10 october 2013 1. follow-up to previous reviews nystatin/triamcinolone combo dur (re-run summer...

Idaho Medicaid Drug Utilization Review Program

10 October 2013

1

Follow-up to Previous ReviewsNystatin/Triamcinolone Combo DUR (re-

run summer months to compare to previous, as well as potent steroid combos – these fall in combo rule so no claims)

Suboxone and Participants Paying Cash for Other Opioids

Hepatitis C DURGeo‐Mapping Analysis

Utilization of Narcotic Analgesics (HIC3 = H3A) 16YO+

2

Nystatin/Triamcinolone Combo DUR

What are the utilization numbers on the various nystatin/triamcinolone combo products?

3


Cream Ointment0

20406080

100120140160180200

161

39

123

24

175

44

138

24

nystatin/triamcinolone products

Recipients 1/1/13 - 4/30/13

Recipients 5/1/13 - 8/31/13

Claims 1/1/13 - 4/30/132

Claims 5/1/13 - 8/31/13

4


betamethasone products

clotrimazole products0

200

400

600

800

1000

1200

1400

427

1119

532

1254

Claims data from 1/1/2013 through 4/30/2013

recipientsclaims

5


Questions/Comments ???

6

Buprenorphine DURSuboxone and Participants Paying Cash for

Other Opioids(includes Suboxone film, Suboxone tablets, buprenorphine/naloxone tablets, buprenorphine

tablets)

7

Buprenorphine DUR Follow-Up Identified all participants with at least one

claim paid for oral buprenorphine by Idaho Medicaid between 6/1/13 and 8/31/13. n=201

Ran Board of Pharmacy report for all of these participants to identify anyone who had received any other opioid with overlapping days of service and noted payment method (cash, Idaho Medicaid, other insurance).

8

Buprenorphine DUR Follow-Up

050

100150200250 200

26

201

27

2/1/2013 - 4/30/20136/1/2013 - 8/31/2013

9


20

7

31

Other Opioids

hydrocodoneoxycodonecodeinefentanyl patch

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

Buprenorphine DUR Follow-Up 2 patients had both Suboxone and another

opioid prescribed by the same doctor. The other 25 patients had different prescriber(s) for the other opioids.

11


1 other prescriber

2 other prescribers

3 other prescribers

8 other prescribers

0

5

10

15

20

25

20

31 1

Number of other prescribers

# o

f p

ati

en

ts

12

Buprenorphine DUR Follow-Up Case Study:

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

Buprenorphine DUR Follow-Up Called Suboxone Prescribers

Was prescriber aware of other opioids paid for with cash?

What was the consequence to the patient?

14


02468

87 7

21

# o

f p

atie

nts

15


0

2

44

21 1

Called prescriber who was unaware that patient had paid cash for other opioids

(n=8)

# of p

atien

ts

16


0

2

4

1

4

2

Called prescriber who was aware that patient had paid cash for other opioids

(n=7)

# of p

atien

ts

17


Suboxone therapy has been discontinued New Suboxone start with single opioid fill on same day as starting Suboxone or within a few

days

0

1

2

3

4

5

4

3

Did not call prescriber (n=7)

18


19

Unable to contact one prescriber (n=2) Left three voicemail messages and sent letters

on two of his patients that had paid fills for hydrocodone as well as Suboxone. Blocking payment to Suboxone one week after letters sent.


20

All prescribers were appreciative of the information Idaho Medicaid provided to them.

Future Plans The department plans on running routine

board of pharmacy reports every 3 to 6 months on all Suboxone patients.

Hepatitis C DURTotal Medicaid patients who received HepC

treatment:53 (36 Incivek, 17 Victrelis)

Letters were sent to prescribers in June 2013 and for those who did not respond sent again August 2013

Requested information returned from prescribers:46 (29 Incivek, 17 Victrelis) (13% no response

from provider) 21

Hepatitis C DUR1A-10, 1B-10, Type 1 unspecified-9

1A-10, 1B-3, Type 1 unspecified-4

1A35%

1B34%

Type 1-Unspecified31%

Incivek Genotypes

1A59%1B

18%

Type 1-Unspecified24%

Victrelis Genotypes

22

Hepatitis C DUR

23

Incivek Victrelis0

5

10

15

20

25

6

3

22

12

12

Previous Dual-Therapy Treatment Received

Yes No

Unknown# P

ati

en

ts

Hepatitis C DURAll patients from both groups who reported

back underwent triple therapy with Pegylated Interferon and Ribavirin

No patients who reported back had an HIV co-infection

Initial Viral LoadsLowest – 18,029, Highest – 69,000,000, Average –

5,777,694Info not received for 5 patients (11%)

24

Hepatitis C DUR

25

Incivek Victrelis0

5

10

15

20

25

30

27

13

1 11

3

HCV Levels After Treatment

Not Detected

High Viral Load

Unkown

# P

ati

en

ts

Hepatitis C DUR

26

Incivek Victrelis0

1

2

3

4

5

6

7

8

9

10

9

3

7

4

9

44

6

Completed Successful Therapy

Yes

No

In Progress

Unknown

# P

ati

en

ts

Hepatitis C DURYes-9, No- 6 d/t SEs & 1 d/t Non-response, In progress-9, Info not provided-4

Yes-3, No-3 d/t SEs & 1 d/t infection, In progress-4, Info not provided-6

27

31%

24%31%

14%

% Completion of Incivek Therapy

Yes No In Progress Unknown

18%

24%24%

35%

% Completion of Victrelis Therapy

Yes No In Progress Unknown

Hepatitis C DUR

28

Incivek Victrelis0

1

2

3

4

5

6

7

1

0

6

3

0

1

Reason for Failed Therapy

Non Responder (9%)

Side Effects (82%)

Co-Morbid Condition (9%)

# P

ati

en

ts

Hepatitis C DURNon-responder-1, Side effects-6,Co-Morbid Condition-0

Non-responder-0, Side effects-3,Co-Morbid Condition-1

Non Responder14%

Side Effects86%

%Failed Therapy With Incivek

Side Effects75%

Co-Morbid Condition25%

%Failed Therapy With Victrelis

29

Hepatitis C DURQuestion/comments ???

30

Geo Mapping Analysis‐Utilization of Narcotic Analgesics (HIC3 = H3A) 16 YO+

Prepared by MMA 6/13/2013 originally Age specific prepared by MMA 8/5/2013

Please refer to handout in Packet

31

Current Interventions/Outcomes StudiesUse of Psychotropic Medications in Foster

Children – Next Steps2012 Data Analysis Update

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

32

Current Interventions/Outcomes StudiesNon-Preferred Growth HormoneLevofloxacinOral ketoconazoleImitrex Pens

33

Use of Psychotropic Medications in Foster Children: Next Steps

51

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior authorization criteria instituted 01-

01-13 for immune globulin (intravenous and subcutaneous) on both the medical side (J-code medical claims) and on the pharmacy side.

52

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectTherapeutic criteria

1. FDA approved indications such as hypogammaglobulinemia (require laboratory confirmation of diagnosis plus follow-up IgG levels while on therapy) and inflammatory demyelinating polyradiculoneuropathy.

2. Other indications that have evidence to support their usage (e.g. Guillain-Barré syndrome).

3. Use ideal body weight or adjusted body weight (ideal body weight plus 50% of the difference between actual body weight and ideal body weight) in obese patients.

4. Round dosages to +/- 5% (note: literature states up to +/- 10%) to use whole vials and reasonable dosages. We discovered during 2012 DUR project that some pharmacies were using many vial sizes to give exact dose – examples would be 57.5gm using two 200ml vials, one 100ml vial, one 50ml vial, one 20ml vial, ½ of 10ml vial.

53

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims

J1459 PrivigenJ1557 GammaplexJ1559 HizentraJ1561 Gamunex-C or GammakedJ1566 Immune Globulin IntravenousJ1568 OctagamJ1569 Gammagard

54


Jan - Jun 2012 Jan - Jun 20130

102030405060708090

10088

29

Number of paid claims (medical)

55



5

10

15

20

25

20

8

Number of Unique Patients (medical)

56


Jan - Jun 2012 Jan - Jun 2013$0

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

$160,000 $148,765

$52,368

$$ (medical)

57


Annualized Cost Savings since prior authorization implementation: $192,794

67% reduction in claims60% reduction in number of unique patients65% reduction in expenditure

58


20 Patients with Medical Claims in 2012 5 of these patients continued on IVIG in 2013

All 5 patients had immunodeficiency diagnoses 15 of these patients with no paid medical claims (or

pharmacy claims) in 2013

59


6

4

2

3

Summary (medical)

Diagnosed with hypogammaglobulinemia and received 1-4 doses of IVIG in 2012 but never received prior authorization request to con-tinue therapy in 2013

No longer eligible for Idaho Medicaid or became Medicare/Medicaid dual

Billing error - meant to bill for phenergan not Privigen (IVIG)

Completed course of therapy in 2012 (congen-ital hemochromatosis, optic neuritis, heart transplant)

60

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical Claims – Prior Authorization Issue

Unbeknownst to us until July 2013, prior authorization for medical claims was only instituted for drugs administered in physician offices and not for drugs administered in outpatient settings such as an infusion clinic where the majority of patients would receive this drug.

61


Only 1 out of 8 patients who received immune globulin as a medical claim between January – June 2013 had a prior authorization request submitted.

Patient descriptions of the 7 patients without prior authorization requests who still had paid claims in 2013: CVID – 5 patients infantile spasms – 1 patient pregnant – 1 patient (don’t know indication for

IVIG)

None of these patients are currently receiving any more IVIG so their prescribers were not contacted for additional information.

62


Even though medical claims would still have paid at medical clinics without prior authorization, the number of patients and number of claims dropped substantially from 2012 to 2013 most likely due to the notification to providers that prior authorization was going to be required effective 01-01-2013.

63


Jan - Jun 2012 Jan - Jun 201370

75

80

85

90

95

100 98

82

Number of claims (pharmacy)

64


Jan - Jun 2012 Jan - Jun 201310

11

12

13

14

15

11

13

Number of Unique Patients (pharmacy)

65


Jan - Jun 2012 Jan - Jun 2013$230,000

$240,000

$250,000

$260,000

$270,000

$280,000

$290,000

$300,000 $290,814

$251,653

$$ (pharmacy)

66

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPharmacy Claims

No individual patient had claims paid as both medical and pharmacy claims.

9 of 11 patients who received IVIG in 2012 continued therapy in 2013 with prior authorization approval. One patient on IVIG in 2012 died in 2012. Another patient on IVIG in 2012 switched over to Medicare in December 2012.

67

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPharmacy Claims

17% reduction in claims18% increase in number of unique patients

(two more patients)13% reduction in expenditure

68



20406080

100120140160180200 186

111

Number of claims (medical and pharmacy claims)

69



5

10

15

20

25

30

3531

21

Number of Unique Patients (medical and pharmacy claims)

70


Jan - Jun 2012 Jan - Jun 2013$0

$50,000 $100,000 $150,000 $200,000 $250,000 $300,000 $350,000 $400,000 $450,000 $500,000

$439,579

$304,021

$$ (medical and pharmacy claims)

71

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectMedical and Pharmacy Claims Combined

40% reduction in claims32% reduction in number of unique patients31% reduction in expenditure

Annualized cost savings since prior authorization requirement instituted January 1, 2013: $271,116

72

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior Authorization Requests Received

Between January – June 2013Total of 26 requests – 25 were approved.The one denial was for IVIG weekly for a child with

encephalitis – no evidence provided to support efficacy for this indication.

14 approvals with paid claims (medical and pharmacy) 13 approvals – paid pharmacy claims 1 approval – paid medical claims

11 approvals with no paid claims

73

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior authorization approvals with no paid

claimsIdaho Medicaid no longer payor: 2Just approved June 2013 with no paid claims yet as

of 6-30-13: 2Requested prn low IgG levels (ITP, s/p liver

transplant) with no paid claims: 2Requested for hypogammaglobulinemia but no paid

claims: 3Single dose approved for ITP but never billed to

Medicaid: 1Myasthenia gravis patient - 1 74

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectPrior Authorization Example - #1

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

Immune Globulin (IV and SQ) Follow-up to 2012 DUR ProjectExample - Rounding doses in obese

patientsIdeal body weight = 60kgActual body weight = 100kgAdjusted body weight = 80kgCost savings when using adjusted body weight

for 1gm/kg/dose monthly: $29,114 per year per patient. Total cost of therapy is still $116,448 per year per patient.

76

Immune Globulin (IV and SQ) Follow-up to 2012 DUR Project Prior Authorization Example - #2

N.P. prescribing high dose IVIG (500mg/kg/daily for 4 days every 4 weeks) and wanting to shorten frequency to every 3 weeks in myasthenia gravis patient who was very symptomatic. N.P. agreed to decrease IVIG dose to usual dose of 500mg/kg monthly and increase oral medications instead. Prescriber’s rationale for wanting to increase IVIG was that patient had a Staph infection and was having difficulty walking. Patient was also on a contra-indicated drug (beta blocker) for a myasthenia gravis patient as well as on lots of sedating medications that could affect walking (methadone, oxycodone, diazepam, diphenhydramine, and carisoprodol).

77

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

78

Non-Preferred Growth Hormone

79

Preferred Growth HormonesNorditropin, Nutropin, Nutropin AQ

Non-Preferred Growth HormonesGenotropin, Humatrope, Omnitrope, Saizen,

Serostim, Tev-Tropin, Zorbtive


Growth Hormone Product05

1015202530354045 39

119

41

POS Claims 5/25/2013 through 8/25/2013

Norditropin*GenotropinNutropin*HumatropeOmnitrope

# o

f re

cip

ien

ts

80

* preferred products


12

1

11

Prescribers

Endocrinologists

P.A. at Endocrinology Clinic

Nephrologist

P.A. (located in Missoula, Mt but prior auth request came from endocrinologist in Idaho)

81


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

82


Potential Cost SavingsSubstantial cost savings will be achieved by

Idaho Medicaid when patients previously on non-preferred growth hormone products are switched over to preferred growth hormone products.

83


Reviewed profiles of 16 patients on non-preferred growth hormone products.9* – growth hormone product was

preferred when first approved; grandfathered ever since

2 - Medicaid is secondary insurance and only paying a small co-pay

84

Non-Preferred Growth HormoneReviewed profiles of 16 patients on non-

preferred growth hormone products.2* – Started on a preferred agent but then

switched to a non-preferred agent (stinging noted with one, can’t call up the old faxes on the other one for the details of why switched)

1 – database error so claim paid for a non-preferred agent even though prior authorization for the medication had been denied

85

Non-Preferred Growth HormoneReviewed profiles of 16 patients on non-

preferred growth hormone products.2 – no clear notes on why started a non-

preferred agent; drug has been grandfathered for years (one patient started therapy in 2003 and the other in 2004*). Not sending a letter to the patient who started therapy in 2003 as medication is up for renewal in October 2013 so will deal with this issue then (and anticipate that growth hormone therapy may be discontinued soon due to patient’s age).

86


Letter sent to prescribers of grandfathered non-preferred growth hormone patients.

Please refer to packet for a copy of the letter sent to the prescribers

87

Non-Preferred Growth Hormone9* – growth hormone product was

preferred when first approved; grandfathered ever sinceSwitched to preferred agent –4Renewal request received for non-preferred

agent – sent back fax to prescriber stating that growth hormone would be approved but patient needed to be switched to a preferred agent; still waiting for response back – 2

NO response yet to letter asking prescriber to switch – 3

No response back from all other letters sent

88


Questions or Comments ???

89

Levofloxacin DURBased on the recommendations from the DUR

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

90

Levofloxacin DUR

Recipients Claims0

5

10

15

20

25

30

811

22

27

Recipients 0 to 15 years old

1/1/2012 to 6/30/20121/1/2013 to 6/30/2013

91

Levofloxacin DUR

Recipients Claims0

200

400

600

800

1000

1200

1400

821

1023951

1169

Recipients 16 years of age and older

1/1/2012 to 6/30/20121/1/2013 to 6/30/2013

92

Levofloxacin DURWhile the number of claims and number of

patients has increased somewhat since the age restriction was removed, claims for children < 16 years old remain a very small percentage of total paid claims for levofloxacin.

27 paid claims for 22 unique patients aged 0-15 years between 1-01-2013 and 6-30-2013Diagnoses on following slides

93

Levofloxacin DURDiagnoses

Pneumonia – 4 patients 15 year old, only antibiotic prescribed 2 year old with trache, one previous antibiotic tried 9 year old, three previous antibiotics tried 2 year old with trache, only antibiotic prescribed

CF – 3 patients (one with 4 paid claims)Tracheitis – 3 patients with CLD with

tracheostomies (one with 3 paid claims)

94


Bronchitis – 2 patients (15 year old; 10 year old with chronic lung disease s/p Augmentin)

URI – 2 patients (13 year old s/p other antibiotic; 4 year old s/p other antibiotic)

UTI – 2 patients (11 years old, chronic kidney disease, s/p other antibiotics; 15 years old, s/p other antibiotic)

Pharyngitis – 1 patient (11 years old)Typhoid fever – 1 patient (12 years old)

95


Orchitis – 1 patient (15 years old)Open wound/fracture – 1 patient (15 years old)Sinusitis – 1 patient (12 years old, s/p 3 other

antibiotics tried)Otitis media – 1 patient (1 year old, s/p 3 other

antibiotics tried)

96

Levofloxacin DURQuestions or comments???

97

Oral Ketoconazole DUROn July 26, 2013 the U.S. Food and Drug

Administration (FDA) released a safety announcement regarding the safe use of oral ketoconazole tablets due to potentially fatal liver injuries, adrenal problems, or drug interactions.

A copy of the Drug Safety Communication handout is available in your packet.

98http://www.fda.gov/downloads/Drugs/DrugSafety/UCM362444.pdf

Oral Ketoconazole DURA report of the paid pharmacy claims for

Idaho Medicaid was run for the time period of 4/26/2013 to 7/26/2013 for oral ketoconazole tablets.

Results31 patients33 claims (one patient had 3 paid claims)

99

Oral Ketoconazole DUROnly 3 patients currently on oral

ketoconazole as of 7/26/13

1. 9 year old male who has been on ketoconazole continuously since January 2011. Diagnosis in electronic profile is unspecified immunity deficiency. His prescriber was sent a letter asking for diagnosis and therapeutic justification for the medication. A copy of the FDA Safety Announcement was included with the letter. Continued on next slide 100

Oral Ketoconazole DUR1. 9 year old male: Did not receive a response to

DUR letter. However, received a prior authorization request on 8-16-13 which was approved in error by a pharmacy technician as a renewal as patient had been on the medication. This error was caught in September 2013 when reviewing patient profiles for this DUR project. Prior authorization for this medication has now been denied with new information faxed back to prescriber and dispensing pharmacy (claim did pay for this medication in September 2013).

101

Oral Ketoconazole DUR1. 9 Year old male:

The information that was on the 8-16-13 prior authorization request stated the diagnosis as GI candidiasis for a patient with “low NK cell and abnormal hyper-sensitivity.”

There has been no response to the September prior authorization denial.

102

Oral Ketoconazole DUR2. 2 year old patient who had a paid claim for 28

days of oral ketoconazole on 7/2/2013 who also had a paid claim for topical ketoconazole on the same day. Not sending a letter as assuming for a topical infection and therapy should be completed soon. No more claims run for oral ketoconazole.

3. 12 year old with a paid claim for 30 days of oral ketoconazole on 7/16/2013. No diagnoses in electronic profile corresponding to oral ketoconazole. Not sending a letter. Will wait and see if prescription is refilled. No more claims run for oral ketoconazole. 103

Oral Ketoconazole DURThe other 28 patients had a single claim paid

for oral ketoconazole with days of service ranging from 2 to 30.1-7 days: 13 patients8-14 days: 7 patients≥15 days: 8 patients

104

Oral Ketoconazole DURInstituted prior authorization requirement on

8/2/2013. Prior to this date, claims would just pay at the pharmacy.

Will track how many prior authorization requests received and how many approved vs. denied

105

Oral Ketoconazole DUR

106

Series10

1

2

3

4

1

3

PA Requests since 8/2/2013

PA ApprovedPA Denied

Oral Ketoconazole DURDenied Prior Authorization Requests

1. Tinea corporis with failure of prednisone and cephalexin

2. Onychomycosis with failure of nystatin cream

107

Oral Ketoconazole DUR

patients claims0

1

2

3

4

5

6

7

8

98 8

2 2

Pharmacy POS paid claims

9/1/2012 - 9/29/20129/1/2013 - 9/29/2013*

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

Oral Ketoconazole DURQuestions or Comments ???

109

Imitrex Pens DUR

110

Imitrex Pens DUR

111

Paid Claims for injectable Imitrex (sumatriptan) between 2/1/2013 – 7/31/201356 unique patients165 total claims$82,597 paid at POS

Imitrex Pens DUR

112

cartridges only pen x 1 then cartridges

single fill of pen

multiple pens filled

0

5

10

15

20

25

20

8

12

16

Claims from 2/1/13 – 7/31/13

Imitrex Pens DUR

113

2 pe

ns

3 pe

ns

4 pe

ns

5 pe

ns

6 pe

ns

8 pe

ns

9 pe

ns

2 pe

ns +

1 car

trid

ge

3 pe

ns +

1 car

trid

ge0

1

2

3

4

5

16 patients with multiple pens filled

# o

f p

ati

en

ts

Imitrex Pens DUR

114

Wal

gree

ns

Sav-

on

Ridle

y's

Fred

Mey

er

Broul

im

Ont

ario

Rx-00

1

Unk

nown

0

2

4

6

8

Pharmacies filling multiple pens 2/1/13 – 7/31/13

Imitrex Pens DUR

115

Letters were sent out to pharmacies filling pens more than once in six months.

A copy of the letter is included in the packet

Questions or comments ???

Proposed Studies for Next Quarter:P&T Committee Narcotic Analgesic

Studies – Next StepsUse of Psychotropic Medications in Foster

Children – Next StepsTamiflu/Influenza Vaccine DURUloric and Colcrys DURAntipsychotic Indication Evaluation- Hold

for Future

116

P&T Committee Narcotic Analgesic Studies – Next Steps

117

Use of Psychotropic Medications in Foster Children The U.S. Government Accountability Office

released the results from a study that they performed examining the rates of psychotropic medications for foster and nonfoster children in 2008.

It was determined that HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions.

118

Foster Children Psychotropic Drugs Red Flags

7/18/2013

119

Red FlagsFive (5) or more psychotropic medications prescribed

concomitantly (reviewed August 2012)Two (2) or more concomitant antidepressants

(reviewed October 2013)Two (2) or more concomitant antipsychotic

medications (current)Two(2) or more concomitant stimulant medications

long-acting plus short-acting okThree (3) or more concomitant mood stabilizer

medicationsPsychotropic polypharmacy (2 or more agents) for a

given mental disorder prescribed before utilizing psychotropic monotherapy 120

121

Implementation of Red Flags

Retroacti

ve Evaluatio

n

Identify outliers

Profile

Review

DUR Board Intervention• Targ

eted education

Re-evaluation• indi

viduals

• overall

Further

Action

Point of service edits• Inform

ational (soft) – pharmacist override

• Hard Stop

ADHD Drugs Anti-depressants Mood Stabilizers Atypical Antipsychotics0%

5%

10%

15%

20%

25%

30%

35%

40%

36%

23%

13%

21%

9%

6%

0%

4%

Percent of Foster and Non-Foster Children Psychotropics by Drug Class

Calendar Year 2011

% Foster Children% Non-foster Children

Total foster =2785Total Non-Foster = 106,024

122

Use of Psychotropic Medications in Foster Children: Next Steps

124

Tamiflu/Influenza Vaccine DUR

125

Uloric and Colcrys DUR

126

Antipsychotic Indication Evaluation- Hold for Future

127

Prospective DUR ReportHistory Errors:

• DD – drug-to-drug• PG – drug to pregnancy• TD – therapeutic

duplication• ER – early refill• MC – drug-to-disease

Non-History Errors:• PA – drug-to-age• HD – high dose• LD – low dose• SX – drug-to-gender

128

Prospective DUR ReportIdaho Medicaid ProgramProDUR Message Report

August-13

ProDUR ProDUR Message MessageMessage Severity Count Amount

Drug To Drug 1 1,618 $515,012.15 2 14,344 $2,509,235.49 3 72,191 $14,625,291.32Drug To Gender 1 177 $33,523.42 2 2,530 $318,273.49Drug To Known Disease 1 72,327 $11,171,612.78 2 255,198 $50,785,564.33 3 313,531 $59,952,053.52Drug To Pregnancy 1 29 $260.80 2 6 $445.83 A 3 $34.95 B 69 $5939.85 C 124 $9849.41 D 6 $37.46 X 2 $43.89Duplicate Therapy 0 115,769 $26,336,886.92Min Max 0 30,794 $4,989,431.70Too Soon Clinical 0 21,579 $7,832,898.27

ALL 900,297 $179,086,395.58 Total Number of Claims with Messages 216,998 Average ProDUR Message Per Claim 4.15

129

DUR Fall NewsletterCopy of Summer Newsletter in packetBrainstorm for new topics

130

Medicaid Update

131

10 october 2013 1. follow-up to previous reviews nystatin/triamcinolone combo dur (re-run summer...

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