TennCare Drug Utilization Review Advisory Board. June 5, 2012 SXC Health Solutions, Inc.

Transcription

1 TennCare Drug Utilization Review Advisory Board June 5, 2012 SXC Health Solutions, Inc.

2 Agenda Call to Order- Toie Alston, PharmD Introductions Approval of Previous Minutes / Additions to the Agenda TennCare Update- Dr. David Collier, Ray McIntire, DPh Old Business Standing Business Blocking Non-Participating Providers TennCare Drug Utilization Data RetroDUR and Provider Practice Activity Review Pharmacy Lock-In Review New Business Adjournment SXC Health Solutions, Inc

3 Review of Minutes March 6, 2012 SXC Health Solutions, Inc

4 TennCare Updates David Collier, MD Ray McIntire, DPh SXC Health Solutions, Inc

5 TennCare Update June 5, 2012

6 Provider Rate Restoration Legislation to restore 1.75% of the 1/1/ % divided rate reduction passed. Resulting rate reduction is 2.5% retroactive to 1/1/2012. Providers affected: nursing homes, MCO administration rates, lab and x-ray services, dental services, ICF-MR Providers, PACE providers, Home health providers (excluding HCBS), NEMT co-pay removed

7 Provider Rate Restoration MCOs are having to program their systems to implement the rate restoration Timetable into September

8 TennCare Benefit Limits Hospital Coverage Assessment passed for a 3 rd year Able to avoid benefit limits Continue at same rate as last year 4.52%

9 Changes TennCare Nursing Facility (NF) Level of Care (LOC) One of 2 eligibility components (financial) for Medicaid reimbursement of NF services & HCBS Today one significant deficiency in a specified ADL needed to satisfy (need for inpatient care) provision. Very generous compared to most states.

10 Changes TennCare plans to raise the NF LOC standards for new applicants effective 7/1/2012 NF LOC Acuity Scale used instead of raising the # of deficiencies required from 1 to 4 Eligibility for NF services will be based on the applicant s cumulative score The new criteria will apply to new applicants after 7/1/2012 seeking services from LTSS

11 Changes CHOICES Group 1: NF applicants people who receive nursing home care CHOICES Group 2: HCBS services certain people who receive home care instead of nursing home care Adults 65 years or older, OR Adults 21 years of age and older with physical disabilities

12 Changes CHOICES Group 3: at risk of NF placement Eligible to receive home-based care Not eligible for residential care Cost: $15,000 per year excluding cost of minor home modifications

13 TennCare PLUS Proposal submitted to Medicare-Medicaid Coordination Office (MMCO) at CMS Full Benefit Dual Eligibles (FBDEs) persons enrolled in both Medicare and Medicaid Implementation date: January 1, 2014 FBDEs will receive Medicare & Medicaid services, & Medicare RX from their TennCare MCO

14 TennCare PLUS Benefits Hospital, physician services, behavioral healthcare LTSS (NF, HCBS) except ICF/MR & HCBS for people with intellectual disabilities (these continue outside TennCare PLUS) New benefits: Basic dental, hearing, vision care Care management and care coordination services

15 TennCare II Waiver Extension request to CMS to be submitted June 30, Period: July 1, 2013 through June 30, 2016 Update obsolete sections Transition plan eligibility changes required by the Affordable Care Act TennCare enrollees not Medicaid eligible will become eligible as of 1/1/2014 and must be moved into Medicaid

16 EHR incentive payments as of 5/23/2012 EP Complete EP Paid EH Complete EH Paid Year 1 1,694 $37,789, $42,351, Year 2 14 $144, $368,198.00

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18 TennCare Pharmacy Update June 5, 2012

19 Pharmacy Update Topics Final Pharmacy Budget Results and Trend Increase Issue, FY2013 Upcoming Changes to the State s Controlled Substance Database Laws CMS s Proposed Pharmacy Reimbursement Changes TennCare s PBM Vendor RFP New TennCare Pharmacy Leadership Announcement and Introduction

20 Final Pharmacy Budget Results and Trend Increase Issue, FY2013 Of the TennCare proposed cuts, only one item was included in the final Fiscal Year 2013 Budget: Enhanced TPL Collection- TennCare s point-of-sale TPL is already operational, and is a continuation of our current program. Increasing Pharmacy Spend Issue: TennCare s pharmacy spend began to increase at an alarming rate during the 4 th quarter of 2011 and 1 st quarter of Although other line items were not included in the FY2013 Budget, TennCare s pharmacy team will continue to adjust to market changes and trends as needed to meet budget demands. TennCare needed to use reserves to balance the increase in pharmacy spend.

21 Prescription Safety Act of TennCare s New Potential CSDB Uses Under past law, information was available only to pharmacists dispensing or considering dispensing controlled substances to the current patient. Exception to the above was only TennCare s Associate Pharmacy Director New law allows a dispenser or pharmacist not authorized to dispense controlled substances conducting drug utilization or medication history reviews who is actively involved in the care of the patient.

22 Prescription Safety Act of 2012, Cont d New opportunities for TennCare to use the CSD to manage utilization of controlled substances: All of TennCare s licensed pharmacists will be able to access the CSD if needed for utilization review. In the past, licensed pharmacists working with TennCare s pharmacy vendor were not able to access the CSD, and will have access in the future for utilization reviews during the following processes: TennCare Enrollee Lock-In Reviews Prior Authorization Requests for controlled substances Fraud investigations

23 Pharmacy Reimbursement Changes Proposed by CMS States currently reimburse for covered outpatient drugs based on the estimated acquisition cost (EAC). EAC, as currently defined is the agency s best estimate of the price paid by pharmacies. EAC is defined by each state, and there are many different calculations using pharmacy standards, e.g., Average Wholesale Price (AWP), Wholesale Acquisition Price (WAC), or Actual Acquisition cost (AAC). CMS is proposing for all states reimbursement to be based on Actual Acquisition Cost (AAC).

24 CMS Reimbursement Changes, cont d Per CMS, using AAC will be more reflective of actual prices paid, as opposed to estimates based on unreliable published compendia pricing: CMS does not offer a definitive method for agency s to determine the actual price of each individual drug. An average of the AAC s from representative pharmacies fits within this definition as data used in the calculation of AAC would be reflective of actual pharmacy purchase prices. Within this framework, states can develop payment methodologies consistent with this regulatory definition for their pharmacy reimbursement.

25 Request For Proposal for PBM Vendor TennCare is in the final stages of preparing an RFP in order to once again ask for bids from prospective pharmacy benefits managers for TennCare s pharmacy program. RFP will be issued to prospective PBM s prior to July 1, 2012, and after proposals are received, the vendor will be announced on October 1, 2012, with PBM services to begin June 1, 2013 for a 3-year period through May 31, 2016, with 2 optional one year renewals.

26 New TennCare Pharmacy Leadership Our new Pharmacy Director is Bryan P. Leibowitz, Pharm.D. Dr. Leibowitz has a Doctor of Pharmacy degree from Rutgers, The State University of New Jersey, and has over 5 years experience in the PBM and Managed Care sector and 4 years experience in Home Infusion and Specialty Pharmacy. Dr. Leibowitz started with TennCare on March 14, and will be relocating his family to the Nashville area from New Jersey.

27 New TennCare Pharmacy Leadership TennCare has also hired an additional Associate Pharmacy Director, Dr. Michael Polson. Dr. Polson received his Doctor of Pharmacy degree from East Tennessee State in May, and he also has a M.S. in Statistics and a Graduate Certificate in Applied Statistical Strategies from The University of Tennessee, and a B.S. in Mathematical Sciences from East Tennessee State. Dr. Polson was previously employed at TennCare in from in Healthcare Informatics.

28 Old Business from March 6, 2012 Meeting SXC Health Solutions, Inc. 28

29 Follow up Issues from March 6, 2012 DUR Meeting Atypical Antipsychotic DUR Activity Letter SXC Health Solutions, Inc

30 Standing Business SXC Health Solutions, Inc

31 Blocking Non-Participating Providers SXC Health Solutions, Inc. 31

32 TennCare Population and Drug Utilization Trends Review SXC Health Solutions, Inc. 32

33 TennCare Pharmacy Data TennCare Statistics Utilization Data Population 1Q12 vs. 1Q11 TennCare Utilizing members Average Prescription Payments Total Population Drug class claim volume and payment amount Individual drug- claim volume and payment amount Adult Population (age 21 and above) Drug class claim volume and payment amount Individual drug- claim volume and payment amount Pediatric Population (ages 0 through 20) Drug class claim volume and payment amount Individual drug- claim volume and payment amount SXC Health Solutions, Inc

34 Population Highlights TennCare Population Remains stable at ~1.2 million members Non Dual Adults- 4.3% increase Utilization (1Q2012 vs. 1Q2011) Utilizing members 3.02% Prescription count 3.65% Payment amount increased 18% Average Payment Per Claim and Average Amount Paid Per Utilizing member ~14% Average Payment Per Claim $65.62 SXC Health Solutions, Inc

35 TennCare Population Eligibility 1Q2012 1Q2011 %Change Non-Dual Children 738, ,823 (1.13) Non-Dual Adults with Rx Limit 323, , Non-Dual Adults without Rx Limit 7,203 6, Dual Eligible Children Dual Eligible Adults* 132, , Total TennCare Population 1,201,963 1,193, Ave Pharmacy Utilizing Members per month < 21 (Children) 215,112 (29.12%) 216,860 (29.0%) (0.81) Ave Pharmacy Utilizing Members per month >= 21 (Adults) 188,843 (57.1%) 186,367 (56.9%) 1.33 * No prescription benefits through TennCare SXC Health Solutions, Inc

36 TennCare Utilizing Members 1Q2012 1Q2011 % Change # Utilizing Members / Month 403, , # Prescriptions / Month 1,132,468 1,092, Total Amount Paid / Month Average # Rxs /Utilizing Member / Month Average Amount Paid / Claim Average Amount Paid / Utilizing Member Average Amount Paid / Eligible Member $74,307,231 $62,832, $65.62 $ $ $ $61.81 $ SXC Health Solutions, Inc

37 Average Prescription Payment Average Payment SXC Health Solutions, Inc

38 38 Utilization Data Total Population SXC Health Solutions, Inc.

39 Utilization Highlights 1Q12 Therapeutic Class by Claim Volume Slight in Narcotic Analgesics claims Payment amount 7.48% Leukotriene Modulators ~6% Payment amount 28.46% Montelukast projected generic entry- August 2012 Therapeutic Class by Payment Amount ADHD agents 22.9% since 1Q11 Ranks #10 in Top Therapeutic Class by Payment Amount for adults Adult claims 9.23% SXC Health Solutions, Inc

40 Utilization Highlights 1Q12 Hepatitis Agents Payment amount >200% since 1Q11 Incivek, Pegasys, Ribavirin Suboxone Payment 25.13% Continuous decline due to new dosing limit SXC Health Solutions, Inc

41 Top 10 Therapeutic Classes By Claim Volume Rank Therapeutic Class 1Q12 # Claims 1Q12 Rank 2011 # Claims 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Narcotic Analgesics 315, ,644 (0.21) Penicillins 160, ,951 (7.22) Anticonvulsants 133, , Sympathomimetics 128, , ADHD Agents 126, , nd Gen Antihistamine 118, , NSAIDs 117, , SSRI 106, , Macrolides 95, ,820 (5.11) Atypical Antipsychotics 73, , SXC Health Solutions, Inc

42 Top 10 Therapeutic Classes By Payment Amount* Rank Therapeutic Class 1Q12 Payment 1Q12 Rank 2011 Payment 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Atypical Antipsychotics $30,971,312 1 $27,057, ADHD agents $21,220,572 2 $17,420, Narcotic Analgesics $11,432,453 3 $12,415,518 (7.48) (2.99) 4 Anticonvulsants $10,102,819 4 $9,581, Leukotriene Modulators $9,673,393 6 $7,566, Sympathomimetics $8,735,095 5 $7,822, Antiretrovirals $7,606,143 7 $6,447, Insulin $7,433,696 9 $6,081, Monoclonal Antibodies $6,748, $5,206, Antihemophilic Products $6,450,167 8 $6,316, (20.08) * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

43 Top 10 Drugs By Claim Volume Rank Drug 1Q12 # Claims 1Q12 Rank 2011 # Claims 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Hydrocodone/APAP 171, ,127 (1.00) (0.99) 2 Albuterol 106, , Amoxicillin 104, ,633 (8.32) Azithromycin 89, ,965 (3.83) Cetirizine 72, , Montelukast 61, , Ibuprofen 56, , Lisinopril 52, , Promethazine 49, ,466 (5.68) Loratadine 44, ,801 (2.39) 7.72 SXC Health Solutions, Inc

44 Top 10 Drugs By Payment Amount* Rank Drug 1Q12 Payment 1Q12 Rank 2011 Payment 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Montelukast $9,664,116 3 $7,558, Quetiapine $9,606,986 1 $8,621, Aripiprazole $8,928,905 2 $7,750, Palivizumab $6,748,876 5 $5,206, Amphetamine Salts $6,589,578 4 $5,703, Olanzapine $4,953,884 6 $4,373, Methylphenidate $4,573,747 7 $4,160, Lisdexamfetamine $4,499,513 9 $3,749, Albuterol $4,420,502 8 $3,813, Dexlansoprazole $3,729, $2,864, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

45 45 Utilization Data Adult Population (Ages 21 and older) SXC Health Solutions, Inc.

46 Claim Volume Per Age Group Total # of Claims Per Month Average Claims PUPM SXC Health Solutions, Inc

47 Payment Amount Per Age Group Total Payment Per Month Average Payment PUPM 1Q12 1Q11 SXC Health Solutions, Inc

48 Top 10 Therapeutic Classes By Claim Volume- Adults Rank Therapeutic Class 1Q12 # Claims 1Q12 Rank 2011 # Claims 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Narcotic Analgesics 263, ,100 (0.24) (0.37) 2 Anticonvulsants 100, , SSRIs 84, ,998 (1.69) NSAIDS 76, , ACEIs 63, , Sympathomimetics 57, , Skeletal Muscle Relaxants 54, , Statin 53, , Proton Pump Inhibitors 52, , Atypical Antipsychotics 44, , SXC Health Solutions, Inc

49 Top 10 Therapeutic Classes By Payment Amount*- Adults Rank Therapeutic Class 1Q12 Payment 1Q12 Rank 2011 Payment 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Atypical Antipsychotics $22,474,156 1 $19,118, Narcotic Analgesics $10,914,727 2 $11,856,616 (8.88) (3.35) 3 Antiretrovirals $7,122,231 4 $5,929, Anticonvulsants $6,972,410 3 $6,398, Insulins $6,210,371 5 $5,025, Hepatitis Agents $5,345, $1,479, Proton Pump Inhibitors $4,123,321 7 $3,164, Sympathomimetics $4,076,896 6 $3,450, SNRIs $3,026,361 8 $2,352, ADHD Agents $2,826, $2,041, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

50 Top 10 Drugs By Claim Volume - Adults Rank Drug 1Q12 # Claims 1Q12 Rank 2011 # Claims 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Hydrocodone/APAP 144, ,134 (1.75) (1.19) 2 Lisinopril 50, , Albuterol 46, , Oxycodone/APAP 39, , Gabapentin 38, , Metformin 31, , Citalopram 31, ,239 (2.97) (0.45) 8 Promethazine 29, ,154 (2.42) Azithromycin 29, ,605 (2.25) Levothyroxine 28, , SXC Health Solutions, Inc

51 Top 10 Drugs By Payment Amount* - Adults Rank Drug 1Q12 Payment 1Q12 Rank 2011 Payment 1Q11 PMPM% Δ Year 1Q12-1Q11 PMPM% Δ Qtr 4Q10-1Q11 1 Quetiapine $7,703,870 1 $6,735, Aripiprazole $4,575,242 2 $3,922, Olanzapine $4,286,712 3 $3,701, Dexlansoprazole $3,416,401 5 $2,596, Telaprevir $2,862, Buprenorphine/Naloxone $2,668,249 4 $3,527,585 (25.13) (7.54) 7 Oxymorphone $2,452,531 6 $2,252, (9.28) 8 Insulin Glargine $1,988, $1,672, Clopidogrel $1,988,198 7 $1,913, Albuterol $1,968,802 9 $1,713, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

52 52 Utilization Data Child Population (Ages 0 through 20) SXC Health Solutions, Inc.

53 Claim Volume for Children Total # of Claims Per Month Average Claims PUPM SXC Health Solutions, Inc

54 Payment Amount for Children Total Payment Per Month Average Payment PUPM SXC Health Solutions, Inc

55 Top 10 Therapeutic Classes By Claim Volume - Children Rank Therapeutic Class 1Q12 # Claims 1Q12 Rank 2011 # Claims 1Q11 PMPM% Δ Year 1Q11-1Q12 PMPM% Δ Qtr 4Q11-1Q12 1 Penicillins 125, ,289 (7.47) ADHD Agents 110, , Antihistamines, 2nd Gen 95, , Sympathomimetics 70, , Macrolides 63, ,775 (5.11) Leukotriene Modulators 56, , Cephalosporins 55, ,800 (4.49) Narcotic Analgesics 52, ,544 (6.47) Glucocorticosteroids 42, , (0.79) 10 NSAIDs 41, , SXC Health Solutions, Inc

56 Top 10 Therapeutic Classes By Payment Amount*- Children Rank Therapeutic Class 1Q12 Payment 1Q12 Rank 2011 Payment 1Q11 PMPM% Δ Year 1Q10-1Q11 PMPM% Δ Qtr 4Q11-1Q12 1 ADHD Agents $18,392,728 1 $15,378, Leukotriene Modulators $8,917,582 3 $6,961, Atypical Antipsychotics $8,498,144 2 $7,939, Monoclonal Antibodies $6,548,495 5 $4,918, Antihemophilic Factor $5,149,732 4 $5,059, (21.53) 6 Sympathomimetics $4,661,270 6 $4,371, Steroid Inhalants $3,946,080 7 $3,636, Anticonvulsants $3,129,935 8 $3,186,844 (0.66) (1.02) 9 Growth Hormones $3,028, $3,067,733 (0.16) (0.35) 10 Cephalosporins $2,878,035 9 $3,123,541 (6.81) * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

57 Top 10 Drugs By Volume - Children Rank Drug 1Q12 # Claims 1Q12 Rank 2011 # Claims 1Q11 PMPM% Δ Year 1Q10-1Q11 PMPM% Δ Qtr 4Q11-1Q12 1 Amoxicillin 87, ,051 (8.76) Cetirizine 63, , Azithromycin 60, ,363 (4.61) Albuterol 60, , Montelukast 56, , Cefdinir 33, ,147 (2.80) Amoxicillin/Clavulanate 32, ,015 (4.18) Loratadine 30, ,950 (0.33) Ibuprofen 30, ,938 (1.64) Amphetamine Salts 27, , SXC Health Solutions, Inc

58 Top 10 Drugs By Payment Amount* -Children Rank Drug 1Q12 Payment 1Q11 Rank 2011 Payment 1Q11 PMPM% Δ Year 1Q10-1Q11 PMPM% Δ Qtr 4Q11-1Q12 1 Montelukast $8,915,113 1 $6,960, Palivizumab $6,548,495 2 $4,918, Amphetamine Salts $4,973,040 3 $4,668, Methylphenidate $4,453,959 4 $4,049, Aripiprazole $4,353,662 5 $3,828, Lisdexamfetamine $4,095,202 6 $3,450, Somatropin $3,028,296 7 $3,067,733 (0.16) (0.35) 8 Albuterol $2,451,700 9 $2,101, Dexmethylphenidate $2,110, $1,238, Budesonide (Inhalation) $1,914, $1,926, * Payment amount reflected is equal to the total amount paid to the pharmacy before rebates and federal match. SXC Health Solutions, Inc

59 59 Prospective Drug Utilization Review (ProDUR) 1 st Quarter 2012 SXC Health Solutions, Inc.

60 Definitions - Edits/Rejections ProDUR Edit A computer system review of the member s medication history Identifies potential drug therapy problems prior to dispensing the medication. Examples would include but not limited to: Therapeutic Duplication (TD), Early Refill (ER), Max Dose, Drug to Gender, Drug to Drug, Drug to Inferred Disease, Geriatric and Pediatric Warnings Types of Rejections: Hard Reject These edits will cause the claim to deny at the point of sale (POS) Soft Reject- These edits will cause the claim to deny at the point of sale. However, with appropriate documentation the pharmacy will be able to re-submit the rejected claim using Professional Pharmacy Service (PPS) codes Message These edits will cause an alert or warning message to be returned to the dispensing pharmacist to inform them of a potential problem. SXC Health Solutions, Inc. 60

61 Summary of ProDUR Edits Remains steady Geriatric Precaution New to the list: Warfarin edits HCTZ edits Quetiapine 254 edits Trazodone 225 edits SXC Health Solutions, Inc

62 Top 10 Therapeutic Duplication ProDUR Drug Name Conflict Drug Total % Paid Albuterol Albuterol 50, % Hydrocodone/APAP Hydrocodone/APAP 47, % Oxycodone/APAP Oxycodone/APAP 11, % Risperidone Risperidone 10, % Citalopram Citalopram 10, % Quetiapine Quetiapine 9, % Amephatamine Salts Amephatamine Salts 9, % Oxycodone/APAP Hydrocodone/APAP 9, % Clonidine Clonidine 9, % Lisinopril Lisinopril 9, % SXC Health Solutions, Inc

63 Top 10 Early Refill ProDUR Edits* Drug #Edits Hydrocodone/APAP 16,770 Gabapentin 10,972 Albuterol 10,835 Citalopram 7,831 Risperidone 7,511 Levothyroxine 7,059 Lisinopril 6,758 Ranitidine 6,507 Clonidine 6,309 Simvastatin 5,987 *Hard reject at point of sale SXC Health Solutions, Inc

64 Top 10 Max Dose ProDUR Edits Drug Total % Soft Edits % Paid Hydrocodone/APAP 17, % 82.8% Cefdinir 13, % 97.8% Polyethylene Gycol , % 90.8% Promethazine 8, % 94.2% Ibuprofen 6, % 97.0% Amoxicillin/Clavulanate 6, % 97.7% Amphetamine Salts 4, % 87.4% Oxycodone/APAP 2, % 84.6% Cyclobenzaprine 2, % 89.9% Cetirizine 2, % 91.4% SXC Health Solutions, Inc

65 Top 10 Drug to Drug ProDUR Edits* Drug Conflict Drug Total % Paid Spironolactone Potassium 1, % Triamterene-HCTZ Potassium % Amiodarone Warfarin % Sulfamethoxazole/TMP Warfarin % Warfarin Tricor % Fluconazole Warfarin % Sertraline Clozapine % Lithium Lisinopril/HCTZ % Lithium HCTZ % Citalopram Clozapine % *Major severity / soft reject at point of sale

66 Top 10 Drug to Inferred Diagnosis Pregnancy Drug Total % Paid Promethazine 2, % Hydrocodone/APAP 2, % Ibuprofen 2, % Oxycodone/APAP 1, % Metronidazole % Nitrofurantoin % Fluconazole % Albuterol % Acetaminophen/Codeine % Buprenorphine % SXC Health Solutions, Inc

67 Top 10 Drug to Gender ProDUR Edits Drug Total % Paid Rizatriptan % Emtricitabine/Tenofovir % Sumatriptan % Ribavirin (Hepatitis C) % Tamsulosin* % Abacavir/Lamivudine % Zolmitriptan % Emtricitabine/Tenofovir % Valganciclovir % Prenatal Vitamins* % *hard reject at point of sale SXC Health Solutions, Inc

68 Top 10 Geriatric Precaution ProDUR Warnings Drug Total % Paid Hydrocodone/APAP % Amlodipine % Lisinopril % Simvastatin % Metformin % Citalopram % Warfarin % HCTZ % Quetiapine % Trazodone % *Medispan defines geriatric as 64 years of age SXC Health Solutions, Inc

69 2012 Beers Criteria Update Partnership - American Geriatric Society and 11 Experts in Geriatric Care and Pharmacotherapy. Grade the strength and quality of each PIM statement based on level of evidence and strength of recommended grading. 53 medications or medication classes Potentially inappropriate medications and classes to avoid in older adults Potentially inappropriate medications and classes to avoid in older adults with certain diseases and syndromes that the drugs listed can exacerbate Medications to be used with caution in older adults SXC Health Solutions, Inc

70 Top 10 Pediatric Precaution ProDUR Warnings Drug Total % Paid Clonidine 22, % Cetirizine 19, % Promethazine* 16, % Azithromycin 16, % Risperidone 15, % Hydrocodone/APAP 14, % Methylphenidate 13, % Ibuprofen 12, % Montelukast 10, % Lisdexamfetamine 10, % *Soft reject at point of sale SXC Health Solutions, Inc

71 71 Review of DUR Activities SXC Health Solutions, Inc.

72 RetroDUR Activities 1Q2012 Jan: Non-Compliance Immunosuppressant Therapy Patient profiles reviewed: 625 Provider letters sent: 250 Patients addressed: 407 Feb: Statin Risk in Pregnancy Patient profiles reviewed: 1,256 Provider letters sent: 835 Patients addressed: 1,254 March: Singulair Utilization Patient profiles reviewed: 1401 Provider letters sent: 468 Patients addressed: 1100 SXC Health Solutions, Inc

73 Top Narcotic Prescriber Provider Practice Analysis Activities 1Q2012 Prescribers Returned: 200 Prescribers Selected and Lettered Specialist: 52 Non-Specialist: 59 Dentist: 15 Short Acting Narcotic Initiative Risk of Diabetes with Statin Prescribers Returned: 2,573 Prescriber Lettered: 800 Prescribers Returned: 800 Prescribers Lettered: 800 SXC Health Solutions, Inc

74 Provider Practice Analysis Activities 1Q2012 Suboxone Tapering Prescribers Returned: 113 Prescribers Lettered: 113 Oral Fluconazole vs. Topical Vaginal Antifungal Prescribers Returned: 940 Prescriber Lettered: 940 SXC Health Solutions, Inc

75 Retrospective Drug Utilization Review (RetroDUR) Activities Overutilization of SABA Insomnia Treatment Migraine Prophylaxis SXC Health Solutions, Inc

76 Provider Practice Analysis Activities Updated Beers Criteria: Potentially Inappropriate Medication Use in Older Adults Zyprexa Conversion Prescribing Multi-Source Agents SXC Health Solutions, Inc

77 Pharmacy Lock-In Program SXC Health Solutions, Inc. 77

78 Member-Pharmacy Lock-In Criteria Criteria includes a review of the following in a 90 day period: Multiple controlled substances Multiple pharmacies Multiple prescribers Targeted pharmacies and prescribers Maximum Daily Dosage Use of buprenorphine for addiction treatment SXC Health Solutions, Inc. 78

79 Lock-In Criteria CRITERIA 1 CRITERIA 2 CRITERIA 3 CRITERIA 4 CRITERIA 5 3 controlled substances 2 controlled substances 2 controlled substances 2 controlled substances 2 controlled substances 3 pharmacies 2 pharmacies 1 targeted pharmacy(ies) 2 pharmacies 1 targeted pharmacy(ies) 3 prescribers 2 prescribers 2 targeted prescribers 1 targeted prescriber(s) 1 targeted prescriber(s) Percentage of Maximum Daily Dosage - N/A 100% of Maximum Daily Dosage 90% of Maximum Daily Dosage 90% of Maximum Daily Dosage 95% of Maximum Daily Dosage CRITERIA 6 Suboxone usage SXC Health Solutions, Inc. 79

80 Pharmacy Lock-In Monthly Totals Month 2012 Lock-In 2011 Lock-In January 0 40 February 0 43 March April 51 May 66 June 115 July 59 August 165 September 69 October 86 November 61 December 63 TOTAL 893 SXC Health Solutions, Inc. 80

81 1Q2012 Re-Reviews Escalation to PA Unlock Members meets 3 of the 4 following criteria over a 3 month period 3 cash prescriptions (verified by CSD) 2 Physicians 2 Pharmacies Concurrently using Suboxone with another narcotic No cash prescriptions for medications covered by TennCare Utilizing only 1 pharmacy Utilizing only 1 physician Not Locked-In Lock Now: 0 Remain on PA Status: 4 Escalate to PA Status: 20 Total enrollee profiles selected for re-review: 146 OIG Referrals: 0 Remove Lock-In: 35 Remain Locked-In: 85 SXC Health Solutions, Inc. 81

82 1Q12 Lock-In Change Requests Number to be Re- Reviewed: 0 Number Changes Denied: 38 Total Lock-In Change Requests 1Q12: 82 Number Changes Approved: 44 Common Denial Reasons Wants pharmacy distance away when others are closer Doctor/Pharmacy shopping Claims recent move, but no address change and refuse to give new address SXC Health Solutions, Inc. 82

83 Lock-In Pharmacy Change Requests Locked-In recipients are allowed 1 pharmacy change per calendar year. Exceptions: Pharmacy does not have medication in stock, verified by SXC call center (after hours) or TennCare during regular business hours Pharmacy is closed, and a clinical pharmacist at SXC call center, after a conversation with the pharmacist requesting an override, and after chart review, determines the situation is an emergency. Recipient has moved (verified by address entered in SXC s system) Recipient has been voluntarily dismissed by their pharmacy Candidates requesting 1 change during the year that is not deemed an emergency or medication remaining are not allowed an override. SXC Health Solutions, Inc. 83

84 84 Next Meeting: September 11, 2012 SXC Health Solutions, Inc.