1 Governor’s Office of Health Policy and Finance MaineCare Pharmacy Initiatives

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

3 PDL What it’s 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)

4 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 won’t need PA 15 States currently PA in this Category

5 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

6 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.

7 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

8 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 PA’s submitted are approved Completed PA receive a decision on average within 3 hours of submission

9 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

10 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.

11 Safety Net Protections Completed PA’s 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

12 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