Transcript Idaho Medicaid Drug Utilization Review Program

14 April 2011
Follow-up to Previous Reviews
 Long Acting Beta Agonist Inhalers
 Lack of Prior Controller Use
 Long Acting Beta Agonist Inhalers with
High Rescue Inhaler Use
 Fentanyl Patch Frequency < 72 Hours
2
Long Acting Beta Agonist Inhalers:
Lack of Controller Use
 Letters sent if patient had at least one fill of a LABA during
the 3 month period that ended on 9/30/2010. History was
evaluated for long term continuous use of a LABA and lack
of a controller medication if applicable.
Results:
 150 patient profiles were evaluated.
 Letters were sent to 32 prescribers about 30 patients on
12/16/2010 (21.3% lettering rate.)
 As of 3/31/2011, 9 responses have been received (28%
response rate.)
 See packet for copy of the letter .
3
Long Acting Beta Agonist Inhalers:
Lack of Controller Use: Response
detail as of 3/31/2011:
 Note that providers may choose more than one selection per response.
 Reviewed and do not believe adjustment is needed
 Reviewed and have or will modify the treatment
 Information clinically useful: plan to monitor
 I will use this information in the care of future pts
 No longer my patient
 My patient, but I did not prescribe this
 Somewhat useful to my practice
 Not useful to my practice
 Information appears to be incorrect
3
2
2
2
1
2
4
2
1
4
Long Acting Beta Agonist Inhalers
with High Rescue Inhaler Use
 Patients were selected for evaluation if they had at
least one fill of a LABA during the 6 month period and
at least 2 fills for a SABA in the period that ended on
10/30/2010.
 208 patient profiles were evaluated.
 Letters were sent to 399 prescribers about 102 patients
on 12/28/2010 (192% lettering rate.)
 As of 3/31/2011, 119 responses have been received (30%
response rate.)
 See packet for copy of the letter.
5
SABA overuse in LABA patients:
Response detail as of 1/1/2011:
 Note that providers may choose more than one selection per response.
 Reviewed and do not believe adjustment is needed
21
 Reviewed and have or will modify the treatment
23
 Attempted to modify therapy unsuccessfully
7
 Information clinically useful: plan to monitor
25
 I will use this information in the care of future pts
8
 Not my patient
8
 Previously saw this pt, but no longer in my care
14
 My patient, but I did not prescribe this
31
 Under my care, but have not seen recently
9
 Extremely useful to my practice
8
 Very useful to my practice
20
 Somewhat useful to my practice
11
 Not useful to my practice
1o
 Information appears to be incorrect
2
 Will discontinue medication
1
 Will change dose
6
6
Fentanyl Topical Patch (Duragesic®):
Frequency of Administration
 Patients were selected for evaluation if they received
more than 10 patches in a 30 day period during the 3
month period that ended on 11/30/2010.
 291 patient profiles were evaluated.
 Letters were sent to 60 prescribers about 44 patients
on 12/28/2010 (21% lettering rate.)
 As of 3/31/2011, 29 responses have been received (48 %
response rate.)
 See packet for copy of the letter.
7
Fentanyl Patch Frequency of Administration:
Response detail as of 1/1/2011:
 Note that providers may choose more than one selection per
response.
 Reviewed and do not believe adjustment is needed
 Reviewed and have or will modify the treatment
 Attempted to modify therapy unsuccessfully
 Information clinically useful: plan to monitor
 Previously saw this pt, but no longer in my care
 Very useful to my practice
 Somewhat useful to my practice
 Will change dose
19
4
4
2
3
2
2
1
8
Low Dose Quetiapine Utilization
Quetiapine (Seroquel® ) is an atypical antipsychotic with
the following indications and recommended doses
Indication
Recommended
Dose Range (PI)
Dose Interval
Schizophrenia, Adults
150-750 mg/day*
BID
Schizophrenia, Adolescents (13-17)
400-800 mg/day
BID-TID
Bipolar Mania, Adults (monotherapy or adjunct
with lithium or divalproex)
400-800 mg/day
BID
Bipolar Mania, Children and Adolescents (10-17)
(monotherapy)
400-600 mg/day
BID-TID
Bipolar Depression, Adults
300 mg/day
QD at HS
Bipolar I Disorder Maintenance, Adults (adjunct
lithium or divalproex)
400-800 mg/day
BID
* Clinical studies indicate that the antipsychotic effect occurs in the range of 600-800mg
9
Seroquel® Dosage
Dosage Strengths Available: 25mg, 50mg, 100mg, 200mg, 300mg,
400mg
Legitimate Use of Lower Strengths
 Initial dose titration (approximately 5 days)
 Dose adjustments
 Dose individualization not covered by single strength tablets
Use of Concern
 Off label use for insomnia
10
Use of Quetiapine for Insomnia
 Used at doses considered sub-therapeutic for
schizophrenia or bipolar disorder
 Used for insomnia in patients who do not have comorbid psychosis
 Not FDA-Approved
 Not supported by available clinical evidence
 Exposure of patients to adverse metabolic effects
including weight gain, hyperglycemia, overt diabetes
and adverse lipid profiles
 More costly than traditional hypnotics
11
Idaho Medicaid DUR Study
April 2008
 Reviewed Medicaid Claims 1/2006 thru 12/2007
 Identified patients using all AAPs at a low dose
without schizophrenia, bipolar disorder or childhood
psychosis/developmental disorders
 Low dose quetiapine defined as < 300 mg/day
 395 patients identified as being on low dose quetiapine
without above designated diagnoses (10% of claims)
 Educational leaflets distributed
12
Current Utilization of Low Dose
Quetiapine
 Evaluated number of recipients receiving quetiapine
50 mg/day or less for more than 30 days for time
period of 4/1/10-3/31/11
 130 recipients receiving <25 mg daily
 525 recipients receiving >25mg & <50mg daily
 Total cost was $378,994
 28% of all quetiapine patients were getting
<50mg/day
13
Current Utilization of Low
Dose Quetiapine by Gender
2500
2000
1500
Females
1000
Males
500
0
</= 25mg
daily
>25 & </= All Seroquel
50mg daily
Information based on Idaho Medicaid Claims most recent 12 months (4/1/10-3/31/11)
14
Current Utilization of Low Dose
Quetiapine by Age
100%
80%
60%
> 65 years
19-65 years
40%
10-18 years
0-9 years
20%
0%
</= 25mg
>25mg &
</=50mg
All Seroquel
15
Proposal for PA Criteria
 Quetiapine cumulative daily doses of < 100 mg will be
automatically approved only for new starts for a
maximum of 15 days. (add all dosage strengths)
 All other uses including dose titration in existing
patients will require prior authorization review
16
Current Intervention/Outcome
Studies
 Tramadol with SSRI’s or SNRI’s

Potential for Serotonin Syndrome
 Thiazolidinedione (TZD) Safety
 Proton Pump Inhibitors

Long Term Continuous Use
17
Serotonin Syndrome
 Potentially life-threatening reaction to an elevation of
serotonin in the body. Agents that block the reuptake of
serotonin, slow breakdown, or increase release can
contribute to development of the syndrome.
 Resolves quickly with appropriate treatment, including
discontinuation of related medication.
 Frequently undiagnosed due to lack of awareness and the
wide range of medications that can cause Serotonin
Syndrome.
18
Tramadol with SSRI’s or SNRI’s:
Potential for Serotonin Syndrome
 Patients were selected if they had more than one tramadol fill, at





least a 30 day overlap with the SSRI or SNRI, and had both a
tramadol and an antidepressant claim within the most recent six
weeks of data.
179 patient profiles were evaluated.
Letters were sent to 174 prescribers about 94 patients on
2/21/2011.
Only prescribers of tramadol, SSRI, or SNRI received letters.
As of 3/31/2011, 39 responses have been received (22% response
rate.)
See packet for copy of the letter and Serotonin Syndrome
Informational sheet.
19
Tramadol with SSRI’s or SNRI’s:
Potential for Serotonin Syndrome
20
Tramadol with SSRI’s or SNRI’s:
Potential for Serotonin Syndrome
30
24
25
20
15
10
5
10
2
1
1
1
0
21
Tramadol with SSRI’s or SNRI’s
Criteria Paragraph
 Tramadol (Ultram®) is a centrally acting synthetic opioid which also
inhibits the reuptake of both serotonin and norepinephrine.
Therefore, serotonin syndrome can occur when tramadol is used
concomitantly with serotonergic drugs such as Selective Serotonin
Reuptake Inhibitors (SSRIs) [examples: citalopram, escitalopram,
fluoxetine, paroxetine, and sertraline] and Serotonin and
Norepinephrine Reuptake Inhibitors (SNRIs) [examples: venlafaxine,
duloxetine and desvenlafaxine]. During a recent review, it was noted
that your patient, Recipient Name, is receiving tramadol and a SSRI or
SNRI. The specific SSRI or SNRI product is noted in the attached
profile. Please review the attached profile and monitor this patient for
potential serotonin syndrome and adjust medications if clinically
appropriate (e.g. use a different analgesic agent). Please refer to the
attached educational leaflet for signs and symptoms of serotonin
syndrome as well as a listing of additional drugs that can precipitate
serotonin syndrome.
22
Tramadol with SSRI’s or SNRI’s: Response
detail as of 3/31/2011:
 Note that providers may choose more than one selection per
response.
 Reviewed and do not believe adjustment is needed
 Reviewed and have or will modify the treatment
 Attempted to modify therapy unsuccessfully
 Information clinically useful: plan to monitor
 Will use this information in care of future patients
 Not my patient, never has been
 Previously saw this pt, but no longer in my care
 Patient under my care, but not seen recently
15
4
3
10
8
2
5
3
23
Tramadol with SSRI’s or SNRI’s: Response
detail as of 3/31/2011 (continued):
 Extremely useful to my practice
 Very useful to my practice
 Somewhat useful to my practice
 Not useful to my practice
 Will discontinue medication
 Will change dose
 Other
3
7
5
4
2
3
5
24
Tramadol with SSRI’s or SNRI’s: Comments
of Interest*
 Profile ID: 0001584482: I was not aware the patient was
on tramadol.
 Profile ID: 0000022513: Defer long term
considerations to patient’s primary provider. I am ER
provider for this patient.
* Profile is in member packet for your review
25
Thiazolidinediones
 Troglitazone – removed from market 1999 due to adverse hepatic effects
 Pioglitazone hydrochloride (Actos ®) – initial approval 1999
 Pioglitazone + metformin (Actoplus Met®, Actoplus Met XR®)
 Pioglitazone + glimepiride (Duetact ®)
 Rosiglitazone maleate (Avandia®) – initial approval 1999
 Rosiglitazone + metformin (Avandamet ®)
 Rosiglitazone + glimepiride (Avandaryl ®)
Plasma glucose is lowered through PPAR gamma receptors
 Liver
 Heart
 Adipose tissue
 Skeletal muscle
 Kidney vascular and gut endothelial cells
26
TZD Adverse Effects
 Risk of Heart Failure
OR 1.32-2.18
 Pio and Rosi
 Risk of Edema
OR 2.26-4.62
 Pio and Rosi
 Fractures in Women
OR 2.23
 Pio and Rosi
 Increased all-cause or cardiovascular mortality
 Rosiglitazone
 No evidence with pioglitazone
 Some studies suggest reduced risk of all-cause and CV mortality
with pioglitazone
27
Regulatory Decisions on
Rosiglitazone
September 2010
The FDA required GSK to implement a restricted access
program for rosiglitazone and combination products that
contain rosiglitazone





Labeling changes
REMS implementation
Cease global marketing and promotion
Independent re-assessment of RECORD study
Suspension of TIDE study
European Medicines Agency announced suspension of
marketing authorization in Europe
28
Risk Evaluation and Mitigation
Strategy (REMS)
Restricted Access (added to labeling 2/4/11)
 Patients already receiving and benefitting
 New patients not controlled with other anti-diabetic
medications and unable to take or do not wish to use
pioglitazone
Documentation
 Prescribers: attest and document patient eligibility
 Patients: consent form acknowledging review and
understanding of risks
REMS to be approved Spring 2011 with implementation
within 6 months
29
Thiazolidinediones (TZDs)
 Safety issues with Avandia® related to increased risk for
Cardiovascular Events.
 “The U.S. Food and Drug Administration announced that it
will significantly restrict the use of the diabetes drug
Avandia® (rosiglitazone) to patients with Type 2 diabetes
who cannot control their diabetes on other medications.
These new restrictions are in response to data that suggest
an elevated risk of cardiovascular events, such as heart
attack and stroke, in patients treated with Avandia®.”
http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm226956.htm
30
Thiazolidinediones (TZD’s)
 Patients were selected for evaluation if there was a
paid claim for a TZD within the last three months.
 83 patient profiles were evaluated.
 Letters were sent to 65 prescribers about 63 patients
on 3/22/2011.
 As of 3/31/2011, 29 responses have been received (48%
response rate.)
 See packet for copy of the letter and FDA Drug Safety
Communication Insert.
31
TZD – Concurrent Medications
Other Concurrent Diabetes Medications
Monotherapy
1 other
2 other
3 other
11
29
17
9
Specific Drugs Used in Combo with Avandia®
Metformin
Sulfonylurea
Insulin
Meglitinide
Incretin Mimetic
48
18
8
2
1
32
TZD – Other Observations
 Adherence issues noted in 13 patients
 Number of Prescribers
 Single
49
 Two
13
 Three
4
 Number of Pharmacies
 Single
62
 Two
4
33
TZD’s
Criteria Paragraph
Your patient, Recipient Name, has received at least one recent prescription for rosiglitazone.
The FDA has notified healthcare professionals and patients that information on the
cardiovascular risks (including heart attack) of rosiglitazone has been added to the
product labeling and patient Medication Guide. This information was first announced
by the FDA on September 23, 2010 as part of new restrictions for prescribing and use of
this drug.
In addition to describing the cardiovascular risks, the drug labels for Avandia,
Avandamet, and Avandaryl have been revised to state that rosiglitazone and
rosiglitazone-containing medicines should only be used:
- In patients already being treated with these medicines
- In patients whose blood sugar cannot be controlled with other anti-diabetic medicines
and who, after consulting with their healthcare professional, do not wish to use
pioglitazone-containing medicines (Actos®, Actoplus Met®, Actoplus Met XR®, or
Duetact®).
Please read the attached FDA Drug Safety Communication. A link to the FDA complete
safety information is included below.
http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm226994.htm
34
TZD’s: Response detail as of
3/31/2011:
 Note that providers may choose more than one selection
per response.
 Reviewed and have or will modify the treatment
 Attempted to modify therapy unsuccessfully
 Information clinically useful: plan to monitor
 Previously saw this pt, but no longer in my care
 Very useful to my practice
 Somewhat useful to my practice
 Will change dose
4
4
2
3
2
2
1
35
TZD’s: Comments of Interest*
 Profile ID: 0001642778: I am already complying with
the above and am no longer prescribing Avandia®.
 Note that prescriber also wrote in next to number 8
that medication was reordered on January 26, 2011
* Profile is in member packet for your review
36
PPI’s: Long Term Use
• There are multiple risks associated with long term
Proton Pump Inhibitor (PPI) use.
• Patients were selected for evaluation if they had at
least 8 claims for a PPI over the six month period.
• Profiles are under development.
• See packet for copy of the letter and Educational
Information Handout*
37
PPI’s: Long Term Use
 Risk of Fracture: On May 25, 2010, the FDA revised the
prescription label for the proton pump inhibitor (PPI)
class of drugs to include new safety information about
a possible increased risk of fractures of the hip, wrist,
and spine with the use of these medications. There is
an associated 25% increase in overall fractures and a
47% increase in spinal fractures in postmenopausal
women.
38
PPI’s: Long Term Use
 Hypomagnesemia: The FDA has also issued a
statement warning that PPIs taken for prolonged
periods of time (in most cases, longer than one year)
may also cause low serum magnesium levels. Low
serum magnesium levels can lead to muscle spasm,
irregular heartbeat, and convulsions.
 Enteric infections: Reduction in acidity may promote
bacterial colonization of the gastrointestinal tract
which may result in clostridium difficile colitis or
bacterial gastroenteritis.
39
PPI’s: Long Term Use
 Community-acquired pneumonia: Reduction in
acidity may allow ingested pathogens to colonize the
stomach with subsequent translocation which
increases the incidence of community-acquired
pneumonias.
40
PPI’s: The review criteria was for 8 or more fills within a six month
period. Considered doses above the FDA approved dose for GERD as high as
listed in table.
FDA approved dose and length of therapy for GERD
PPI
FDA approved GERD dose
Length of Therapy
dexlansoprazole (Dexilant®)
30 mg daily
4 weeks
esomeprazole (Nexium®)
20 mg daily
lansoprazole (Prevacid®)
15 mg daily
4 weeks: may repeat an additional
4 weeks if not healed
8 weeks
omeprazole (Prilosec®)
20 mg daily
4-8 weeks
pantoprazole (Protonix®)
40 mg daily
rabeprazole (Aciphex®)
20 mg daily
8 weeks: may repeat an additional
8 weeks if not healed
4-8 weeks
*Zegerid® not payable by Idaho Medicaid
41
PPI’s
Criteria Paragraph
 During a retrospective drug utilization review, it was noted that your patient,
«MemberName», has received 8 or more fills for a PPI over the 6 month
review period. The FDA has recently revised the prescription label for the
proton pump inhibitor (PPI) class of drugs to include new safety information
about a possible increased risk of fractures of the hip, wrist, and spine and may
also cause low serum magnesium levels. The FDA recommends that when
healthcare professionals prescribe PPI's, they should utilize the lowest dose and
shortest duration of therapy to adequately treat the patient's condition.
42
PPI’s:
Findings Upon Review:
Over 49 years of age
Less than 50 years of
age
One PPI
19
22
One PPI with an H2 antagonist
1
Two strengths of one PPI
1
3
Two strengths of one PPI with an
H2 antagonist
Two PPIs
1
8
12
Two PPIs with an H2 antagonist
1
2
Three PPIs
2
4
Three PPIs with an H2 antagonist
1
43
PPI’s:
Findings Upon Review:
 Four participants < 50 years of age were previously
denied twice daily therapy
 three are now receiving two PPIs
 one is now receiving two PPIs and an H2 antagonist
 Three participants over 49 years of age are receiving
one PPI at GERD dosing
44
NIMH Study Specific Aims
 Specific Aim 1: Among Medicaid beneficiaries with a mental illness,
compare utilization trends of newer sedative hypnotics, alone and in
combination with other psychotropics, across three state Medicaid
programs from 2003-2008.
Specific Aim 2: Examine the effects of prescription access policies on
the utilization of newer sedative hypnotics, pre-to-post policy
implementation in each state, and potential substitutions to other
psychotropic drugs such as low dose atypical antipsychotics.
Specific Aim 3: Compare the impact of implementing prescription
access restriction policies on overall prescription drug expenditures
and service utilization expenditures among Medicaid beneficiaries
with a mental illness diagnosis, pre- and post-policy implementation.
Specific Aim 4: Compare changes in use of sleep aids (atypical
antipsychotics and/or newer sedative hypnotics) attributable to
changes in drug policy between people with and without documented
mental illness.
45
Proposed Studies for Next Quarter:
 Analysis of Auto Refill Practice*
 Atypical Antipsychotics: Impact of P&T Recommendations
 Colchicine Usage
 Place in Therapy for Treatment of Gout
 High Dose Utilization Through Multiple Dosage Strengths
 Oxycodone
 Atypical Antipsychotics
 Injectable Antipsychotics
All information based on Idaho Medicaid Pharmacy Data 1st Quarter 2011 (1/1/11-3/31/11) unless
otherwise indicated.
46
Auto Refill Practices
Some pharmacies are instituting Auto Refill policies
which allow them to automatically dispense refills
based on days since last fill
 Issues
 Potential for stockpiling
 Potential for continued fill of discontinued medications
 Increase cost/waste
47
Atypical Antipsychotics
P&T Recommendations
 Approved for diagnosis per FDA indications or off-label indications





with supporting evidence-based literature.
All patients receiving at least 90 days of therapy for the past 120 days as
of implementation date will be grandfathered. No criteria for diagnosis
required.
No PDL requirements for patients with schizophrenia and related
psychosis.
Bipolar, major depression adjunctive, autism and other designated
acceptable diagnoses will require failure of a preferred agent for
designated non-preferred agents.
Age, dose and quantity per labeling information on all drugs.
If the medical diagnosis and required drug history have been
submitted as prior claims then the prescription will auto-approve at
point of sale. i.e. No written PA required.
48
Atypical Antipsychotics
P&T Recommendations
Agent
Diagnoses/Criteria
Abilify®
Schizophrenia and Related Psychoses; Bipolar
Disease; Autism; Adjunctive Therapy in Major
Depression with continuous antidepressant therapy
within the last eight weeks with trials of a minimum
of two different antidepressants with a minimum
trial of two weeks each.
Abilify® Injectable
Schizophrenia and Related Psychoses with Acute
Agitation; Bipolar Disease with Acute Agitation
Clozapine
Resistant Schizophrenia and Related Psychoses
Fanapt®
Schizophrenia and Related Psychoses
Geodon®
Schizophrenia and Related Psychoses; Bipolar
Disease – Mania and Mixed State
Geodon® Injectable
Schizophrenia and Related Psychoses with Acute
Agitation
49
Atypical Antipsychotics
P&T Recommendations (continued)
Agent
Invega®
 Adherence
Diagnoses/Criteria
RatesSchizophrenia and Related Psychoses
Invega Sustenna®
Schizophrenia and Related Psychoses AND
History of Oral Invega® or Risperidone within
the past 2 years AND
Failure of Risperdal Consta®
Risperidone
Schizophrenia and Related Psychoses; Bipolar
Disease – Mania and Mixed State; Autism; Disruptive
Behavioral Disorders; Obsessive Compulsive
Disorder
*Brand name will deny for brand/generic rule
Risperdal Consta®
Schizophrenia and Related Psychoses
Saphris®
Schizophrenia and Related Psychoses; Bipolar
Disease – Mania and Mixed State
50
Atypical Antipsychotics
P&T Recommendations (continued)
Agent
Seroquel®
 Adherence
Diagnoses/Criteria
RatesSchizophrenia and Related Psychoses ; Bipolar
Disease – Mania and Mixed State; Bipolar
Depression; Obsessive Compulsive Disorder
Seroquel XR®
Schizophrenia and Related Psychoses ; Bipolar
Disease – Mania and Mixed State; Bipolar
Depression; Adjunctive Major Depression
Continuous - antidepressant therapy within the last
eight weeks with trials of a minimum of two different
antidepressants with a minimum trial of two weeks
each.
Symbyax®
Treatment Resistant Depression - Continuous
antidepressant therapy within the last eight weeks
with trials of a minimum of two different
antidepressants with a minimum trial of two weeks
each.
51
Atypical Antipsychotics
P&T Recommendations (continued)
Agent
Zyprexa®
 Adherence
Diagnoses/Criteria
RatesSchizophrenia and Related Psychoses, Acute
Agitation; Bipolar, Acute Agitation
Zyprexa Injection®
Schizophrenia and Related Psychoses; Bipolar
Disease, Acute Agitation
Zyprexa Relprevv®
Reimbursed as Medical Benefit Only; Schizophrenia
and Related Psychoses
52
Atypical Antipsychotics
P&T Recommendations
Patients Receiving Atypical Antipsychotics
35%
65%
With Approvable
Diagnosis
Without Approvable
Diagnosis
All information based on Idaho Medicaid Pharmacy Data 1st Quarter 2011
(1/1/11-3/31/11).
53
Gout Treatment
Colchicine’s Place in Therapy

Acute Gout Attacks –
 NSAIDS and/or corticosteroids can be used for the management of an
acute gout attack.
 Management of Chronic Gout –
 Allopurinol is the drug of choice to lower serum uric acid and does not
require prior authorization.
 Uloric® will be approved for payment only after (1) continuation of gout
attacks after three months of allopurinol therapy at a therapeutic dose, (2)
serum urate levels > 6mg/dl after three months of allopurinol therapy at a
therapeutic dose, or (3) documented intolerance to allopurinol. To
prevent an acute attack as a result of starting allopurinol, low dose NSAID
(e.g. naproxen 250mg twice daily) or prophylactic Colcrys® can be used if
there are no contra-indications.
 Probenecid increases uric acid excretion and does not require prior
authorization.
54
Gout Treatment
Colchicine’s Place in Therapy
 Utilization Overview
Number of
Recipients
Number of
Claims
Average
Cost/Claim
Allopurinol
179
419
$6.56
Colcrys®
18
26
$325.83
Probenecid
3
9
$27.86
Uloric®
9
19
$160.47
All information based on Idaho Medicaid Pharmacy Data 1st Quarter 2011
(1/1/11-3/31/11).
55
High Dose Oxycodone Long Acting
Six recipients received more than one strength of LA Oxycodone during Jan,
Feb, Mar 2011
1
2
1
40mg + 10mg
10mg+20mg
80mg + 30mg
2
80mg + 40mg
All information based on Idaho Medicaid Pharmacy Data 1st Quarter
2011 (1/1/11-3/31/11).
56
High Dose Atypical Antipsychotics
377 recipients received multiple doses of the same atypical antipsychotic
during Jan, Feb, Mar 2011
Product Distribution by Number of Recipients
Multiple Doses of Same Agent
1
FANAPT
1 23
1
SAPHRIS
SYMBYAX
18
166
65
INVEGA
61
99
52
CLOZAPINE
ZYPREXA
GEODON
ABILIFY
RISPERIDONE
SEROQUEL
All information based on Idaho Medicaid Pharmacy Data 1st Quarter 2011 (1/1/11-3/31/11).
57
Injectable Atypical Antipsychotics
Invega® Sustenna® and Risperdal® Consta®
 Indications
Agent
Indication
Invega® Sustenna®
Acute and Maintenance Treatment of Schizophrenia
Risperdal® Consta®
Treatment of Schizophrenia
Risperdal® Consta®
Mono or Adjunct therapy to Lithium or Valproate in
Bipolar I Disorder
 Utilization Overview
Agent
Recipients
Invega® Sustenna®
106
Risperdal® Consta®
148
Oral Agents
6936
Patients Receiving Both Oral and Injectable – 1st Quarter 2011
148
*Idaho Medicaid Data 4th Quarter 2010 (10/1/2010-12/31/2010)
58
Injectable Atypical Antipsychotics
Invega® Sustenna® and Risperdal® Consta®
 Goal 1:
Evaluate Adherence Rates




 Goal 2:


Oral use prior
Current adherence
For Invega Sustenna – previous adherence on Risperdal
Consta
Ensure not receiving oral therapy in addition to injectable
Program Integrity
Ensure doses dispensed by the pharmacy are actually
administered
Compare drug profiles, medication administration records
and time period
59
Injectable Atypical Antipsychotics
Study Responsibilities
 MMA:



Program Integrity:



Request and obtain the medication administration records and
the progress notes
Take action on any identified fraud or billing irregularities
Medicaid Pharmacy Staff



Patient list
Pharmacy and Prescriber identification
Compile and analyze treatment for each patient
Present an analysis of the data to DUR Board and P&T Committee
DUR Board and P&T Committee


Review and interpret results
Make Conclusions and Recommendations
60
Injectable Atypical Antipsychotics
Invega® Sustenna® and Risperdal® Consta®
 Adherence Rates
Agent
Adherence Rate
Oral Therapy
66%
Risperdal® Consta®
71%
Invega® Sustenna®
76%
Adherence calculated by evaluating claims for patients receiving
multiple claims for the same agent and comparing difference
between days’ supply and days between refills.
*Idaho Medicaid Data 3rd Quarter 2010 (7/1/2010-9/30/2010)
61
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
62
ProDUR Message Report: December 2010 (for comparison)
ProDUR
Message
ProDUR
Severity
Message
Count
Message
Amount
Drug To Drug
1
1,173
$146,999.56
2
12,182
$1,700,261.43
3
51,685
$7,325,789.80
9
1
$23.47
1
96
$10,359.56
2
51
$2,176.82
1
64,326
$7,320,792.62
2
233,655
$32,056,536.99
3
211,605
$31,687,569.10
1
108
$2,681.28
2
73
$1,643.76
A
85
$1,236.49
B
105
$14,363.74
C
215
$27,401.45
D
13
$354.95
X
50
$3,617.89
Duplicate
Therapy
0
108,695
$18,457,983.74
Min Max
0
37,916
$5,383,620.08
Too Soon
Clinical
0
21,418
$3,482,239.41
743,472
$107,625,652.14
Drug To Gender
Drug To Known
Disease
Drug To
Pregnancy
ALL
63
ProDUR Message Report: February 2011
ProDUR
Message
ProDUR
Severity
Message
Count
Message
Amount
Drug To Drug
1
1,094
$250,625.86
2
11,728
$1,670,211.54
3
49,213
$7,140,413.18
1
98
$31,833.78
2
27
$712.45
1
57,509
$6,975,504.23
2
209,206
$28,797,060.87
3
188,395
$29,958,468.53
1
93
$1,567.73
2
85
$2,115.35
A
59
$1,340.40
B
111
$12,052.25
C
219
$16,090.54
D
8
$183.34
X
5
$209.55
Duplicate Therapy
0
96,700
$17,494,927.78
Min Max
0
38,748
$6,081,549.57
Too Soon Clinical
0
18,377
$2,771,725.82
671,675
$101,206,592.77
Drug To Gender
Drug To Known Disease
Drug To Pregnancy
ALL
64
Top Drugs for Selected ProDUR Type:
Duplicate-Therapy
 Hydrocodone/APAP with other Hydrocodone/APAP – 2,516 alerts






(14.44% of claims for Hydrocodone/APAP)
Methylphenidate with other methylphenidate – 1,917 alerts (34.72% of
claims for methylphenidate)
Quetiapine with other quetiapine – 1,915 alerts (51.41% of claims for
quetiapine)
Oxycodone/APAP with hydrocodone/APAP – 1,448 alerts (57.57% of
claims for oxycodone/APAP)
Venlafaxine with other venlafaxine – 1,438 alerts (73.90% of claims for
venlafaxine)
Bupropion with bupropion – 1,409 alerts (45.61% of claims for
bupropion)
Hydrocodone/APAP with tramadol – 1,166 alerts (6.69% of claims for
bupropion)
65
DUR Spring Newsletter
 Brainstorm for new topics
66
New Annual DUR Report
Electronic Submission
Background
Each State must submit an annual DUR report that includes
 Nature and Scope Description





Prospective DUR Program
Retrospective DUR Program
Assessment of Education Program
Description of DUR Board Activities
Assessment of DUR Program


Impact on Quality of Care
Cost Savings Generated by Program
67
New Annual DUR Report
Electronic Submission
Differences from Previous Report
1. New Sections





2.
Physician Administered Drugs
Generic Policy and Utilization
Fraud, Waste and Abuse Detection
Innovative Practices
E-Prescribing
Changes




ProDUR focus on early refill and therapeutic duplication and associated
override and PA policies
Less emphasis on DUR meeting statistics and policies
More emphasis on DUR Involvement in programs such as Disease
Management and Medication Therapy Management
New format and evaluation process for program evaluation and cost
savings.
68
Medicaid Update
69