alabama medicaid · 2019. 3. 8. · clemice hurst, rph alexander jenkins, pharmd clinical...

Alabama MedicaidOpioid Prescribing/Pharmacy Trends

KELLI LITTLEJOHN NEWMAN, PHARM. D.

DIRECTOR, CLINICAL SERVICES AND SUPPORT

Objectives

Medicaid Opioid Trends

Opioid Naïve Edit

Upcoming Cumulative MME Edit

Prescription Opioid Use

3

What are Opioids?Opioids are substances that act on opioid receptors to produce morphine-like effects. They are used to treat acute and chronic pain.

Examples of generic opioids: morphine, hydrocodone, oxycodone and fentanylExamples of brand opioids: Norco, Percocet, OxyContin, Vicodin, Dilaudid, Lortab and DuragesicStreet example: heroin

Prescription Opioid Use Overview

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• Alabama has led the nation for the past 6 years in the opioid prescribing rate per 100 population (121 in 2016, 107.2 in 2017) and had nearly 3 times more opioid prescriptions per 100 population than New York (CDC.gov).

• In 2016, 37% of AMA members aged 19 to 64 had an AMA opioid claim.

• In 2016, AMA members with opioid claims aged 19 to 64 had an average of 4.0 opioid claims.

• The average days’ supplied for AMA members with opioid claims in 2016 was 7.6 for children (0-12), 7.8 for teenagers (13-18) and 73.2 for adults (19-64).

MEDICAID OPIOID PRESCRIBING TRENDS: CY 2011- CY 2017

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MEDICAID OPIOID PRESCRIBING TRENDS: FY 2011- FY 2017

Avg Daily MMEs

Unique Annual RecipientsAvg Monthly RecipientsAvg Monthly Quantity Dispensed

6

-30%

-20%

-10%

0%

10%

20%

30%

FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017

Perc

ent C

hang

e fr

om F

Y 20

11

Alabama Medicaid AgencyChange in Full Agonist Opioid Prescribing

FY 2011 to FY 2017

5,000

10,000

15,000

20,000

25,000

30,000

2011 2012 2013 2014 2015 2016 2017

Num

ber o

f Mem

bers

Medicaid Members Ages 13-18 Prescribed an OpioidBy Prescribing Provider Specialty

CY 2011 - 2017

Dentists and Oral Surgeons All Others

7

Trends in Prescribing Sources

Change from 2011-2017: Emergency Room -57%Family Medicine -50%OB/GYN -36%Pediatrician -52%Internal Medicine -49%General Practitioner -62%

+8%

-44%

• Based on address of fully-eligible recipients • Recipients with greater than 11 months of eligibility

CY 2017CY 2016Percentage of Adult Medicaid Members Prescribed an Opioid*

CY 2017CY 2016

• Based on address of fully-eligible recipients • Recipients with greater than 11 months of eligibility

Percentage of Medicaid Members Aged 13-18 Prescribed an Opioid*

10

Opioid Pharmacy Claims 2017 versus 2018

Source: Pharmacy Cube Opioids = AHFS 28080811/1 - 11/30; 12/1-12/31

17.4% decrease

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Opioid Pharmacy Claims 2017 versus 2018

Source: Pharmacy Cube Opioids = AHFS 28080811/1 - 11/30; 12/1-12/31

18.6% decrease

12

US State Opioid Prescribing Rates per 100https://www.cdc.gov/drugoverdose/maps/rxstate2017.html

CDC.gov: US State Opioid Prescribing Rates per 100

Rank State 2016 2017 % Decrease

1 Alabama 121 107.2 11.4%

2 Arkansas 114.6 105.4 8.0%

3 Tennessee 107.5 94.4 12.2%

4 Mississippi 105.6 92.9 12.0%

5 Louisiana 98.1 89.5 8.8%

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US State Opioid Prescribing Rates per 100https://www.cdc.gov/drugoverdose/maps/rxstate2017.html

2016

2017

14

Members Excluded: 1) Not eligible the entire year, 2) PlanFirst (family planning only) at any time during the year, 3) Ever had cancer diagnosis, 4) Ever had sickle cell anemia diagnosis, 5) Mothers giving birth during the year, 6) dually eligible for Medicare/Medicaid at any time during the year and 7) age 65 and older. Total cohort after exclusions of 232,166 members.

$0

$5,000

$10,000

$15,000

$20,000

$25,000

13-18.08%106

19-445.0%3,168

45-645.3%2,267

Overall2.4%5,441

Avg

Annu

al C

laim

s Cos

t Per

Mem

ber

Age Group

Alabama Medicaid AgencyEffect of Opioid Dependency on Avg Annual Claims Cost Per

MemberFY 2016

Diagnosis Not Present Diagnosis Present

% Members Diagnosed

+416%

+111%

+71%

+195%

Number of Members

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Probability of Continued Opioid Usage Among Naïve PatientsBased on Number of Days Supply in Initial Opioid Prescription

Source: Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use —United States, 2006–2015Centers for Disease Control and Prevention

At 5 Days

~10%

~ 5%

“Legitimate opioid use before high school graduation is independently associated with a 33% increase in the risk of future opioid misuse after high school. This association is concentrated among individuals who have little to no history of drug use and…strong disapproval of illegal drug use at baseline.”

- Monitoring the Future Study National Survey Results on Drug Use, January 2017

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Morphine Milligram Equivalents (MMEs)

MMEs: Daily morphine milligram equivalents, also called morphine equivalent daily dose (MEDD), are used to assess comparative potency of opioids, but not to convert a particular opioid dosage from one product to another.

The calculation to determine MMEs includes drug strength, quantity, days supply and a defined conversion factor unique to each drug.

- Medicaid is currently using FDB calculation for MMEs [CDC,2014].

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Morphine Milligram Equivalents (MMEs)

AMA covers methadone for pain. Medication Assisted Treatment [MAT] is covered by the Alabama Department of Mental Health.

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Alabama BME Requirements: Risk and Abuse Mitigation Strategies (eff 3/9/17)

ALABAMA STATE BOARD OF MEDICAL EXAMINERS RULES & REGULATIONS540-X-4-.09 Risk and Abuse Mitigation Strategies by Prescribing Physicians

(1) The Board recognizes that the best available research demonstrates that the risk of adverse events occurring in patients who use controlled substances to treat pain increases as dosage increases.

The Board adopts the "Morphine Milligram Equivalency" ("MME") daily standard as set out by the Centers for Disease Control and Prevention ("CDC") for calculating the morphine equivalence of opioid dosages.

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Alabama BME Requirements: Risk and Abuse Mitigation Strategies

(effective 3/9/17)(2) It is the opinion of the Board that the best practice when prescribing controlled substances for the treatment of pain shall include medically appropriate risk and abuse mitigation strategies, which will vary from patient to patient. Examples of risk and abuse mitigation strategies include, but are not limited to:

(a) Pill counts;(b) Urine drug screening;(c) PDMP checks;(d) Consideration of abuse-deterrent medications;(e) Monitoring the patient for aberrant behavior;(f) Providing a patient with opiate risk education prior to prescribing controlled substances; and(g) Using validated risk-assessment tools, examples of which shall be maintained by the Board.

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(3) For the purpose of preventing controlled substance diversion, abuse, misuse, addiction, and doctor-shopping, the Board sets forth the following requirements for the use of Alabama's Prescription Drug Monitoring Program (PDMP):

(a) For controlled substance prescriptions totaling 30 MME or less per day, physicians are expected to use the PDMP in a manner consistent with good clinical practice.

b) When prescribing a patient controlled substances of more than 30 MME per day, physicians shall review that patient's prescribing history through the PDMP at least two (2) times per year, and each physician is responsible for documenting the use of risk and abuse mitigation strategies in the patient’s medical record.

(c) Physicians shall query the PDMP to review a patient's prescribing history every time a prescription for more than 90 MME per day is written, on the same day the prescription is written.

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(effective 3/9/17)

(4) Exemptions: The Board's PDMP requirements do not apply to physicians writing controlled substance prescriptions for:

(a) Nursing home patients;(b) Hospice patients, where the prescription indicates hospice on the physical prescription;(c) When treating a patient for active, malignant pain; or(d) Intra-operative patient care.

(5) Due to the heightened risk of adverse events associated with the concurrent use of opioids and benzodiazepines, physicians should reconsider a patient's existing benzodiazepine prescriptions or decline to add one when prescribing an opioid and consider alternative forms of treatment.

Short Acting Opiate Limitsfor Treatment Naïve Patients

Days’ supply edit implemented 11/1/18 for short-acting opiates:• Treatment-naïve patients (no opioid claims hx in past 6m/180d)• Maximum 7ds for adults/5ds for children (ages 18y and younger)• Maximum 50 MME/day (one prescription)• Oncologists excluded• LTC and Hospice recipients excluded; children included • “Refills” within 30 days will not count toward 5rx limit for adults • Overrides available for medical necessity

Opioid Claims Days’ Supply 1-7 Nov/Dec 2018

Souce: Pharmacy Cube Opioids = AHFS 28080811/1 - 11/30; 12/1-12/31

Opioid Claims Days’ Supply 8-34Nov/Dec 2018

Opioid Naïve Overrides

Opioid Naïve Overrides

Nov-18 Percentage Dec-18 Percentage Approved 59 37% 73 25%Denied 102 63% 216 75%Total Requests 161 100% 289 100%Source: HID

ONO_11_2018

Opioid Naïve Overrides 11/2018

Recip IDDrug NamePA StatusDate

530000961422ACETAMIN-CAFF-DIHYDROCOD 320.5Approved11/14/18

500002730781HYDROCODONE-ACETAMIN 10-325 MGApproved11/16/18



530001335606HYDROCODONE-ACETAMIN 10-325 MGApproved11/27/18Opioid Naïve Overrides


500000118332HYDROCODONE-ACETAMIN 5-325 MGApproved11/27/18Nov-18Percentage Dec-18Percentage

500001469138HYDROCODONE-ACETAMIN 5-325 MGApproved11/6/18Approved 5937%7325%

500001897826HYDROCODONE-ACETAMIN 5-325 MGApproved11/20/18Denied 10263%21675%

500002783684HYDROCODONE-ACETAMIN 5-325 MGApproved11/27/18Total Requests 161100%289100%

500002919086HYDROCODONE-ACETAMIN 5-325 MGApproved11/15/18Source: HID





530000291285HYDROCODONE-ACETAMIN 7.5-325Approved11/28/18


500001407832HYDROCODONE-ACETAMN 7.5-325/15Approved11/20/18





















530000889575HYDROCODONE-IBUPROFEN 7.5-200Approved11/16/18

500000480764OXYCODON-ACETAMINOPHEN 7.5-325Approved11/8/18


530000153050OXYCODONE HCL 5 MG/5 ML SOLNApproved11/9/18





530000111553OXYCODONE-ACETAMINOPHEN 10-325Approved11/19/18






500000215174TRAMADOL HCL 50 MG TABLETApproved11/14/18






500001300474TRAMADOL-ACETAMINOPHN 37.5-325Approved11/20/18

530001402688ACETAMINOPHEN-COD #3 TABLETDenied11/30/18

500000162331HYDROCODONE-ACETAMIN 10-325 MGDenied11/20/18
































500001056617HYDROCODONE-ACETAMIN 7.5-325Denied11/27/18















500001585912HYDROCODONE-ACETAMN 7.5-325/15Denied11/27/18














530000519581MEPERIDINE 50 MG/5 ML SOLUTIONDenied11/6/18

500002921295OXYCODON-ACETAMINOPHEN 7.5-325Denied11/20/18

500000567198OXYCODONE HCL 15 MG TABLETDenied11/14/18




500002738702OXYCODONE HCL 5 MG/5 ML SOLNDenied11/27/18





500000228241OXYCODONE-ACETAMINOPHEN 10-325Denied11/28/18


















500000123188TRAMADOL HCL 50 MG TABLETDenied11/30/18











500001300474TRAMADOL-ACETAMINOPHN 37.5-325Denied11/20/18

ONO_12_2018

Opioid Naïve Overrides (12/2018)

Recip IDDrug NamePA StatusDate

500002102040ACETAMINOPHEN-COD #3 TABLETApproved12/21/18

530001068567ACETAMINOPHEN-COD #3 TABLETApproved12/12/18








































530001299001MEPERIDINE 50 MG/5 ML SOLUTIONApproved12/19/18





500002890494OXYCODONE HCL 5 MG TABLETApproved12/10/18



























530001357388ACETAMINOP-CODEINE 120-12 MG/5Denied12/26/18





























































































































































































530000268122TRAMADOL ER 100 MG TABLETDenied12/11/18



























500002522086TYLENOL WITH CODEINE #4 TABLETDenied12/18/18

Max Units 2017 vs 2018

Max Unit Overrides:Hydrocodone/APAP 10-325

Nov-17 Percentage Nov-18 Percentage Approved 375 93% 368 77%Denied 30 7% 108 23%Total Requests 405 100% 476 100%

Dec-17 Percentage Dec-18 Percentage Approved 386 92% 334 83%Denied 33 8% 67 17%Total Requests 419 100% 401 100%Source: HID

MAX_11_2017

Maximum Unit Overrides - Short Acting Opioids 11/2017

Drug NameApprovalsDenialsTotal

ACETAMINOPHEN-COD #3 TABLET404


BUTALB-ACETAMIN-CAFF 50-300-40101


BUTALB-ACETAMINOPH-CAFF-CODEIN101

BUTALB-CAFF-ACETAMINOPH-CODEIN112 Max Unit Overrides:

BUTALBITAL-ASA-CAFFEINE CAP202Hydrocodone/APAP 10-325

HYDROCODON-ACETAMIN 7.5-325/15718Nov-17Percentage Nov-18Percentage

HYDROCODON-ACETAMINOPH 7.5-32542446Approved 37593%36877%

HYDROCODON-ACETAMINOPHEN 5-32513316Denied 307%10823%

HYDROCODON-ACETAMINOPHN 10-3251197126Total Requests 405100%476100%

HYDROCODONE-ACETAMIN 10-300 MG101


HYDROCODONE-ACETAMIN 5-325 MG31031Dec-17Percentage Dec-18Percentage

HYDROCODONE-ACETAMIN 7.5-3251016107Approved 38692%33483%

HYDROCODONE-ACETAMN 7.5-325/1527330Denied 338%6717%

HYDROCODONE-IBUPROFEN 10-200101Total Requests 419100%401100%

HYDROCODONE-IBUPROFEN 7.5-200314Source: HID

HYDROMORPHONE 2 MG TABLET235



OXYCODON-ACETAMINOPHEN 7.5-32542648

OXYCODONE HCL 10 MG TABLET24226





OXYCODONE-ACETAMINOPHEN 10-32512415139


PENTAZOCINE-NALOXONE TABLET101

TRAMADOL HCL 50 MG TABLET16420

TRAMADOL-ACETAMINOPHN 37.5-325202

MAX_11_2018

Maximum Unit Overrides - Short Acting Opioids (11/2018)


ACETAMINOP-CODEINE 120-12 MG/5011



BUTALB-ASPIRIN-CAFFE 50-325-40022

HYDROCODON-ACETAMINOPH 7.5-325303

HYDROCODON-ACETAMINOPHN 10-325303




HYDROCODONE-ACETAMIN 7.5-32513037167

HYDROCODONE-ACETAMN 7.5-325/1551015

HYDROCODONE-IBUPROFEN 7.5-200224



MORPHINE SULF 20 MG/5 ML SOLN011

MORPHINE SULFATE IR 15 MG TAB202









OXYCODONE HCL 5 MG/5 ML SOLN145



OXYMORPHONE HCL 10 MG TABLET101




MAX_12_2017



ACETAMIN-CAFF-DIHYDROCOD 320.5112





FENTANYL 100 MCG/HR PATCH011

HYDROCODON-ACETAMINOPH 7.5-325202






HYDROCODONE-ACETAMN 7.5-325/1534236


















MAX_12_2018



ACETAMIN-CAFF-DIHYDROCOD 320.5314









HYDROCODONE-IBUPROFEN 10-200101


MORPHINE SULF 20 MG/5 ML SOLN101











OXYMORPHONE HCL 10 MG TABLET202




MME Cumulative Edit •Calculate the daily MME for a patient and deny claims that exceed a certain threshold

•Phased in with higher MME, gradually decrease• 250MME, phase down by 50MME Q4months

•Oncologists excluded•LTC and Hospice excluded, children included •Overrides available for medical necessity •Extensive training Estimated implementation: Phase in informational Spring 2019, hard edit beginning Summer 2019

Other Pharmacy Updates

Ingredient Duplication Edit (July 2, 2018)•New edit reviews claims history for possible ingredient duplication•Concurrent use of same active ingredient by DIFFERENT prescribers•Different strengths by SAME prescriber will not hit edit•Edit requires manual override/Form 409•Drugs implemented:

• Pregabalin (ex Lyrica)• Gabapentin (ex Neurontin)

Contact Info

Health Information Designs (PAs)

(800) 748-0130

Myers & Stauffer (AAC)

(800) 591-1183

DXC (formally HPE/EDS) Claims Processing

(800) 456-1242

RECIPIENT HOTLINE FRAUD Hotline

(800) 362-1504 (866) 452-4930

Pharmacy Services (334) 242-5050

Kelli Littlejohn Newman, Pharm DDirector, Clinical Services and Support

(334) [email protected]

Clemice Hurst, RPh Alexander Jenkins, PharmDClinical Pharmacist Audit Pharmacist

(334) 353-4593 (334) [email protected] [email protected]

www.medicaid.alabama.gov

mailto:[email protected]:[email protected]:[email protected]://www.medicaid.alabama.gov/

Alabama Medicaid�Opioid Prescribing/Pharmacy Trends ObjectivesPrescription Opioid Use Prescription Opioid Use �OverviewSlide Number 5Slide Number 6Trends in Prescribing SourcesPercentage of Adult Medicaid Members Prescribed an Opioid*Percentage of Medicaid Members Aged 13-18 Prescribed an Opioid*Slide Number 10Slide Number 11Slide Number 12Slide Number 13Slide Number 14Probability of Continued Opioid Usage Among Naïve Patients�Based on Number of Days Supply in Initial Opioid Prescription��Short Acting Opiate Limits�for Treatment Naïve PatientsOpioid Claims Days’ Supply 1-7 Nov/Dec 2018Opioid Claims Days’ Supply 8-34�Nov/Dec 2018Slide Number 25Slide Number 26MME Cumulative Edit Other Pharmacy UpdatesContact Info�Slide Number 30

alabama medicaid · 2019. 3. 8. · clemice hurst, rph alexander jenkins, pharmd clinical...

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