedication Therapy Management
1232011 Annual DUR Report Cost Savings from DUR Projects: $815,633 October 1, 2010 through September 30, 2011October 2010: $216,834Type 2 diabetes management – underutilizing metforminCost savings if use metformin rather than more expensive hypoglycemic agentEstimate based on 50 patients using metformin rather than incretin enhancerAnnual savings: $129,960Suboxone/Subutex – requiring diagnosis of opioid abuse/dependency (not covering for pain)Cost avoidance (based on 6 less patients per year): $36,114Suboxone/Subutex – not paying for concomitant opioid therapy while on Suboxone/SubutexCost avoidance (based on 124 patients receiving concomitant opioids): $44,640Multiple long acting opioidsCost avoidance (based on 17 patients receiving one less LAO monthly): $6120
1242011 Annual DUR Report January 2011: $384,165 Overuse of short acting albuterol inhalerAnnual cost avoidance (of two extra albuterol inhalers/year x 102 patients): $12,125Inappropriate use of LABA/Steroid MDIAnnual cost avoidance (of monthly inhalers for 15 patients): $86,810Fentanyl patches – administered every 72 hours rather than every 48 hoursAnnual cost savings (10 patches rather than 15 patches monthly x 44 patients): $25,872Ondansetron utilization review – compare utilization with other states that do not have therapeutic criteriaEstimated increase in cost if double utilization (conservative estimate)1085 average monthly claims x $19.92 average monthly claim x 12 months/year$259,358
1252011 Annual DUR Report April 2011: $115,663 Limit quetiapine doses < 50mg/day to initial dose titration (not cover for insomnia)Annual cost avoidance: $106,118PPIs – hard edit for two concomitant PPIsAnnual cost avoidance (of one PPI monthly for 22 patients): $5000PPIs – education on using for as short of a time interval as possibleAnnual cost avoidance (of one PPI monthly for 20 patients): $4545
1262011 Annual DUR Report July 2011: $98,971 Colcrys prior authorization criteria (did not have criteria for generic colchicine)Annual cost avoidance: $98,663Ketorolac – quantity allowed decreased from 10 tablets daily to 4 tablets daily9 patients in 6 months who had received too many tabletsAnnual cost avoidance: $308 (18 fewer prescriptions/year)Tramadol with SSRI/SNRI (possible serotonin syndrome)No real cost savings as potential for switching from tramadol to non-interacting analgesic agent instead (e.g. hydrocodone/acetaminophen)
1272011 Annual DUR Report Fraud, Waste, and Abuse Detection Does the State have ways to identify fraud or abuse of controlled drugs by recipients, prescribers, and/or providers?Prescription Drug Monitoring Program (Attachment 7)Innovative PracticesE-PrescribingExecutive Summary
1282011 Annual DUR ReportSee Packet for Annual Report Summary Handout
129Prospective DUR Report History Errors:DD – drug-to-drugPG – drug to pregnancyTD – therapeutic duplicationER – early refillMC – drug-to-diseaseNon-History Errors:PA – drug-to-ageHD – high doseLD – low doseSX – drug-to-gender
130Prospective DUR Report Idaho Medicaid ProgramProDUR Message ReportSeptember-12ProDURMessageSeverityCountAmountDrug To Drug11,982$508,240.31213,721$2,366,938.96364,858$10,803,435.099$10.00Drug To Gender142$25,871.4766$3,314.61Drug To Known Disease60,144$7,566,928.90231,138$37,167,498.02278,367$45,042,030.49Drug To Pregnancy78$727.5815$617.84A11$63.92B90$12,830.64C215$14,358.85D30$3,238.68X71$1,850.44Duplicate Therapy109,074$22,436,109.73Min Max29,581$4,187,367.17Too Soon Clinical20,666$3,380,392.35ALL810,250$133,521,825.05 Total Number of Claims with Messages 201,368 Average ProDUR Message Per Claim 4.02
131DUR Fall Newsletter Copy of Summer Newsletter in packet Brainstorm for new topics