pharmaceutical assistance contract for the elderly … · 5th floor harrisburg, pa 17101-1919...

PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY

ANNUAL REPORT TO THE PENNSYLVANIA GENERAL ASSEMBLY

JANUARY 1 - DECEMBER 31, 2013

For the Pennsylvania Department of Aging Director Thomas M. Snedden Outreach and Enrollment Manager Rose M. Paulus Administrative Officer Kyle Kessler Administrative Officer Janis L. Rhodes Operations Manager Rebecca D. Lorah, MPA Administrative Assistant Carol Bebawi Administrative Assistant Megan McDaniel Research and Evaluation Chief Theresa V. Brown, MPA Program Analyst Ellaheh Otarod Program Analyst Antonino G. Vetrano, MPA

Pennsylvania Department of Aging

The PACE Program Forum Place Building

555 Walnut Street 5th Floor

Harrisburg, PA 17101-1919 717-787-7313 [email protected]

For Magellan Medicaid Administration, Inc. Officer in Charge Donald C. Moore Director, PACE Operations Bradley I. Kohler Assistant Director, PACE Operations Jean B. Sanders Cardholder Services Manager Janet N. Casterella Health Outcomes Scientist Jian Ding, PhD Clinical Pharmacist Judith Dooley, RPh Provider Services Manager Richard J. Flage Clinical Pharmacist Margaret R. Glessner, PharmD Senior Health Outcomes Scientist Debra A. Heller, PhD, MPH Medicare Part D Manager Lisa M. Irwin Clinical Pharmacist Colleen M. Moyer, RPh Business Services Manager Donald G. Smith LAN/WAN Manager W. Todd Spacht Quality Assurance Manager Lisa Spiegel Systems Manager John K. Wheeler

Magellan Medicaid Administration 4000 Crums Mill Road, Suite 301

Harrisburg, PA 17112 717-651-3600

Any questions or comments pertaining to information within this report may be addressed to the Pennsylvania Department of Aging at the address given above.

Revised January 2015

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TABLE OF CONTENTS

Frequently Requested Program Statistics ......................................................................................... 1

History ............................................................................................................................................... 3

Administration ................................................................................................................................... 5

Section 1 – Program Research Highlights .............................................................................. 7-14

Section 2 – Financial Data by Date of Service ...................................................................... 15-30

Table 2.1A Historical Claim and Expenditure Data for PACE Enrolled ........................... 17-18 and Participating Cardholders by Semi-Annual Period Based On Date of Service January 1991 - December 2013 Table 2.1B Historical Claim and Expenditure Data for PACENET Enrolled .................... 19-20 and Participating Cardholders by Semi-Annual Period Based On Date of Service July 1996 - December 2013 Figure 2.1 PACE and PACENET Claim Distribution by Amount Paid per Claim ................ 21 January - December 2013 Figure 2.2 Distribution of PACE Annual Benefit .................................................................. 22 January - December 2013 Figure 2.3 Distribution of PACENET Annual Benefit .......................................................... 23 January - December 2013 Table 2.2 Total Prescription Cost, Expenditures, Offsets and Recoveries ........................ 24 January - December 2013 Figure 2.4 PACE and PACENET Enrollment, Claims, and ................................................. 25 Claims Expenditures by Calendar Year 1988-2013 Figure 2.5A PACE Total Enrolled and Participating Cardholders ......................................... 26 By Month January 2003 – January 2014 Figure 2.5B PACENET Total Enrolled and Participating Cardholders .................................. 27 By Month January 2003 – January 2014 Figure 2.6A PACE Average Wholesale Price (AWP) and .................................................... 28 Average Manufacturer’s Price (AMP), Brand Products Only, by Quarter January 2000 – December 2013

Figure 2.6B PACE Average Wholesale Price (AWP) and .................................................... 29 Average Manufacturer’s Price (AMP), Generic Products Only, by Quarter

January 2000 – December 2013

Section 3 – Program Data by Date of Payment ..................................................................... 31-44

Table 3.1 PACE and PACENET Claims and Expenditures Paid by Fiscal Year .......... 33-35 July 1984 - December 2013 Table 3.2A PACE High Expenditure and High Volume Claims ....................................... 36-38 January - December 2013 Table 3.2B PACENET High Expenditure and High Volume Claims ................................ 39-41 January - December 2013 Table 3.3 PACE and PACENET Number and Percent of ............................................ 42-43 Expenditures and Claims by Manufacturer January - December 2013 Table 3.4 Manufacturers' Rebate Cash Receipts by Quarter/Year .................................... 44 Billed and by Fiscal Year Received January 1991 - December 2013

Section 4 – Cardholder Utilization Data ................................................................................. 45-60

Table 4.1 PACE and PACENET Cardholder Enrollments by Quarter .......................... 47-49 July 1984 – December 2013 Table 4.2A PACE Cardholder Enrollment, Participation, Utilization, ............................... 50-51 and Expenditures by Demographic Characteristics January - December 2013 Table 4.2B PACENET Cardholder Enrollment, Participation, Utilization, ....................... 52-53 and Expenditures by Demographic Characteristics January - December 2013 Figure 4.1A Percent of Enrolled PACE Cardholders by Income and Marital Status ............. 54 January - December 2013 Figure 4.1B Percent of Enrolled PACENET Cardholders by Income and Marital Status ...... 55 January - December 2013 Table 4.3 Other Prescription Insurance Coverage of PACE and ....................................... 56 PACENET Enrolled Cardholders January - December 2013 Table 4.4 Part D Cardholder Enrollment, Participation, and Expenditures ................... 57-58 January - December 2013 Table 4.5 Annual Drug Expenditures for PACE/PACENET Enrolled ................................. 59 By Total Drug Spend, Part D Status, and LIS Status January - December 2013 Figure 4.2 PACE Generic Utilization Rates by Quarter ...................................................... 60 December 1988 - December 2013

Section 5 – County Data .......................................................................................................... 61-68

Table 5.1 Number and Percent of PACE and PACENET Cardholders ........................ 63-65 and Number of Providers by County January - December 2013 Figure 5.1 PACE and PACENET Cardholder, Claim, and Provider .................................... 66 Information by County Type (Percent of County Population Living in Urban Area) January - December 2013 Figure 5.2 Percent of Elderly Enrolled in PACE/PACENET and ......................................... 67 Percent Urban Population by County January - December 2013

Section 6 - Provider Data ......................................................................................................... 69-78

Table 6.1 PACE Claims by Product and Provider Type .................................................... 71 January - December 2013 Table 6.2 PACE Expenditures and Average State Share by Product and ........................ 72 Provider Type January - December 2013 Table 6.3 PACENET Claims and Expenditures by Provider Type ..................................... 73 January - December 2013 Table 6.4 PACENET Claims Volume by Phase of Coverage, ........................................... 74 Product Type, and Provider Type January - December 2013 Table 6.5 PACENET Expenditures by Phase of Coverage, ......................................... 75-76 Product Type, and Provider Type January - December 2013 Table 6.6 Average Cardholder and State Share Cost per PACENET ............................... 77 Claim by Phase of Coverage, Product Type, and Provider Type January - December 2013

Section 7 - Therapeutic Class Data and Drug Utilization Review Data ............................... 79-88

Table 7.1A Number and Percent of PACE Claims, State Share Expenditures, .............. 81-82 and Cardholders with Claims by Therapeutic Class January – December 2013 Table 7.1B Number and Percent of PACENET Claims, State Share .............................. 83-84 Expenditures, and Cardholders with Claims by Therapeutic Class January – December 2013 Figure 7.1 Percent of PACE State Share Expenditures by Therapeutic Class ................... 85 January - December 2013 Figure 7.2 Number and Percent of PACE and PACENET Claims ................................. 86-87 with a Prospective Review Message by Therapeutic Class January - December 2013

Section 8 - Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) .............. 89-92 Appendix A - The PACE/PACENET Medical Exception Process.................................................... 93

Appendix B - American Hospital Formulary Service (AHFS) Classifications .................................. 94

Appendix C - PACE Prospective Drug Utilization Review Criteria ........................................... 95-114

FREQUENTLY REQUESTED PROGRAM STATISTICS

The table below provides frequently requested Program information and lists references within the Annual Report for additional details.

2013 PACE AND PACENET SUMMARY PACE PACENET REFER TO: DEMOGRAPHIC DATA Total enrolled for 2013 119,491 195,788 Tables 4.2, A and B % Participating 78.9% 78.9% Tables 4.2, A and B Avg. age for enrolled 79.8 yrs. 78.5 yrs. Tables 4.2, A and B Female, avg. age 80.5 yrs. 78.9 yrs. Male, avg. age 77.2 yrs. 77.6 yrs. % Female 78.7% 67.0% Tables 4.2, A and B % Own residence 54.8% 68.6% Tables 4.2, A and B % Rent 27.8% 20.4% Tables 4.2, A and B % Married 7.9% 35.3% Tables 4.2, A and B Avg. Income $12,187 $21,296 Tables 4.2, A and B % Cardholders in urban counties 41.3% 36.8% Table 5.1 % Cardholders in rural counties 13.6% 14.2% Table 5.1 BENEFIT DATA Avg. total expenditures per enrolled cardholder $1,990 $2,131 Table 4.4 Avg. total expenditures per participant $2,522 $2,700 Table 4.4 Avg. total expenditures per claim $64.76 $72.24 Table 4.4 Avg. state share per enrolled cardholder $604 $593 Table 4.4 Avg. state share per participant $765 $752 Table 4.4 Avg. state share per claim $19.65 $20.11 Table 4.4 Avg. cardholder share per enrolled cardholder $151 $288 Table 4.4 Avg. cardholder share per participant $191 $365 Table 4.4 Avg. cardholder share per claim $4.91 $9.77 Table 4.4 Avg. TPL share per enrolled cardholder $1,235 $1,250 Table 4.4 Avg. TPL share per participant $1,565 $1,583 Table 4.4 Avg. TPL share per claim $40.20 $42.36 Table 4.4

2013 percent change in state share per claim 0.4% decrease

5.3% increase

Figure 2.1, 2012 and 2013

Avg. claims per participant 38.9 37.4 Tables 4.2, A and B Avg. number of therapeutic classes per participant 5.2 5.2 Tables 7.1, A and BUTILIZATION DATA (by date of payment) Total claims 3,678,853 5,774,601 Tables 6.1 and 6.4 Avg. claims per cardholder 30.8 29.5 Tables 6.1 and 6.4 Avg. deductible claims per cardholder - 6.0 Table 6.4 Avg. copaid claims per cardholder - 23.5 Table 6.4 Generic utilization rate 80.2% 79.7% Tables 6.1 and 6.4 PAYMENT DATA Total Program payout $67.81 M $112.89 M Table 3.1 Avg. weekly Program payout $1.30 M $2.17 M Table 3.1 Avg. annual Program payout per pharmacy $22,625 $37,666 Tables 3.1 and 5.1 % Program payout to chain pharmacies 59.3% 62.0% Tables 6.2 and 6.3

1

PENNSYLVANIA PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY History The Pharmaceutical Assistance Contract for the Elderly (PACE) Program was enacted in November 1983, and implemented on July 1, 1984. Its purpose is to assist qualified state residents who are 65 years of age or older in paying for their prescription medications. The PACE legislation was amended in 1987 for reauthorization and, in 1992, for the manufacturers’ rebate reauthorization and additional cost containment initiatives. The legislature expanded income eligibility for PACE on four occasions: 1985, 1991, 1996, and 2003. The 1996 legislation also created the PACE Needs Enhancement Tier (PACENET). In July 2001, Act 2001-77, the Pennsylvania Master Tobacco Settlement, increased PACENET income eligibility by $1,000. Recognizing that the nominal increases in Social Security income were making enrollees ineligible for PACE, the legislature also created a limited PACE moratorium, effective January 1, 2001, until December 31, 2002, which permitted enrollees to remain in benefit even though their incomes exceeded the eligibility limits. Late in 2002, Act 2002-149 extended the moratorium for the PACE enrollment and expanded it to include the PACENET enrollment as well. While this moratorium expired on December 31, 2003, cardholders who were enrolled prior to the expiration, and had their eligibility periods extending into 2004, were permitted to remain in the Program until their eligibility end date. In November 2003, Act 2003-37 enabled an unprecedented expansion for enrollment eligibility in the Programs, modified the $500 annual PACENET deductible, and changed the PACE copay structure. The legislation raised the income limits for PACE to $14,500 for individuals and $17,700 for married couples; it boosted the income cap for PACENET to $23,500 for single persons and to $31,500 for married couples. With a $480 deductible divided into monthly $40 amounts, PACENET paid benefits after the first $40 in prescription costs each month. Beginning in 2004, PACE and PACENET had a two-tiered prescription copayment structure. The PACE copayment became $6 for generic drugs and $9 for brand name products. The PACENET copayment remained at the original amounts of $8 for generics and $15 for brand name drugs. Act 37 required both Programs to adjust the copayments to reflect increasing drug prices over time. Act 37 instituted federal upper limits (FUL) in the provider reimbursement formula and raised the dispensing fee fifty cents. The Program began to reimburse pharmacies the lesser of three prices: the Average Wholesale Price (AWP) minus 10%, plus a $4.00 dispensing fee; the Usual and Customary charge to the cash-paying public; or, the most current FUL established in the Medicaid program, plus a $4.00 dispensing fee. All payment methods include the subtraction of the cardholder’s copayment. The federal Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a new outpatient prescription drug benefit, Part D of Medicare. Prior to the full implementation of Medicare Part D and beginning in June 2004, low income, non-HMO, PACE enrollees (134,393 cardholders over 18 months) were auto-enrolled into the interim Medicare Drug Discount Card and Transitional Assistance Program. They received a discount card that allowed for $600 per year in drug expenses in 2004 and again in 2005. Additional cardholders, estimated at 30,000, received this assistance through cards issued by their HMO. The PACE Program covered the Medicare drug card copayments for the auto-enrolled cardholders. The Medicare Transitional Assistance Program was a source of significant drug coverage for cardholders, with known savings in Program benefit payments of $112 million for the auto-enrolled cardholders.

3

The Medicare Part D drug benefit began in January 2006. The PACE Program elected to be a qualified State Pharmacy Assistance Program which, along with the passage of state Act 111 in July 2006, allowed for the creation of PACE Plus Medicare. The successful launch of PACE Plus Medicare on September 1, 2006, saw thousands of cardholders take advantage of the features of both PACE and Medicare Part D. With the goal of providing seamless coverage, PACE Plus Medicare provides benefits when Medicare Part D does not, for example, during the deductible and the coverage gap, for drugs excluded under MMA, for drugs not in a plan’s formulary, and for copayment differentials between the Part D plan coverage and the PACE and PACENET copayments. PACE Plus pays the Medicare premiums for Part D coverage for PACE cardholders. Act 111 also eliminated the monthly deductible for PACENET cardholders. PACENET cardholders who choose to forego Part D coverage are now responsible for a monthly benchmark premium payment ($32.59 in 2006; $28.45 in 2007; $26.59 in 2008; $29.23 in 2009; $32.09 in 2010; $34.07 in 2011, $34.32 in 2012; $36.57 in 2013; $35.50 in 2014; and, $33.91 in 2015) to the Program. The benchmark premium payment remains lower than the prior $40 per month deductible for the Program. Act 111 recreated the PACE and PACENET moratoriums thereby permitting some 14,000 seniors to maintain their PACE or PACENET status despite disqualifying increases in their overall income due to Social Security cost-of-living increases. The PACE moratorium expired at the end of 2006; the PACENET moratorium continued through 2007. The Act revised provider reimbursement by adjusting the Average Wholesale Price formula from AWP minus 10% to AWP minus 12%, plus a $4.00 dispensing fee. Act 69 of 2008 recreated the PACE and PACENET moratoriums, thereby permitting 15,400 seniors to maintain their Program enrollment in 2010 despite disqualifying increases in their overall 2008 income due to Social Security cost-of-living increases. Act 21 of 2011 extended the moratorium until December 31, 2013, allowing 31,000 persons to remain enrolled. Act 12 of 2014 established the moratorium expiration date for December 31, 2015, preserving the enrollment for 28,000 older adults. This Act also instituted the exclusion of Medicare Part B premium costs from the definition of total income used for income eligibility determination. As of May 2014, 46,000 cardholders retained their enrollment in the Program due to these two provisions of Act 12. PACE covers all medications requiring a prescription in the Commonwealth, as well as insulin, insulin syringes, and insulin needles, unless a manufacturer does not participate in the Manufacturers’ Rebate Program. PACE does not cover experimental medications, medications for hair-loss or wrinkles, or any medication that can be purchased without a prescription. With appropriate documentation, PACE covers Drug Efficacy Study Implementation (DESI) medications. PACE requires generic substitution of brand multi-source products when an approved, Food and Drug Administration (FDA) A-rated generic is available. At the time of dispensing, a cardholder may encounter a prospective drug utilization review edit; PACE will not reimburse the prescription unless the pharmacist or physician documents the medical necessity for it. The Department of Aging recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. Appendix A contains a description of the PACE/PACENET medical exception process. With the advent of PACE Plus, cardholders enrolled in Part D plans conform to the reimbursement limits established by the plans, some of which allow up to a ninety-day supply. Otherwise, cardholders not enrolled in a Part D Plan receive a thirty-day supply or 100 units (tablets or capsules) whichever is less. The Program guarantees reimbursement to the provider (including nearly 2,900 Pennsylvania pharmacies) within 21 days, paying interest on any unpaid balance after 21 days. Six types of providers dispense PACE/PACENET-funded prescriptions

4

to cardholders. The majority of providers are either independent pharmacies or chain pharmacies. Other provider types include institutional pharmacies, nursing home pharmacies, mail order pharmacies, and dispensing physicians. All providers may offer mail order services if they are enrolled as a mail order pharmacy and if they follow specialized program requirements pertaining to record keeping and cardholder verification procedures. Manufacturers for innovator products pay the Program a rebate similar to the federal “best price” Medicaid rebate. Generic manufacturers pay an 11% rebate based on the average manufacturer price (AMP). An inflation penalty applies to innovator products if annual price increases exceed the consumer price index. The inflation penalty rebate was discontinued for generic products at the end of 2006. Effective January 2010, the federal Medicaid flat rebate rate increased from 15.1% of the AMP to 23.1% and the generic rate increased from 11% to 13%. Administration The Pennsylvania Department of Aging administers the PACE/PACENET Program. A contractor directly responsible to the Department assists in conducting many of the day-to-day operations. Four primary operational responsibilities of the Program are to process applications, reimburse providers for prescriptions, protect enrollees from adverse drug events, and obtain the most cost-efficient reimbursement possible for the Program. Administrative responsibilities include research and policy development, monitoring and evaluating operations and ensuring that the mandates of the Act and Program regulations are met. Activities in these areas include conducting audits of not only the providers, but also of the cardholders and the contracting agency. The Program routinely reviews medication utilization profiles of the cardholders and dispensing practices of the providers and physicians. The Department also evaluates the procedures used to implement the Program, identifies any trends which may be relevant for future administration, and carefully scrutinizes all expenditures. The Department of Aging receives funds through restricted revenue accounts to serve as the administrative and fiscal agent for other Commonwealth-sponsored drug reimbursement programs. Pharmaceutical claims for the Chronic Renal Disease Program, Cystic Fibrosis Program, Spina Bifida Program, Metabolic Conditions Program, including Maple Syrup Urine Disease Program and the Phenylketonuria Program (all within the Department of Health), and the two Special Pharmaceutical Benefits Programs (Department of Health for SP1 and Department of Public Welfare for SP2) are processed through the PACE/PACENET system. The program also adjudicates claims for two programs in the Department of Insurance, the Workers’ Compensation Security Fund and the Pennsylvania Automobile Catastrophic Loss Benefits Continuation Fund. The PACE Program serves as the fiscal agent for the General Assistance Program (Department of Public Welfare), the Special Pharmaceutical Assistance Program, and the Chronic Renal Disease Program for the collection of rebates from pharmaceutical manufacturers. The Program processes eligibility applications for the Chronic Renal Disease Program and for the SP1 Program. The Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) is available to assist all adult Pennsylvanians with the cost of prescription drugs. PA PAP outreaches to those who are uninsured or under-insured by helping them to apply for prescription assistance through various programs. Details about the Clearinghouse are found in Section 8 of this report.

5

SECTION 1

PROGRAM RESEARCH HIGHLIGHTS

7

INTERV

ENTIONS, GEN

ERAL

PRO

GRA

M ASSESSM

ENTS, A

ND M

EDICAT

ION ADHER

ENCE

STU

DIES

CURR

ENT PA

CE/PAC

ENET

COLLAB

ORA

TIVE

RESEA

RCH AND EVA

LUAT

ION PRO

JECT

S, 2008 ‐ 2

014

INTERV

ENTIONS

TOPIC

TITLE / RE

SEAR

CH GRO

UP

DESCR

IPTION

ASSESSMEN

T FO

R DEP

RESSION,

ANXIETY, AND

SLEEP

DISORD

ERS

TELEPH

ONE‐BA

SED

BEHAV

IORA

L HEA

LTH

ASSESSMEN

T FO

R SENIORS

ON

NEW

PSYCH

OTR

OPIC

MED

ICAT

ION

Beha

vioral Health

Lab

oratory,

Med

ical Schoo

l, University

of

Penn

sylvan

ia

Results from aPACE statew

ide collaborative care program

by the Beh

avioral H

ealth Laboratory (begun in

2008) support

concerns related to psychotropic m

edication prescribing in the elderly and raise additional questions about off‐label or

inappropriate prescribing. Overall, 45.0%

of p

articipan

ts did not m

eet criteria fo

r any

men

tal health

disorde

r with

low

symptom

s ind

icated

. Just 6% m

et th

e crite

ria fo

r anxiety disorde

rs. The study found that older, community dwelling

patients received new

psychotropic m

edications in excess of what m

ight be expected based

on their relatively low sym

ptom

burden

. Many reported

that the prescription was for a psychosocial stressor (43.8%), while 15.8% were unaw

are of the

reason for the prescription. In

terven

tion aims includ

e assigning individu

als with

clin

ically significan

t sym

ptom

s to m

inim

al

mon

itorin

g or m

onito

ring with

care man

agem

ent a

nd so

cial service su

pport in orde

r to de

term

ine whe

ther th

e clinical

services are im

pacting ou

tcom

es.

The project is in

Phase II with interven

tion protocols that address persons with either high or low sym

ptom m

easures. In the

high sym

ptom group, care managem

ent advice has led to the referral of 39 persons to specialist care. With low sym

ptom

patients, the assessmen

t explores reasons for the psychotropic m

edication and consideration of discontinuation after

persisten

ce of measured low sym

ptoms.

Care m

anagem

ent cases are asked

at the

nine week follo

w up ab

out the

ir satisfaction level. The

re is a very high

level of

enrollee satisfaction with

the care m

anagem

ent service (>

95%

satisfaction).

During Ph

ase II, The

Beh

avioral H

ealth

Lab

oratory also promotes non

‐pha

rmacological interven

tions and

offers

assessmen

t and

assistance with

add

ressing psycho

social stressors prio

r to the use of m

edication therap

y. The academ

ic

detailer in the Philadelphia region m

arketed the assessmen

t services to physicians visited through

academ

ic detailing (see

next page). In 2012, letters were sent to all psychotropic prescribers inviting them

to contact the project for assistance with

men

tal health assessm

ent and m

edication therapies. A

bout 42% of Phase II participants are m

inim

ally sym

ptomatic.

A recent ana

lysis o

f patient chron

ic pain foun

d significant differen

ces in levels of d

epression, anxiety, and

qua

lity of life

betw

een those who

experience interferen

ce of p

ain versus th

ose who

do no

t.

In 2013, the PACE Program

added

a dem

entia care m

anagem

ent program

, the Ca

regiver T

eleh

ealth

Edu

catio

n Program, for

cardho

lders w

ith m

oderate to severe cognitive

impa

irmen

t/de

men

tia and

their informal caregivers; 38 caregivers

participated

. Overall for the year, the Beh

avioral H

ealth Laboratory completed 839 initial assessm

ents for cardholders and

caregivers. There were 2,551 follow‐up assessm

ents with cardholders and caregivers. A

mong them

, 115 cardholders

received

care managem

ent services and 428 cardholders received

sym

ptom and m

edication m

onitoring services. Eleven

cardholders were referred

to specialty men

tal health services.

FALLS

PREV

ENTION

FALLS‐FR

EE PA

Gradu

ate Scho

ol of P

ublic

Health

, University

of P

ittsburgh

The Cen

ters for Disease Control and Prevention provided

funds for this two year research grant. R

esearche

rs at the

Gradu

ate Scho

ol of P

ublic Health

at the

University

of P

ittsburgh

and

the PA

Dep

artm

ent o

f Aging

examined

cou

nty level

falls incide

nce an

d the effect of the

Dep

artm

ent’s

Hea

lthy Step

s for Older Adu

lts and

Hea

lthy Steps in Motion projects. A

physician ed

ucation compo

nent includ

ed su

rveying ph

ysicians who

see

older adu

lts in

their p

ractice an

d offerin

g mailed

and on

line ed

ucationa

l materials (h

ealth

yaging.pitt.edu

) with

CME/CEU credits. Findings from the evaluation of the

Healthy Step

s program

s were incorporated into well‐received

Preventing Falls Among the Elderly m

odule developed

by the

Indep

enden

t Drug Inform

ation Service (IDIS) for the PACE Program

’s academ

ic detailing effort in

2014.

9

AC

ADEM

IC

DETAILING

UPD

ATING PHY

SICIAN

S AB

OUT

CHAN

GING THE

RAPIES IN

CO

MPLICAT

ED DISEA

SE STA

TES

The Division of Pha

rmaco‐

epidem

iology and

Pha

rmaco‐

econ

omics o

f the

Brig

ham and

Wom

en’s Hospital/Harvard

Med

ical Schoo

l

Since 2005, P

ACE ha

s offered a ph

ysician ed

ucation program. Ph

ysicians at the

Harvard M

edical Schoo

ltrain clin

ical

educators to m

eet o

ne‐on‐on

e with

clin

icians caring for a

large nu

mbe

r of p

atients en

rolled in PAC

E. During the office

visits, w

hich began

in 2005, the ed

ucators provide objective, research‐based

inform

ation about the most effective drugs and

non‐m

edication therapeu

tic options for common chronic conditions. A

s of M

ay 2014, clin

ical edu

cators com

pleted

19,800

visits.

In 2008‐2010, a parallel program

delivered

three ed

ucational m

odules that focused on preventing the need for

hospitalizations and institutionalizations due to cognitive im

pairm

ent and associated

beh

avioral problems (709 visits), falls

and m

obility problems (668 visits), and incontinen

ce (823 visits).

As of May 2014, for FY 2013‐14, fou

r mod

ules accou

nted

for 9

1% of the

2,100

visits

to nearly

800

physician

s.

The diab

etes m

anagem

ent m

odule (259 visits) assesses the comparative effectiven

ess and safety of type 2 diabetes

med

ications, presents eviden

ce regarding appropriate therapy, and weighs the ben

efits, risks, and value of treatm

ent

options with the intent to im

prove the quality of prescribing and patient care.

The falls prevention mod

ule (331 visits) addresses the reduction of the risk of falls among the elderly. Clinicians receive

inform

ation on how to screen patients for increased risk of falls, how to carry out a multifactorial falls assessm

ent of patients

at higher risk, and how to tailor interven

tions to red

uce this risk.

The CO

PD m

odule (576 visits) discusses the curren

t med

ical literature about chronic obstructive pulm

onary disease and

offers practical strategies for diagnosis, m

anaging stable disease, red

ucing the risk of exacerbations, and treating

exacerbations that do occur.

The mod

ule on

obe

sity (6

92 visits) provides inform

ation for primary care providers on approaches to help obese patients

achieve weight loss through

changes in diet and exercise. It also discusses the risks and ben

efits of available weight loss

med

ications, over‐the‐counter supplemen

ts, and surgical procedures.

For each topic in the academ

ic detailing program

, the IDIS staff develops print materials, trains the detailing staff and

manages the interven

tion. The physician faculty develops the modules based

upon common drugs used by and conditions

affecting the elderly. For each m

odule, drug ed

ucators distribute several different types of documen

ts to physicians during

face‐to‐face meetings: comprehen

sive reviews of biomed

ical literature, known as eviden

ce docum

ents; distillations of key

inform

ation to be used as the basis for the discussion between practitioner and the consultant, known as summary

documen

ts; p

atient or caregiver brochures that provide key inform

ation geared to the lay public, including resources for

additional inform

ation and support; and, lam

inated

, pocket‐sized

quick reference cards on treatmen

t and drug efficacy.

These materials detail unb

iased an

d ba

lanced

inform

ation useful to

the ph

ysician, fo

r example, which patient con

ditio

ns

warrant use of e

ach drug, and

clarify whe

n more costly, b

rand

‐nam

e drug

s are more effective, and

whe

n less expen

sive

gene

ric or o

ver‐the‐coun

ter d

rugs m

ay be eq

uivalent or b

etter. M

aterials can

be foun

d at www.alosafoun

datio

n.org.

In 2014, a m

odule evaluation survey for the new

est module on fall prevention m

easured strong physician agreemen

t in

response to the questions about whether the program

had

an im

pact on clinical decisions in caring for older patients.

Satisfaction elemen

ts receiving the highest agreem

ent scores included

: “The PACE academ

ic detailer presented useful,

eviden

ce‐based

inform

ation on assessing fall risk in

my elderly patients” and “The PACE academ

ic detailer provided

me with

eviden

ce‐based

recommen

dations on effective interven

tions to red

uce fall risks.” Evaluation of tw

o mod

ules, n

on‐steroidal

anti‐infla

mmatory drugs/coxib use an

d acid su

ppressing drugs, dem

onstrated that th

e program achieved significant

redu

ctions in

the med

ications ta

rgeted

.

10

GEN

ERAL

PRO

GRA

M ASSESSM

ENTS

TOPIC

TITLE / RE

SEAR

CH GRO

UP

DESCR

IPTION

IMPR

OVE

D

HEA

LTH

STAT

US AN

D

AVOIDAN

CE

OF NURS

ING

HOME EN

TRY

AND LAT

ER

ENTR

Y INTO

WAIVE

R PR

OGRA

MS

PACE

ENRO

LLMEN

T PR

OVIDE

S AD

VANTA

GE FO

R LO

W

INCO

ME, PRE

‐MED

ICAID

SENIORS

Pe

nnsylvan

ia Dep

artm

ents of

Aging an

d Pu

blic W

elfare,

Office of Lon

g Term

Living,

Magellan Health

Services/PAC

E, M

ercer

Governm

ent H

uman

Services

Consultin

g, and

the Health

Po

licy Institu

te at G

eorgetow

n University

A 2010 analysis dem

onstrates that the PACE Program

supports many seniors prior to their Med

icaid enrollm

ent. Data

compare consumers who “had” and “did not have” PACE in a five year period prior to using long‐term

care or nursing waiver

services. Re

sults

suggest P

ACE en

rollm

ent e

nables sen

iors to

remain in th

e commun

ity longer, w

ith better h

ealth

, and

to

delay en

try into and

utilization of long

‐term care an

d waiver services. Findings include:

Average length of nursing facility stay over a 5‐year period was 40 days less for previous PACE en

rolled.

PACE mem

bers were older at en

try into a nursing facility by 2.8 years.

The ages at waiver en

try show PACE mem

bers were older by 3.1 years.

Later age of entry into nursing facilities provided

an estim

ated

annual savings of $728.8 M

.

Deferred waiver program

produced estim

ated

annual savings of $86.5 M

.

PACE en

rollees who have subsequen

t Med

icaid enrollm

ent have lower costs as a result of earlier PACE coverage.

The Program

takes advantage of its ideal position to educate those PACE seniors, w

ho are specifically known to be

income eligible, about the comprehen

sive health care coverage available through

Med

icaid, producing a unique,

efficien

t outreach and im

proved coordination with M

edicaid.

Analysts at Mercer Governmen

t Human

Services Consulting evaluated

the study and were prepared

to certify results.

SATISFAC

TION

SURV

EYS

PACE

/PAC

ENET

SURV

EY ON

HEA

LTH AND W

ELL‐BE

ING

Magellan Health

Services/PA

CE

The Survey on Hea

lth and

Well‐B

eing

provides inform

ation ab

out the

cardh

olde

r pop

ulation. Q

uestions m

easure

cardho

lders’ self‐rep

orted he

alth status, self‐rep

orted med

ication ad

herence an

d affordab

ility, and

satisfaction with

their

PACE

/PAC

ENET

coverage. Survey da

ta are freq

uently link

ed with

other im

portan

t data sources, in

clud

ing prescriptio

n records, M

edicare services re

cords, and

vita

l statistics records, and

are used for p

rogram

evaluation an

d original re

search

stud

ies. Included

in the PACE/PACEN

ET new

enrollm

ent application, the optional survey gathers im

portant inform

ation

about a person’s health im

med

iately prior to joining PACE. The optional ren

ewal survey is m

ailed to existing cardholders

throughout the year. Most ren

ewal survey questions are the same as the new

enrollm

ent survey, but a few questions are

different. It provides im

portant inform

ation about the cardholder’s health after being in PACE. A

nnual updates allow the

study of changes in health over time. The revised response rate (after rem

oval of 3,324 deceased cardholders) was 49.9% for

the 2012 ren

ewal survey.

Results

from

5% Ran

dom Sam

ple: N

early 31% of curren

t responden

ts indicated

that they did not complete high school w

ith

11% of curren

t responden

ts indicating that they had

an 8

th grade or less education. Understanding the ed

ucational

background of the population helps to ensure that cardholder communications are at an appropriate reading level. Among

cardholders who were en

rolled in

PACE at the time that they completed the survey, 88% rep

orted

that they were either

“extremely” or “quite a bit” satisfied with PACE. A

mong PACEN

ET enrolled cardholders, 78% were “extremely” or “quite a

bit” satisfied that PACEN

ET. Another 9% of PACE en

rollees and 15% of PACEN

ET enrollees were “m

oderately” satisfied

. These data indicate high levels of satisfaction with both Program

s. Cardholders who responded

to the survey also expressed

a high degree of satisfaction with the combination of PACE/PACEN

ET and M

edicare Part D by scoring a high average

satisfaction that ranged between strongly and somew

hat agree

that the combination works well for them

(1.3 for PACE and

1.5 for PACEN

ET on a 4.0 scale).

Nearly

41%

of respo

nden

ts se

lf‐repo

rted

a fa

ll in th

e pa

st year, with

abo

ut 12%

of respo

nden

ts indicatin

g more than

one

fall an

d least o

ne injury due

to th

e fall. For global self‐rated health, 38% of responden

ts had

fair or poor health. PACEN

ET

cardholders report “not filling prescriptions due to cost” more frequently than

PACE cardholders with 12% of them

not filling

a prescription two or more tim

es in

past year compared

to 7% for PACE. PACE cardholders have lower cost sharing.

11

SELF‐RAT

ED

HEA

LTH

IMPA

CT OF VA

NTA

GE PO

INT

ON THE AS

SOCIAT

ION

BETW

EEN SELF‐RA

TED HEA

LTH

AND M

ORT

ALITY

Magellan Health

Services/PA

CE

and Th

e Med

icine, Health

, and

Ag

ing Project a

t Pen

n State

University

Numerous studies dem

onstrate that self‐rated health predicts m

ortality. The

goa

l of this s

tudy

was to

explore how

self‐

ratin

g vantage po

int a

ffects m

ortality pred

ictio

n. Subjects included

137,188 PACE en

rollees.

Three self‐rated he

alth van

tage points were used

: glob

al, age‐com

parativ

e (others o

f sam

e age) and

time compa

rativ

e (present vs. one

year a

go). M

ultivariate Cox proportional‐hazards regression was used to predict subsequen

t mortality over

two years, controlling for dem

ographics and m

edication‐based

comorbidity.

When

comparing global and age‐comparative ratings, 73% of persons reported

equal global and age‐comparative scores;

19% had

age‐comparative scores that exceeded

global scores; and, 8% indicated

age‐comparative scores worse than

global.

Age comparative scores worse than

global increased risk of mortality, while age‐comparative scores exceed

ing global scores

reduced risk. The im

pact of age‐comparative deviation from global was stronger in younger age groups. Controlling for

global self‐rated health, self‐assessed

change over the past year in

either direction increased m

ortality risk, but the effect

varied

by age (interaction p < .001), with the greatest im

pact observed

among younger elderly aged 65‐79.

These results

suggest tha

t com

parativ

e ratin

gs are particularly useful w

hen used

alongside

globa

l ratings, and

that

potential age differen

ces in van

tage

point m

eaning

may have a be

aring on

mortality pred

ictio

n.

BERE

AVEM

ENT

AND

MORT

ALITY

MORT

ALITY FO

LLOWING

WIDOWHOOD:

THE RO

LE OF PR

IOR SPOUSA

L HEA

LTH

Magellan Health

Services/PAC

E, The

Med

icine,

Health

, and

Aging

Project at

Penn

State University

, and

Em

ory University

Rollin

s Scho

ol

of Pub

lic Health

Prior research has shown that widowhood is associated

with increased m

ortality risk; h

owever,it is not clear whether the

rapidity of the predeceased spouse’s health decline affects this risk. This s

tudy

used grou

p‐ba

sed trajectory m

odeling to

describ

e pred

eceased spou

ses’ patterns of health

declin

e, and

examined

associatio

ns with

post‐widow

hood

survival.

Subjects included

9,967 PACE/PACEN

ET cardholders who were widowed

between 2000 and 2006. The predeceased and

bereaved spouses’ health trajectories in

the year before widowhood were evaluated

for three measures: the Combined

Comorbidity Score, inpatient hospitalized

days, and ambulatory visits. M

ultivariate Cox proportional hazards models were

used to evaluate whether the predeceased spouse’s pattern of health decline affected

the the subsequen

t survival of the

bereaved spouse, w

hile controlling for the bereaved spouse’s own historical health trajectory and other factors.

Multiple trajectory patterns of health decline before death emerged in

the predeceased sam

ple. Among predeceased

hospice users, stable low and late onset comorbidity patterns were both associated

with greater m

ortality in the bereaved,

relative to chronic high comorbidity (HR=1.47 and 1.62, respectively). Relative to stable m

edium levels of am

bulatory visits

among the predeceased, chronically high visit levels were associated

with a lower m

ortality rate in

the bereaved (HR=0.67),

while very low visit levels were associated

with higher post‐w

idowhood m

ortality in the bereaved (HR=1.32).

These results

dem

onstrate th

e utility of group

‐based

trajectory m

odels for describing pa

tterns of e

nd‐of‐life

declin

e, and

suggest tha

t una

nticipated

deaths m

ay be associated

with

greater post‐widow

hood

mortality risk for b

ereaved spou

ses.

OUTR

EACH

PA

CE APP

LICA

TION CEN

TER

Bene

fits D

ata Trust,

Philade

lphia

The PACE Application Cen

ter locates and submits PACE applications for eligible persons and enrolls eligible persons in the

Med

icare Part D Low Income Subsidy.

PACE

Enrollm

ent O

utreach: The Cen

ter uses Property Tax and Ren

t Reb

ate rolls, and energy, food and prescription

assistance listings to iden

tify enrollm

ent candidates. In 2013, outreach ha

d 523,000 mailin

gs abo

ut th

e Program,

successfully m

ade 47,500

con

tacts for e

ligibility, and

sub

mitted

12,750 ap

plications fo

r older Pen

nsylvanian

s.

Low In

come Subsidy (LIS) O

utreach: The PACE Program

, by wrapping around the Part D ben

efit, incurs costs that could be

offset by LIS ben

efits, which provide financial help to low income en

rollees. In 2013, th

e Ce

nter re

ache

d 24

,400

existing an

d po

tential cardh

olde

rs to

inform

them

abo

ut LIS, screene

d them

for e

ligibility, and

sub

mitted

7,188

app

lications on be

half

of older Pen

nsylvanian

s.

12

MED

ICAT

ION UTILIZA

TION STU

DIES

TOPIC

TITLE / RE

SEAR

CH GRO

UP

DESCR

IPTION

MED

ICAT

ION

ADHER

ENCE

AN

D HEA

LTH

OUTC

OMES

PROTO

N PUMP INHIBITO

R AD

HER

ENCE

AND FRA

CTURE

RISK

IN THE ELDER

LY

Magellan Health

Services/PA

CE

and Th

e Med

icine, Health

, and

Ag

ing Project a

t Pen

n State

University

Results of several recen

t studies suggest that long‐term

use of proton pump inhibitors (PPIs) may be associated

with an

increased risk of fracture. The

goa

l of this s

tudy

was to

examine the relatio

nship be

tween med

ication ad

herence and

fracture risk amon

g elde

rly PPI users. The study cohort included

1,604 community‐dwelling PPI users and 23,672 non‐users

who were en

rolled in

the PACE Program

. Proportion of Days Covered (PDC) was computed to m

easure adheren

ce based

on prescription refill patterns. Tim

e‐dep

enden

t Cox proportional hazards models were used to estim

ate adjusted

hazard ratios of PPI use/adheren

ce for fracture

risk while controlling for dem

ographics, comorbidity, body mass index, smoking and non‐PPI m

edication use. The overall

inciden

ce of any fracture per 100 person‐years was 8.7 for PPI users and 5.0 for non‐users. A gradient in fracture risk

according to PPI adheren

ce was observed

. Relative to non‐users, fracture hazard ratios associated

with the highest

adheren

ce (PDC > 0.80), interm

ediate (PDC 0.40‐0.79), and lowest (PDC < 0.40) adheren

ce levels were 1.46 (p < 0.0001), 1.30

(p = 0.02), and 0.95 (p = 0.75), respectively.

These results

provide

furthe

r evide

nce that PPI use m

ay increase risk in

the elde

rly, and

highlight th

e ne

ed fo

r clin

icians to

pe

riodically re

assess elderly patients’ individu

alized

needs fo

r ongoing

PPI th

erap

y, while weighing po

tential risks and

be

nefits. The findings were published

in Calcified Tissue

Internationa

l in April 2014.

STAT

IN USE

ASSO

CIAT

ION BETWEEN

STAT

IN USE AND FRA

CTURE

RISK

AMONG THE ELDER

LY

Magellan Health

Services/PA

CE

and Th

e Med

icine, Health

, and

Ag

ing Project a

t Pen

n State

University

The im

pact of statins (w

idely used to treat hyperlipidem

ia)on fracture risk is still under deb

ate. The

goa

l of this s

tudy

was to

exam

ine the association be

tween statin use and

fracture risk amon

g the elde

rly by follo

wing 5,524 ne

w statin

users and

27

,089

non

‐users fo

r an average of 3.5 years.

Time‐dep

enden

t Cox proportional hazards models were used to estim

ate adjusted

hazard ratios of statin use for fracture risk

while controlling for dem

ographics, comorbidity, body mass index, smoking status, alcohol use, and certain therapeu

tic

classes. The

incide

nce of any

fracture per 100

person‐years was 3.0 fo

r statin

users and

7.8 fo

r non

‐users. Re

lativ

e to non

‐users, th

e ha

zard ra

tio associated with

statin use was 0.86 (p < 0.001

). Statin

users with

highe

r and

lower average daily

dose were associated

with

18%

and

9% decreased

fracture risk, respe

ctively.

The ha

zard ra

tio fo

r atorvastatin

was 0.81 (p < 0.001

), an

d the effects w

ere no

t significan

t for sim

vastatin and

pravastatin.

The protectiv

e effect of statin

user a

ppeared to be stronger amon

g users olde

r tha

n 85

years old. These results suggested

statin use is associated

with red

uced fracture risk am

ong the elderly, and the effect m

ay be dep

enden

t on age and statin

type. The ben

eficial effect of statin on bone may be helpful in the prevention of fractures am

ong elderly.

13

SECTION 2

FINANCIAL DATA

BY DATE OF SERVICE

15

TA

BL

E 2

.1A

HIS

TO

RIC

AL

CL

AIM

AN

D E

XP

EN

DIT

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E D

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A F

OR

PA

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EN

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LL

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AN

D P

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IPA

TIN

G C

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DH

OL

DE

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BY

SE

MI-

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RIO

D B

AS

ED

ON

DA

TE

OF

SE

RV

ICE

JAN

UA

RY

199

1 -

DE

CE

MB

ER

201

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PA

GE

1

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IMS

PE

RC

LAIM

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AV

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AG

ES

EM

I-AN

NU

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LLE

DP

AR

TIC

IPA

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GTO

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EN

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LLE

DP

AR

TIC

IPA

TIN

GTO

TAL

STA

TE S

HA

RE

PE

RIO

DC

AR

DH

OLD

ER

SC

AR

DH

OLD

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SC

LAIM

SC

AR

DH

OLD

ER

CA

RD

HO

LDE

RE

XP

EN

DIT

UR

ES

PE

R C

LAIM

JAN

-JU

N 1

991

405,

358

337,

684

5,28

0,37

613

.03

15.6

4$1

16,0

74,6

18$2

86.3

5$3

43.7

4$2

1.98

JUL-

DE

C 1

991

394,

055

324,

574

4,67

7,15

911

.87

14.4

1$1

09,8

71,6

50$2

78.8

2$3

38.5

1$2

3.49

JAN

-JU

N 1

992

399,

721

326,

469

4,65

6,98

611

.65

14.2

6$1

16,0

82,5

06$2

90.4

1$3

55.5

7$2

4.93

JUL-

DE

C 1

992

385,

103

313,

430

4,60

2,26

111

.95

14.6

8$1

17,0

81,6

02$3

04.0

3$3

73.5

5$2

5.44

JAN

-JU

N 1

993

376,

916

310,

438

4,40

2,17

111

.68

14.1

8$1

13,0

68,7

54$2

99.9

8$3

64.2

2$2

5.68

JUL-

DE

C 1

993

357,

777

296,

802

4,45

6,22

312

.46

15.0

1$1

16,1

64,3

81$3

24.6

8$3

91.3

9$2

6.07

JAN

-JU

N 1

994

354,

819

293,

462

4,32

0,15

912

.18

14.7

2$1

15,4

13,5

42$3

25.2

7$3

93.2

8$2

6.72

JUL-

DE

C 1

994

340,

607

281,

465

4,40

4,25

712

.93

15.6

5$1

19,1

00,7

41$3

49.6

7$4

23.1

5$2

7.04

JAN

-JU

N 1

995

331,

965

277,

461

4,38

3,96

813

.21

15.8

0$1

21,1

47,2

11$3

64.9

4$4

36.6

3$2

7.63

JUL-

DE

C 1

995

317,

719

263,

576

4,34

7,33

513

.68

16.4

9$1

22,1

58,8

72$3

84.4

9$4

63.4

7$2

8.10

JAN

-JU

N 1

996

306,

062

253,

283

4,24

4,19

013

.87

16.7

6$1

20,8

68,6

54$3

94.9

2$4

77.2

1$2

8.48

JUL-

DE

C 1

996

292,

755

238,

963

4,20

4,46

114

.36

17.5

9$1

20,4

29,8

40$4

11.3

7$5

03.9

7$2

8.64

JAN

-JU

N 1

997

286,

126

236,

157

4,28

6,47

814

.98

18.1

5$1

16,7

32,8

47$4

07.9

8$4

94.3

0$2

7.23

JUL-

DE

C 1

997

276,

180

226,

806

4,35

8,89

215

.78

19.2

2$1

23,4

82,0

56$4

47.1

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44.4

4$2

8.33

JAN

-JU

N 1

998

267,

225

222,

465

4,23

5,61

915

.85

19.0

4$1

26,8

72,5

48$4

74.7

8$5

70.3

0$2

9.95

JUL-

DE

C 1

998

257,

009

213,

694

4,33

1,39

016

.85

20.2

7$1

37,1

46,4

44$5

33.6

3$6

41.7

9$3

1.66

JAN

-JU

N 1

999

246,

467

208,

992

4,31

6,58

817

.51

20.6

5$1

42,4

12,9

78$5

77.8

2$6

81.4

3$3

2.99

JUL-

DE

C 1

999

238,

388

200,

921

4,45

0,89

318

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53,5

96,6

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44.3

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64.4

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4.51

JAN

-JU

N 2

000

237,

017

202,

683

4,44

9,10

218

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21.9

5$1

60,6

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77.6

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92.4

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6.10

JUL-

DE

C 2

000

230,

752

197,

777

4,53

0,82

919

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22.9

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69,8

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76$7

36.2

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58.9

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7.50

JAN

-JU

N 2

001

225,

325

197,

082

4,55

8,33

920

.23

23.1

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78,6

50,9

79$7

92.8

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06.4

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9.19

JUL-

DE

C 2

001

218,

576

190,

540

4,59

0,21

621

.00

24.0

9$1

87,8

20,5

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59.2

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85.7

3$4

0.92

JAN

-JU

N 2

002

216,

719

190,

131

4,55

8,00

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23.9

7$1

94,7

88,8

89$8

98.8

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$42.

74

JUL-

DE

C 2

002

209,

737

183,

318

4,60

5,90

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03,5

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$44.

20

JAN

-JU

N 2

003

209,

761

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FIG

UR

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FIG

UR

E 2

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PERCENT OF ENRO

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PD

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23

JAN - JUN JUL - DEC CY 2013

TOTAL PRESCRIPTION COST (DATE OF SERVICE) 322,402,275$ 332,682,046$ 655,084,321$ MEDICARE PART D PREMIUMS 16,649,075 16,339,789 32,988,864

GROSS CLAIMS/PREMIUMS SUBTOTAL 339,051,350 349,021,835 688,073,185 96.9%

MHS CONTRACT OPERATIONS (INCLUDES POSTAGE) 5,867,985 8,692,293 14,560,278

GROSS CONTRACT SUBTOTAL 5,867,985 8,692,293 14,560,278 2.1%

PDA ADMINISTRATION PERSONNEL 442,523 477,800 920,323 OPERATIONS 70,162 34,745 104,907

GROSS PDA ADMIN. SUBTOTAL 512,685 512,545 1,025,230 0.1%

OTHER ADMINISTRATION AUDITS 380,000 342,500 722,500 MEDICAL ADVISOR 1,475 3,675 5,150 THIRD PARTY RECOVERY 525,159 364,882 890,041

GROSS OTHER ADMIN. SUBTOTAL 906,634 711,057 1,617,691 0.2%

BEHAVIORAL HEALTH INTERVENTIONS 635,242 284,508 919,750 0.1%

ENROLLMENT OUTREACH 1,164,252 1,234,107 2,398,359 0.3%

PRESCRIBER EDUCATION 750,000 750,000 1,500,000 0.2%

GROSS EXPENDITURES 348,888,148 361,206,345 710,094,493 100.0%

PRESCRIPTION COST OFFSETS PART D/OTHER PAYER OFFSETS (190,718,452) (201,578,484) (392,296,936) -55.2% CARDHOLDER COPAYMENTS (38,262,905) (36,189,649) (74,452,554) -10.5%

TOTAL OFFSETS (228,981,357) (237,768,133) (466,749,490) -65.7%

RECOVERIES MANUFACTURER REBATES (20,484,902) (21,805,922) (42,290,824) AUDIT ADJUSTMENTS IN CHECKWRITES (280,172) (363,191) (643,364) ATTORNEY GENERAL SETTLEMENTS (6,848,176) - (6,848,176) ATTORNEY GENERAL COLLECTIONS (3,230) (316) (3,546) THIRD-PARTY REIMBURSEMENTS (4,446,976) (5,234,424) (9,681,400)

COMBINED RECOVERIES (32,063,456) (27,403,853) (59,467,310) PRIOR YEARS' REBATE REFUNDS 686,238 65,328 751,566

NET RECOVERIES (31,377,218) (27,338,525) (58,715,744) -8.3%

NET PRESCRIPTION EXPENDITURES STATE SHARE BEFORE RECOVERIES 93,420,918 94,913,913 188,334,831 26.5% STATE SHARE AFTER RECOVERIES 62,323,872 67,938,579 130,262,451 18.3%

NET STATE EXPENDITURES

AFTER OFFSETS AND RECOVERIES 88,529,573$ 96,099,687$ 184,629,259$ 26.0%

NOTES

AUDIT ADJUSTMENTS ARE BY AUDIT DATE; RECOVERIES OCCURRED IN CY 2013 AND CY 2014. REBATES ($42.3 M) ARE 22.5% OF TOTAL STATE SHARE PRESCRIPTION DRUG COST ($188.3 M). TOTAL PRESCRIPTION COST DOES NOT INCLUDE CLAIMS PROCESSED ONLY BY THIRD PARTY COVERAGE.

TABLE 2.2TOTAL PRESCRIPTION COST, EXPENDITURES, OFFSETS AND RECOVERIES

JANUARY - DECEMBER 2013

EXPENDITURES, RECOVERIES, OFFSETS% OF TOTAL

GROSS EXPENDITURES

TABLE USES PHASE REPORT FOR ANNUAL DRUG EXPENDITURES (DATE OF SERVICE).

24

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2003

2004

2005

2006

2007

2008

2009

2010

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10.3

%

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177,

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120,

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117,

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%

INC

REA

SE

35.2

%

INC

REA

SE

137.

1%

INC

REA

SE

2003

2004

2005

2006

22.2

%

INC

REA

SE

2007

2008

2009

%D

ECR

EASE

2010

9.1%

INC

REA

SE

2011

14.7

%IN

CR

EASE

2012

3.7%

INC

REA

SE

22,4

68

30,3

68

30,7

35

50,0

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72,0

06

87,9

86

95,9

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2013

27

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7

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9

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2

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$10.

00

$12.

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$16.

00

$18.

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PRICE

Mea

n AW

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L IN

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12

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34

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34

12

34

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34

12

34

12

34

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2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

UNIT

TOTA

L IN

CR

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1.95

2.07

2.16

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$2.0

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$3.0

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$3.5

0

PRICE

Mea

n AW

P U

nit P

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Mea

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L IN

CR

EA

SE

IN M

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IT

PR

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OV

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14

YE

AR

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295

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FIG

UR

E 2

.6B

PA

CE

AV

ER

AG

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HO

LE

SA

LE

PR

ICE

(A

WP

) A

ND

AV

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AG

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AN

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AC

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PR

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(A

MP

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NE

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PR

OD

UC

TS

ON

LY

, B

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UA

RT

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JA

NU

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00

0 -

DE

CE

MB

ER

20

13

0.74

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1.50

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0.15

0.17

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0.20

0.21

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0.23

0.21

0.29

0.27

$0.0

0

$0.5

0

$1.0

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$1.5

0

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

12

34

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

UNIT P

TOTA

L IN

CR

EA

SE

IN M

EA

N A

MP

UN

IT

PR

ICE

OV

ER

14

YE

AR

S =

73.

5%

SO

UR

CE

: P

AC

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RY

AN

D M

AN

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TE H

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LUD

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QU

AR

TER

IN 2

000-

2013

.

29

SECTION 3

PROGRAM DATA BY DATE OF

PAYMENT

31

PACE PACENET

NUMBER OF SEMI-ANNUAL PROCESSED

PERIOD CLAIMS EXPENDITURES

JUL-DEC 1984 26 2,101,419 $20,714,685 $9.86JAN-JUN 1985 26 3,475,440 $36,579,102 $10.53

1st YEAR TOTAL 5,576,859 $57,293,787 $10.27

JUL-DEC 1985 26 4,372,468 $50,616,334 $11.58JAN-JUN 1986 26 4,966,536 $61,368,193 $12.36

2nd YEAR TOTAL 9,339,004 $111,984,527 $11.99

JUL-DEC 1986 26 5,237,141 $68,786,114 $13.13JAN-JUN 1987 26 5,257,747 $72,761,148 $13.84

3rd YEAR TOTAL 10,494,888 $141,547,262 $13.49

JUL-DEC 1987 27 5,515,827 $80,237,477 $14.55JAN-JUN 1988 25 5,440,743 $84,469,697 $15.53

4th YEAR TOTAL 10,956,570 $164,707,174 $15.03

JUL-DEC 1988 27 6,055,327 $99,192,197 $16.38JAN-JUN 1989 26 5,937,088 $103,781,619 $17.48

5th YEAR TOTAL 11,992,415 $202,973,816 $16.93

JUL-DEC 1989 26 5,709,497 $106,600,899 $18.67JAN-JUN 1990 26 5,544,295 $110,848,137 $19.99

6th YEAR TOTAL 11,253,792 $217,449,036 $19.32

EXPENDITURESPER PROCESSED

CLAIM **PROCESSED

WEEKS CLAIMS

TABLE 3.1PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR

JULY 1984 - DECEMBER 2013

NUMBER NUMBER OFSTATE SHARE STATE SHAREAVERAGE AVERAGE

PER PROCESSEDCLAIM *

OF

JUL-DEC 1990 26 5,352,797 $112,293,188 $20.98JAN-JUN 1991 26 5,453,044 $117,814,625 $21.61

7th YEAR TOTAL 10,805,841 $230,107,813 $21.29

JUL-DEC 1991 26 5,073,452 $115,304,410 $22.73JAN-JUN 1992 26 4,816,750 $115,596,910 $24.00

8th YEAR TOTAL 9,890,202 $230,901,320 $23.35

JUL-DEC 1992 26 4,724,142 $115,980,339 $24.55JAN-JUN 1993 26 4,403,096 $108,876,491 $24.73

9th YEAR TOTAL 9,127,238 $224,856,830 $24.64

JUL-DEC 1993 26 4,729,097 $118,778,523 $25.12JAN-JUN 1994 26 4,341,896 $111,401,456 $25.66

10th YEAR TOTAL 9,070,993 $230,179,979 $25.38

JUL-DEC 1994 26 4,721,702 $122,294,905 $25.90JAN-JUN 1995 27 4,228,653 $111,136,630 $26.28

11th YEAR TOTAL 8,950,355 $233,431,535 $26.08

JUL-DEC 1995 26 4,895,160 $131,701,547 $26.90JAN-JUN 1996 26 4,443,096 $121,066,818 $27.25

12th YEAR TOTAL 9,338,256 $252,768,365 $27.07

JUL-DEC 1996 26 4,334,551 $119,612,179 $27.60 540 $23 $0.04JAN-JUN 1997 26 4,523,225 $116,697,725 $25.80 74,647 $586,350 $7.85

13th YEAR TOTAL 8,857,776 $236,309,904 $26.68 75,187 $586,373 $7.80

JUL-DEC 1997 26 4,546,360 $121,880,844 $26.81 150,263 $2,680,675 $17.84JAN-JUN 1998 26 4,497,031 $126,776,785 $28.19 171,797 $2,860,833 $16.65

14th YEAR TOTAL 9,043,391 $248,657,629 $27.50 322,060 $5,541,508 $17.21

33

PACE PACENET



JUL-DEC 1998 26 4,504,394 $134,229,706 $29.80 233,277 $4,737,561 $20.31JAN-JUN 1999 26 4,220,448 $139,246,165 $32.99 256,109 $5,410,383 $21.13

15th YEAR TOTAL 8,724,842 $273,475,871 $31.34 489,386 $10,147,944 $20.74

JUL-DEC 1999 26 4,456,680 $153,781,999 $34.51 310,165 $7,421,422 $23.93JAN-JUN 2000 26 4,453,977 $160,846,800 $36.11 339,250 $8,389,295 $24.73

8,910,657 $314,628,799 $35.31 649,415 $15,810,717 $24.35

JUL-DEC 2000 26 4,538,814 $170,118,213 $37.48 382,379 $10,200,170 $26.68JAN-JUN 2001 26 4,536,651 $177,830,053 $39.20 420,529 $11,319,858 $26.92

9,075,465 $347,948,266 $38.34 802,908 $21,520,028 $26.80

JUL-DEC 2001 26 4,635,934 $189,489,307 $40.87 480,559 $13,924,106 $28.97JAN-JUN 2002 26 4,554,962 $194,745,251 $42.75 542,321 $16,348,022 $30.14

9,190,896 $384,234,558 $41.81 1,022,880 $30,272,128 $29.59

JUL-DEC 2002 26 4,615,282 $203,947,092 $44.19 615,169 $20,100,929 $32.68JAN-JUN 2003 26 4,554,809 $208,208,623 $45.71 644,320 $21,608,906 $33.54

19th YEAR TOTAL 9,170,091 $412,155,715 $44.95 1,259,489 $41,709,835 $33.12

JUL-DEC 2003 26 4,688,095 $221,734,037 $47.30 722,537 $25,698,628 $35.57JAN-JUN 2004 26 4,581,399 $205,908,844 $44.94 1,268,014 $47,385,206 $37.37

20th YEAR TOTAL 9,269,494 $427,642,881 $46.13 1,990,551 $73,083,834 $36.72

PER PROCESSED

17th YEAR TOTAL

AVERAGE AVERAGENUMBER STATE SHARE NUMBER OF

OF PROCESSEDSTATE SHARE



16th YEAR TOTAL

PER PROCESSEDWEEKS CLAIM * CLAIMS

18th YEAR TOTAL

EXPENDITURES CLAIM **

, , $ , , $ , , $ , , $

JUL-DEC 2004 26 4,646,945 $178,347,082 $38.38 1,922,663 $71,852,034 $37.37JAN-JUN 2005 26 4,613,122 $166,886,748 $36.18 2,178,944 $81,479,300 $37.39

21st YEAR TOTAL 9,260,067 $345,233,830 $37.28 4,101,607 $153,331,334 $37.38

JUL-DEC 2005 26 4,632,516 $208,781,508 $45.07 2,451,200 $96,468,947 $39.36JAN-JUN 2006 26 4,484,886 $196,409,910 $43.79 2,708,585 $100,489,805 $37.10

9,117,402 $405,191,418 $44.44 5,159,785 $196,958,752 $38.17

JUL-DEC 2006 26 4,074,738 $126,753,319 $31.11 2,686,230 $77,256,980 $28.76JAN-JUN 2007 26 3,642,398 $82,054,486 $22.53 2,633,012 $59,270,762 $22.51

23rd YEAR TOTAL 7,717,136 $208,807,805 $27.06 5,319,242 $136,527,742 $25.67

JUL-DEC 2007 26 3,491,014 $99,077,033 $28.38 2,688,584 $85,271,656 $31.72JAN-JUN 2008 26 3,015,416 $70,145,582 $23.26 2,947,413 $67,641,825 $22.95

24th YEAR TOTAL 6,506,430 $169,222,615 $26.01 5,635,997 $152,913,481 $27.13

JUL-DEC 2008 26 2,882,322 $76,213,073 $26.44 3,082,226 $89,890,137 $29.16JAN-JUN 2009 26 2,675,602 $55,324,827 $20.68 2,960,252 $66,702,151 $22.53

25th YEAR TOTAL 5,557,924 $131,537,900 $23.67 6,042,478 $156,592,288 $25.92

JUL-DEC 2009 26 2,560,054 $63,361,329 $24.75 3,031,954 $91,430,885 $30.16JAN-JUN 2010 26 2,380,428 $56,111,899 $23.57 2,824,223 $76,675,981 $27.15

26th YEAR TOTAL 4,940,482 $119,473,228 $24.18 5,856,177 $168,106,866 $28.71

JUL-DEC 2010 26 2,182,334 $61,837,441 $28.34 2,853,692 $101,435,537 $35.55JAN-JUN 2011 26 2,226,942 $45,437,610 $20.40 3,102,948 $65,404,599 $21.08

27th YEAR TOTAL 4,409,276 $107,275,051 $24.33 5,956,640 $166,840,136 $28.01

22nd YEAR TOTAL

34

PACE PACENET



JUL-DEC 2011 26 2,067,181 $42,933,134 $20.77 3,072,410 $63,057,042 $20.52JAN-JUN 2012 26 2,093,727 $42,352,837 $20.23 3,035,747 $64,106,702 $21.12

28th YEAR TOTAL 4,160,908 $85,285,971 $20.50 6,108,157 $127,163,744 $20.82

JUL-DEC 2012 26 1,924,040 $36,823,185 $19.14 2,963,999 $58,046,309 $19.58JAN-JUN 2013 26 1,853,713 $36,063,995 $19.46 2,897,931 $57,828,530 $19.96

29th YEAR TOTAL 3,777,753 $72,887,180 $19.29 5,861,930 $115,874,839 $19.77

JUL-DEC 2013 26 1,597,139 $31,742,735 $19.87 2,702,648 $55,057,471 $20.3730th YEAR-TO-DATE TOTAL 1,597,139 $31,742,735 $19.87 2,702,648 $55,057,471 $20.37

CUMULATIVE TOTAL 246,083,542 $6,619,912,800 $26.90 59,356,537 $1,628,039,020 $27.43

AVERAGENUMBER STATE SHARE NUMBER OF STATE SHARE

PROCESSED PER PROCESSEDOF PER PROCESSED

Reimbursement formulas for PACE:

July 1, 1984 - June 1985: The lesser of either the Average Wholesale Price (AWP) plus a $2.50 dispensing fee or the Usual and Customary

WEEKS CLAIM * CLAIMS

Charge (U&C), then subtracting a $4.00 cardholder payment.



AVERAGE

EXPENDITURES CLAIM **

manufacturers, recoupments from insurance carriers, or audit disallowances received from providers and enrollees. The number of claims

original, paid claim would be higher than the values shown on this table.

November 22, 1996 - December 31, 2003: The lesser of either the AWP minus 10% plus a $3.50 dispensing fee, or the U&C, then

July 1, 1991 - November 21, 1996: Same as above with copayment increased to $6.00.

July 1, 1985 - June 1991: The lesser of either the AWP plus a $2.75 dispensing fee or the U&C, then subtracting a $4.00 cardholder payment.

* The State Share is the amount paid by the PACE Program for each claim. The State Share per processed claim does not reflect rebates from

includes all original, debit, credit and void claims. Some claims, therefore, do not have a payment associated with them. The State Share per

September 2006 - Present: Program providers are required to accept the Medicare Part D Plan reimbursements for those claims in the coverage

June 2004 - Present: Average state share per claim reflects savings from Medicare Part D.

September 2006 - Present: Program providers are required to accept the Medicare Part D Plan reimbursements for those claims in the coverage

June 2004 - Present: Average state share per claim reflects savings from Medicare Part D.

SOURCE: PDA/MRW200-01 & MRM730-01

copayment can be adjusted annually.


Reimbursement formulas for PACENET:

November 22, 1996 - December 31, 2003: The lesser of either AWP minus 10% plus a $3.50 dispensing fee, or the U&C, then subtracting

subtracting a $6.00 copayment.

June 2004 - December 2005: Average PACE state share per claim reflects additional savings from the Transitional Assistance benefit for Medicare

January 1, 2004 - July 9, 2006: The lesser of either AWP minus 10% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit for a generic product plus a $4.00 dispensing fee, then subtracting a copayment of $6.00 for generics and $9.00 for brand products. The

plus a $4.00 dispensing fee for claims not covered by an enrollee’s Part D Plan.

Discount Program cardholders.

phase received by cardholders who are enrolled in both Medicare Part D and the PACE/PACENET Program. These Part D Plan reimbursementsare comparable to the average commercial rate of AWP minus 17% plus a $2.00 dispensing fee. The Program reimburses at AWP minus 12% plus a $4.00 dispensing fee for claims not covered by an enrollee’s Part D Plan.

generic product plus a $4.00 dispensing fee, then subtracting a copayment of $8.00 for generics and $15.00 for brand products. The

** The State Share is the amount paid by the PACENET Program when the cost of the claim(s) exceeds the monthly deductible premium amount plus the copayment. The number of processed claims includes all original, debit, credit and void claims and claims without a State Share payment in the premium deductible phases and all other claims with a State Share payment. Therefore, the State Share per claim on this table is lower

generic product plus a $4.00 dispensing fee, then subtracting a copayment of $8.00 for generics and $15.00 for brand products. The

than the State Share for claims beyond the premium deductible phase. The State Share per processed claim does not reflect rebates frommanufacturers, recoupments from insurance carriers, or audit disallowances received from providers.

phase received by cardholders who are enrolled in both Medicare Part D and the PACE/PACENET Program. These Part D Plan reimbursementsare comparable to the average commercial rate of AWP minus 17% plus a $2.00 dispensing fee. The Program reimburses at AWP minus 12%

July 10, 2006 - Present: The lesser of either AWP minus 12% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit for a

a copayment of $8.00 for generics and $15 for brand products.

January 1, 2004 - July 9, 2006: The lesser of either AWP minus 10% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit for a


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SECTION 4

CARDHOLDER UTILIZATION

DATA

45

NEWLYQUARTER ENROLLED *

1st JUL-SEP 1984 273,001 100.0 273,001PROGRAM OCT-DEC 1984 23,561 7.9 296,562YEAR JAN-MAR 1985 20,941 6.6 317,503

APR-JUN 1985 69,436 17.9 386,939

2nd JUL-SEP 1985 38,750 10.0 389,177PROGRAM OCT-DEC 1985 20,522 5.0 409,699YEAR JAN-MAR 1986 18,770 4.4 428,469

APR-JUN 1986 17,367 3.9 445,836

3rd JUL-SEP 1986 23,595 5.6 420,776PROGRAM OCT-DEC 1986 14,982 3.4 435,758YEAR JAN-MAR 1987 18,130 4.0 453,888

APR-JUN 1987 18,853 4.0 472,741

4th JUL-SEP 1987 26,133 5.9 439,967PROGRAM OCT-DEC 1987 10,432 2.3 450,399YEAR JAN-MAR 1988 13,429 2.9 463,828

APR-JUN 1988 13,944 2.9 477,772

ENROLLMENT NEWLY AT END

QUARTER OF QUARTER**


APR-JUN 1989 57,406 12.7 451,547


APR-JUN 1990 40,169 9.8 408,493


APR-JUN 1991 46,020 12.4 371,592


APR-JUN 1992 44,986 12.2 369,919


APR-JUN 1993 41,397 12.1 341,361


APR-JUN 1994 33,967 10.4 325,090


APR-JUN 1995 31,995 10.5 304,153


APR-JUN 1996 22,518 8.1 279,397

TABLE 4.1PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER

PACE

JULY 1984 - JUNE 1988% OF NEWLY CUMULATIVEENROLLED ENROLLMENTS

PACE

JULY 1988 - JUNE 1996CUMULATIVE % OF

NEWLYENROLLED ENROLLED

47

ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END

QUARTER OF QUARTER** ENROLLED ENROLLED OF QUARTER

13th JUL-SEP 1996 4,127 1.5 267,049PROGRAM OCT-DEC 1996 9,332 3.6 260,678 1,523 100.0 1,523YEAR JAN-MAR 1997 23,797 8.6 275,607 5,771 100.0 5,771

APR-JUN 1997 30,602 11.6 264,414 9,088 100.0 9,088

14th JUL-SEP 1997 4,536 1.8 257,291 1,949 17.7 11,037PROGRAM OCT-DEC 1997 8,694 3.5 250,671 3,801 29.5 12,889YEAR JAN-MAR 1998 16,693 6.6 251,915 5,710 48.5 11,771

APR-JUN 1998 22,838 9.3 245,553 7,419 53.8 13,802

15th JUL-SEP 1998 4,375 1.8 237,753 879 5.8 15,213PROGRAM OCT-DEC 1998 8,042 3.5 230,722 1,504 9.4 15,964YEAR JAN-MAR 1999 14,744 6.4 231,049 3,216 19.9 16,164

APR-JUN 1999 20,672 9.1 227,041 4,722 27.2 17,372

16th JUL-SEP 1999 4,086 1.8 221,535 761 4.2 18,195PROGRAM OCT-DEC 1999 7,981 3.7 217,103 1,510 8.1 18,655YEAR JAN-MAR 2000 18,146 8.2 220,896 4,169 21.6 19,298

APR-JUN 2000 25,583 11.8 217,140 6,125 30.1 20,375


APR-JUN 2001 24,932 12.0 207,193 6,603 28.9 22,875


APR-JUN 2002 22,742 11.4 198,629 9,938 32.7 30,346


APR-JUN 2003 21,287 10.9 194,961 9,654 29.7 32,520


APR-JUN 2004 28,312 14.3 197,600 43,224 49.7 87,007

21st JUL-SEP 2004 4,222 2.2 194,488 7,598 8.1 94,002PROGRAM OCT-DEC 2004 6,717 3.5 191,669 15,186 15.3 99,572YEAR JAN-MAR 2005 13,536 7.0 193,946 25,934 28.2 92,035

APR-JUN 2005 19,467 10.2 190,273 35,063 34.2 102,622

22nd JUL-SEP 2005 3,935 2.1 187,696 6,301 5.9 107,240PROGRAM OCT-DEC 2005 9,001 4.8 188,495 15,579 13.3 116,755YEAR JAN-MAR 2006 14,476 7.6 190,654 25,774 20.8 123,687

APR-JUN 2006 23,477 12.5 187,311 42,841 33.4 128,212

23rd JUL-SEP 2006 2,084 1.1 184,106 3,182 2.5 127,978PROGRAM OCT-DEC 2006 5,269 2.9 179,240 11,330 8.5 132,764YEAR JAN-MAR 2007 8,687 4.8 182,332 19,571 14.6 134,018

APR-JUN 2007 11,621 6.5 178,746 26,974 19.7 136,805


APR-JUN 2008 9,712 6.3 155,026 29,033 17.2 169,043

TABLE 4.1 PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER


PACE PACENET

CUMULATIVE % OF NEWLY

ENROLLED ENROLLED

48

ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END

QUARTER OF QUARTER** ENROLLED ENROLLED OF QUARTER


APR-JUN 2009 8,521 6.3 134,590 23,075 13.8 167,488


APR-JUN 2010 7,344 5.7 128,651 29,944 16.8 178,574


APR-JUN 2011 6,438 5.4 118,605 20,912 11.6 181,016


APR-JUN 2012 7,259 6.5 110,863 13,971 7.8 178,290


APR-JUN 2013 5,971 5.7 104,853 11,836 6.8 173,220

30th JUL-SEP 2013 966 0.9 102,787 2,555 1.5 170,876PROGRAM OCT-DEC 2013 2,273 2.2 101,375 6,018 3.5 173,456YEAR

* THE NEWLY ENROLLED NUMBER IS CALCULATED AS A TOTAL FOR THE QUARTER.** ENROLLMENT AT END OF QUARTER REPRESENTS THE ENROLLMENT REPORTED ON THE LAST DAY OF THE QUARTER (I.E., 101,375 PACE CARDHOLDERS AND 173,456 PACENET CARDHOLDERS ON THE FILE ON DECEMBER 31, 2013).

SOURCE: PDA/MR-0-01A/CARDHOLDER FILE

TABLE 4.1 PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER


PACE PACENET

CUMULATIVE % OF NEWLY

ENROLLED ENROLLED

49

PA

GE

1

CLA

IMS

PE

RS

TATE

SH

AR

E P

ER

OF

ALL

TOTA

LP

AR

TIC

IPA

TIN

GS

TATE

SH

AR

EP

AR

TIC

IPA

TIN

GS

TATE

SH

AR

EC

LAIM

SC

AR

DH

OLD

ER

EX

PE

ND

ITU

RE

SC

AR

DH

OLD

ER

TOTA

L11

9,49

194

,296

3,67

2,46

610

0.0

38.9

$72,

166,

997

$765

.32

100.

0

SE

X FEM

ALE

94,0

8976

,688

3,04

6,51

283

.039

.7$5

9,13

6,57

8$7

71.1

381

.9

MA

LE25

,402

17,6

0862

5,95

417

.035

.5$1

3,03

0,41

9$7

40.0

318

.1

AG

E 65-6

9 Y

EA

RS

15,4

2310

,355

300,

323

8.2

29.0

$6,4

98,1

86$6

27.5

49.

0

70-7

4 Y

EA

RS

19,4

3814

,965

554,

794

15.1

37.1

$11,

472,

301

$766

.61

15.9

75-7

9 Y

EA

RS

22,4

9618

,040

719,

351

19.6

39.9

$15,

097,

487

$836

.89

20.9

80-8

4 Y

EA

RS

24,6

6320

,403

848,

324

23.1

41.6

$16,

813,

849

$824

.09

23.3

85 Y

EA

RS

OR

OV

ER

37,4

7130

,533

1,24

9,67

434

.040

.9$2

2,28

5,17

5$7

29.8

730

.9

RE

SID

EN

CE

TY

PE

OW

N65

,474

52,5

112,

016,

126

54.9

38.4

$41,

662,

481

$793

.40

57.7

RE

NT

33,2

5425

,275

981,

627

26.7

38.8

$17,

359,

692

$686

.83

24.1

NU

RS

ING

HO

ME

/1,

973

1,50

083

,801

2.3

55.9

$1,3

50,1

82$9

00.1

21.

9 P

ER

SO

NA

L C

AR

E H

OM

E

LIV

E W

ITH

RE

LATI

VE

10,1

738,

066

319,

850

8.7

39.7

$6,8

36,6

48$8

47.5

99.

5

OTH

ER

7,31

45,

936

232,

578

6.3

39.2

$4,1

47,8

06$6

98.7

55.

7

MIS

SIN

G1,

303

1,00

838

,484

1.0

38.2

$810

,188

$803

.76

1.1

MA

RIT

AL

STA

TUS

SIN

GLE

OR

WID

OW

ED

91,2

5772

,914

2,89

0,77

778

.739

.6$5

5,46

5,06

2$7

60.6

976

.9

MA

RR

IED

9,43

07,

061

255,

448

7.0

36.2

$5,4

04,8

41$7

65.4

57.

5

DIV

OR

CE

D14

,509

11,0

6039

8,53

610

.936

.0$8

,601

,092

$777

.68

11.9

MA

RR

IED

, LIV

ING

4,29

53,

261

127,

705

3.5

39.2

$2,6

96,0

02$8

26.7

43.

7 S

EP

AR

ATE

LY

PE

RC

EN

TO

F TO

TAL

CLA

IMS

PE

RC

EN

T

EX

PE

ND

ITU

RE

S

TA

BL

E 4

.2A

PA

CE

CA

RD

HO

LD

ER

EN

RO

LL

ME

NT

, PA

RT

ICIP

AT

ION

, UT

ILIZ

AT

ION

, AN

D E

XP

EN

DIT

UR

ES

BY

DE

MO

GR

AP

HIC

CH

AR

AC

TE

RIS

TIC

SJA

NU

AR

Y -

DE

CE

MB

ER

201

3

CA

RD

HO

LDE

RS

EN

RO

LLE

DTO

TAL

CA

RD

HO

LDE

RS

PA

RTI

CIP

ATI

NG

TOTA

L

50

PA

GE

2

CLA

IMS

PE

RS

TATE

SH

AR

E P

ER

OF

ALL

TOTA

LP

AR

TIC

IPA

TIN

GS

TATE

SH

AR

EP

AR

TIC

IPA

TIN

GS

TATE

SH

AR

EC

LAIM

SC

AR

DH

OLD

ER

EX

PE

ND

ITU

RE

SC

AR

DH

OLD

ER

PE

RC

EN

TO

F TO

TAL

CLA

IMS

PE

RC

EN

T

EX

PE

ND

ITU

RE

S

TA

BL

E 4

.2A

PA

CE

CA

RD

HO

LD

ER

EN

RO

LL

ME

NT

, PA

RT

ICIP

AT

ION

, UT

ILIZ

AT

ION

, AN

D E

XP

EN

DIT

UR

ES

BY

DE

MO

GR

AP

HIC

CH

AR

AC

TE

RIS

TIC

SJA

NU

AR

Y -

DE

CE

MB

ER

201

3

CA

RD

HO

LDE

RS

EN

RO

LLE

DTO

TAL

CA

RD

HO

LDE

RS

PA

RTI

CIP

ATI

NG

TOTA

L

ETH

NIC

OR

IGIN

WH

ITE

98,3

2579

,830

3,20

3,13

187

.240

.1$6

1,60

8,00

2$7

71.7

485

.4

AFR

ICA

N-A

ME

RIC

AN

10,3

737,

067

227,

680

6.2

32.2

$4,8

59,4

74$6

87.6

36.

7

AM

ER

ICA

N IN

DIA

N15

411

23,

849

0.1

34.4

$85,

673

$764

.94

0.1

HIS

PA

NIC

1,86

31,

183

40,5

231.

134

.3$7

82,4

86$6

61.4

41.

1

AS

IAN

1044

655

16,3

630.

425

.0$5

73,1

98$8

75.1

10.

8

OTH

ER

1,01

569

720

,562

0.6

29.5

$680

,953

$976

.98

0.9

MIS

SIN

G6,

717

4,75

216

0,35

84.

433

.7$3

,577

,211

$752

.78

5.0

INC

OM

E -

SIN

GLE

$0-$

2,99

92,

364

1,14

840

,935

1.1

35.7

$1,1

62,6

69$1

,012

.78

1.6

$3,0

00-$

5,99

93,

078

2,41

091

,269

2.5

37.9

$1,6

23,7

84$6

73.7

72.

3

$6,0

00-$

8,99

911

,461

8,92

132

1,63

28.

836

.1$6

,999

,939

$784

.66

9.7

$9,0

00-$

11,9

9928

,790

22,6

0385

9,08

823

.438

.0$1

6,80

1,29

6$7

43.3

223

.3

$12,

000-

$14,

500

50,1

3440

,287

1,60

0,00

743

.639

.7$2

9,99

1,27

1$7

44.4

441

.6

$14,

500

+14

,234

11,8

6650

4,08

713

.742

.5$1

0,18

3,19

6$8

58.1

814

.1

INC

OM

E -

MA

RR

IED

$0-$

2,99

931

617

63,

778

0.1

21.5

$183

,361

$1,0

41.8

20.

3

$3,0

00-$

5,99

912

073

2,43

50.

133

.4$6

5,85

5$9

02.1

20.

1

$6,0

00-$

8,99

929

417

05,

406

0.1

31.8

$119

,784

$704

.61

0.2

$9,0

00-$

11,9

9959

340

613

,420

0.4

33.1

$330

,703

$814

.54

0.5

$12,

000-

$14,

999

1,52

61,

137

39,9

381.

135

.1$1

,103

,586

$970

.61

1.5

$15,

000-

$17,

700

4,50

33,

418

122,

581

3.3

35.9

$2,3

84,7

08$6

97.6

93.

3

$17,

700

+2,

078

1,68

167

,890

1.8

40.4

$1,2

16,8

46$7

23.8

81.

7

SO

UR

CE

: P

DA

/CLA

IMS

HIS

TOR

Y, C

AR

DH

OLD

ER

FIL

EN

OTE

: DA

TA IN

CLU

DE

OR

IGIN

AL,

PA

ID C

LAIM

S B

Y D

ATE

OF

SE

RV

ICE

, EX

CLU

DE

PA

CE

NE

T C

LAIM

S.

THE

HIG

HE

ST

INC

OM

E C

ATE

GO

RY

INC

LUD

ES

CA

RD

HO

LDE

RS

WH

O H

AV

E R

EM

AIN

ED

IN T

HE

PR

OG

RA

M E

VE

N T

HO

UG

H T

HE

IR IN

CO

ME

S E

XC

EE

D IN

CO

ME

E

LIG

IBIL

ITY

LIM

ITS

DU

E T

O N

OM

INA

L IN

CR

EA

SE

S IN

TH

EIR

SO

CIA

L S

EC

UR

ITY

INC

OM

E.

THIS

INC

OM

E G

RO

UP

MA

Y A

LSO

INC

LUD

E C

ARD

HO

LDE

RS

WH

O E

XC

EE

D

THE

INC

OM

E L

IMIT

S A

ND

LO

SE

ELI

GIB

ILIT

Y D

UR

ING

TH

E Y

EA

R.

51

PA

GE

1

TOTA

LS

TATE

% O

FC

AR

DH

OLD

ER

SH

AR

ETO

TAL

TOTA

LTO

TAL

AN

D T

PL

EX

PE

ND

I-C

LAIM

SC

LAIM

SE

XP

EN

DIT

UR

ES

EX

PE

ND

ITU

RE

STU

RE

S

TOTA

L19

5,78

815

4,52

95,

776,

051

100.

037

.4$4

17,2

57,8

83$3

01,0

90,0

5072

.2$1

16,1

67,8

3327

.8$7

51.7

510

0.0

SE

X FEM

ALE

131,

172

107,

437

4,12

8,23

371

.538

.4$2

92,0

57,7

76$2

11,6

42,0

4172

.5$8

0,41

5,73

527

.5$7

48.4

969

.2M

ALE

64,6

1647

,092

1,64

7,81

828

.535

.0$1

25,2

00,1

07$8

9,44

8,00

871

.4$3

5,75

2,09

928

.6$7

59.2

030

.8

AG

E 65-6

9 Y

EA

RS

29,8

8621

,264

645,

927

11.2

30.4

$56,

323,

621

$41,

780,

844

74.2

$14,

542,

777

25.8

$683

.92

12.5

70-7

4 Y

EA

RS

36,5

9028

,886

1,04

6,89

918

.136

.2$8

5,75

2,05

6$6

2,19

8,65

672

.5$2

3,55

3,40

127

.5$8

15.3

920

.375

-79

YE

AR

S39

,898

32,2

121,

237,

853

21.4

38.4

$94,

026,

750

$67,

666,

166

72.0

$26,

360,

583

28.0

$818

.35

22.7

80-8

4 Y

EA

RS

41,1

0733

,512

1,30

8,00

522

.639

.0$9

0,32

4,33

1$6

4,34

2,07

071

.2$2

5,98

2,26

128

.8$7

75.3

122

.485

YE

AR

S O

R O

VE

R48

,307

38,6

551,

537,

367

26.6

39.8

$90,

831,

125

$65,

102,

314

71.7

$25,

728,

811

28.3

$665

.60

22.1

RE

SID

EN

CE

TY

PE

OW

N13

4,32

910

6,05

13,

836,

041

66.4

36.2

$279

,970

,810

$201

,149

,586

71.8

$78,

821,

223

28.2

$743

.24

67.9

RE

NT

39,9

1930

,984

1,20

1,05

920

.838

.8$8

4,99

6,33

8$6

1,93

8,52

172

.9$2

3,05

7,81

727

.1$7

44.1

819

.8N

UR

SIN

G H

OM

E/

3,26

12,

625

154,

725

2.7

58.9

$8,4

47,2

21$6

,062

,522

71.8

$2,3

84,6

9828

.2$9

08.4

62.

1

PE

RS

. CA

RE

HO

ME

LIV

E W

ITH

RE

LATI

VE

9,82

18,

106

323,

868

5.6

40.0

$24,

917,

844

$18,

028,

982

72.4

$6,8

88,8

6227

.6$8

49.8

55.

9O

THE

R6,

746

5,38

820

9,99

53.

639

.0$1

5,03

9,63

5$1

1,04

1,24

973

.4$3

,998

,386

26.6

$742

.09

3.4

MIS

SIN

G1,

712

1,37

550

,363

0.9

36.6

$3,8

86,0

36$2

,869

,189

73.8

$1,0

16,8

4726

.2$7

39.5

30.

9

MA

RIT

AL

STA

TUS

SIN

GLE

OR

WID

OW

ED

108,

125

86,8

923,

364,

825

58.3

38.7

$233

,293

,773

$168

,814

,996

72.4

$64,

478,

778

27.6

$742

.06

55.5

MA

RR

IED

69,0

2953

,356

1,89

7,20

832

.835

.6$1

43,0

25,0

17$1

02,7

22,1

8071

.8$4

0,30

2,83

728

.2$7

55.3

634

.7D

IVO

RC

ED

15,1

6411

,606

408,

683

7.1

35.2

$32,

917,

443

$23,

809,

884

72.3

$9,1

07,5

5927

.7$7

84.7

37.

8M

AR

RIE

D, L

IVIN

G3,

470

2,67

510

5,33

51.

839

.4$8

,021

,649

$5,7

42,9

9071

.6$2

,278

,659

28.4

$851

.84

2.0

SE

PA

RA

TELY

ETH

NIC

OR

IGIN

WH

ITE

166,

279

133,

029

5,07

6,48

187

.938

.2$3

64,9

50,1

09$2

63,5

49,0

3872

.2$1

01,4

01,0

7127

.8$7

62.2

587

.3A

FRIC

AN

-AM

ER

ICA

N10

,309

7,42

923

7,23

94.

131

.9$1

8,05

5,00

4$1

2,79

1,81

470

.8$5

,263

,191

29.2

$708

.47

4.5

AM

ER

ICA

N IN

DIA

N19

013

04,

262

0.1

32.8

$339

,068

$247

,885

73.1

$91,

183

26.9

$701

.41

0.1

HIS

PA

NIC

1,73

31,

244

40,2

620.

732

.4$2

,952

,813

$2,1

91,3

5174

.2$7

61,4

6225

.8$6

12.1

10.

7A

SIA

N82

455

513

,112

0.2

23.6

$1,3

44,3

10$9

20,2

7468

.5$4

24,0

3631

.5$7

64.0

30.

4O

THE

R1,

866

1,39

144

,866

0.8

32.3

$3,4

66,0

61$2

,514

,233

72.5

$951

,828

27.5

$684

.28

0.8

MIS

SIN

G14

,587

10,7

5135

9,82

96.

233

.5$2

6,15

0,51

8$1

8,87

5,45

572

.2$7

,275

,063

27.8

$676

.69

6.3

AN

D T

PL

TUR

ES

CLA

IMS

CA

RD

HO

LDE

RS

EN

RO

LLE

DTO

TAL

CA

RD

HO

LDE

RS

PA

RTI

CIP

ATI

NG

TOTA

L

CA

RD

HO

LDE

R

STA

TES

HA

RE

EX

PE

ND

I -TU

RE

SP

ATI

NG

SH

AR

E P

ER

PA

RTI

CI-

EX

PE

ND

I-

TA

BL

E 4

.2B

PA

CE

NE

T C

AR

DH

OL

DE

R E

NR

OL

LM

EN

T, P

AR

TIC

IPA

TIO

N, U

TIL

IZA

TIO

N, A

ND

EX

PE

ND

ITU

RE

S

JAN

UA

RY

- D

EC

EM

BE

R 2

013

BY

DE

MO

GR

AP

HIC

CH

AR

AC

TE

RIS

TIC

S

% O

F

PE

R

CA

RD

HO

LDE

RS

TATE

SH

AR

E (%

)

EX

PE

ND

I-TU

RE

SC

IPA

NT

OF

TOTA

LP

AR

TI-

STA

TES

HA

RE

(%)

OF

TOTA

L

52

PA

GE

2

TOTA

LS

TATE

% O

FC

AR

DH

OLD

ER

SH

AR

ETO

TAL

TOTA

LTO

TAL

AN

D T

PL

EX

PE

ND

I-C

LAIM

SC

LAIM

SE

XP

EN

DIT

UR

ES

EX

PE

ND

ITU

RE

STU

RE

S

AN

D T

PL

TUR

ES

CLA

IMS

CA

RD

HO

LDE

RS

EN

RO

LLE

DTO

TAL

CA

RD

HO

LDE

RS

PA

RTI

CIP

ATI

NG

TOTA

L

CA

RD

HO

LDE

R

STA

TES

HA

RE

EX

PE

ND

I -TU

RE

SP

ATI

NG

SH

AR

E P

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ME

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AR

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AR

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CO

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8

NO

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PA

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MS

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OR

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AR

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SU

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OR

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UG

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AT

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D

56

TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES


PAGE 1

PACE PACENET TOTAL

Part D, Auto-Enrolled 45,560 53,688 98,364Part D, Not Auto-Enrolled 59,172 111,942 168,268Not Enrolled in Part D 14,759 30,158 44,300Total PACE/PACENET Enrolled 119,491 195,788 310,932

Part D, Auto-Enrolled 39,717 48,781 87,761Part D, Not Auto-Enrolled 44,640 89,174 131,988Not Enrolled in Part D 9,939 16,574 26,194Total Participating Cardholders 94,296 154,529 245,943

Part D, Auto-Enrolled 1,686,063 2,152,657 3,838,720Part D, Not Auto-Enrolled 1,582,563 3,053,876 4,636,439Not Enrolled in Part D 403,840 569,518 973,358Total Claims 3,672,466 5,776,051 9,448,517

Part D, Auto-Enrolled 37.01 40.10 39.03Part D, Not Auto-Enrolled 26.75 27.28 27.55Not Enrolled in Part D 27.36 18.88 21.97All PACE/PACENET Enrolled 30.73 29.50 30.39

Part D, Auto-Enrolled $26,076,055 $32,532,218 $58,608,273Part D, Not Auto-Enrolled $21,879,818 $54,371,017 $76,250,835Not Enrolled in Part D $24,211,124 $29,264,599 $53,475,722All PACE/PACENET Enrolled $72,166,997 $116,167,833 $188,334,830

Part D, Auto-Enrolled $15.47 $15.11 $15.27Part D, Not Auto-Enrolled $13.83 $17.80 $16.45Not Enrolled in Part D $59.95 $51.38 $54.94All PACE/PACENET Enrolled $19.65 $20.11 $19.93




Total Cardholder Expenditures

Cardholder Share Per Claim

TPL Share

State Share Expenditures

State Share Per Claim

Enrolled Cardholders

Participating Cardholders

Claims

Claims Per Enrollee

57

TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES


PAGE 2

PACE PACENET TOTAL



Full LIS 20,879 5,220 25,955Partial LIS 3,186 3,319 6,451No LIS 21,495 45,149 65,958Total Auto-Enrolled Cardholders 45,560 53,688 98,364

Part D LIS Status Among Other Part D EnrolledFull LIS 30,044 11,823 41,142Partial LIS 4,119 7,705 11,635No LIS 25,009 92,414 115,491Total Other Part D Enrolled Cardholders 59,172 111,942 168,268

Notes: Auto-enrolled cardholders include individuals who were auto-enrolled by PACE/PACENET into Part D plans for 2013. The expenditure totals shown are based only on claims that were recorded in the PACE/PACENET claim adjudication system. There may be additional prescription expenditures that were not submitted to PACE/PACENET.

Total Expenditures (State, Cardholder, TPL)

Part D LIS Status Among Auto-Enrolled

TPL Share Per Claim

58

TOTA

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7,57

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91,0

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65,5

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29,4

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6,80

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66,4

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70,5

98

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70.0

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5,85

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PA

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76,0

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9,09

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033,

155

$92,

265,

794

> $2

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NO

PA

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730

548,

312

$53,

174,

316

$43,

496,

298

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176,

763

PA

RT

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3,17

6,25

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15,5

60$9

0,40

7,99

0$3

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3,77

4$2

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23,7

96TO

TAL

75,0

874,

910,

689

$487

,661

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$148

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$41,

852,

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$297

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$2,9

70.0

1-$6

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$6,9

54.5

2*N

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AR

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5,33

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8,73

3$2

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6$1

9,05

2,24

3$3

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$1,8

76,9

87P

AR

T D

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14,4

4084

8,81

3$6

5,32

7,78

2$7

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$3,8

74,6

67$5

4,01

5,57

2P

AR

T D

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LIS

34,6

422,

027,

522

$156

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$47,

319,

946

$19,

576,

404

$90,

074,

410

TOTA

L54

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3,20

5,06

8$2

46,6

41,8

08$7

3,80

9,73

3$2

6,86

5,10

7$1

45,9

66,9

69

> $6

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.75/

$6,9

54.5

2*N

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AR

T D

2,39

121

9,57

9$2

8,83

1,05

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4,44

4,05

5$2

,303

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$2,0

82,9

98P

AR

T D

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4,39

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DE

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201

3

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OF

% U

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AN

VE

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O

564

1,19

21,

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0.6

1,37

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63,2

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368

835

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489

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019

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TON

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040

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ING

36

157

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80.

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16.5

$449

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11,5

1117

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$289

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YO

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3,

205

6,78

19,

833

3.2

7,79

682

75.3

$4,6

40,0

8999

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727

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17,9

14$3

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SO

UR

CE

: P

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; CLA

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: D

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67

SECTION 6

PROVIDER DATA

69

PR

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NO

.%

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.%

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IND

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MU

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IND

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$12,

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55.0

$71.

69$3

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13.9

$61.

55$7

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0$2

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9,41

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DIS

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$30,

911

73.4

$363

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$9,0

3621

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22.7

2$2

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010

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$176

.28

PH

YS

ICIA

NS

INS

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L$7

1,61

932

.5$6

5.35

$37,

953

17.2

$50.

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2450

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.52

$220

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100.

0$1

4.83

PH

AR

MA

CIE

S

CH

AIN

$23,

828,

021

55.7

$71.

91$6

,286

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14.7

$59.

24$1

2,68

9,44

329

.6$7

.22

$42,

803,

676

100.

0$1

9.49

PH

AR

MA

CIE

S

NU

RS

ING

HO

ME

$2,6

96,0

3253

.2$6

0.45

$595

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11.8

$46.

89$1

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35.1

$6.5

4$5

,069

,990

100.

0$1

5.40

PH

AR

MA

CIE

S

MA

IL O

RD

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$859

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85.9

$217

.11

$73,

925

7.4

$60.

15$6

7,36

26.

7$3

.51

$1,0

00,8

2010

0.0

$41.

03P

HA

RM

AC

IES

TOTA

L$4

0,13

1,36

355

.6$7

1.99

$10,

195,

547

14.1

$59.

04$2

1,81

9,61

430

.2$7

.40

$72,

146,

525

100.

0$1

9.61

SO

UR

CE

: PD

A/P

S-0

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, CLA

IMS

HIS

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Y N

OTE

: DA

TA IN

CLU

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AL,

PA

ID C

LAIM

S B

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OF

PA

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T, E

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AC

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ET

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.

BR

AN

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%

TA

BL

E 6

.2P

AC

E E

XP

EN

DIT

UR

ES

AN

D A

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RA

GE

ST

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T A

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PR

OV

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R T

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AR

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DE

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3

PR

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R

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BR

AN

D M

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I-SO

UR

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GE

NE

RIC

TOTA

L, A

LL P

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DU

CTS

EX

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ND

ITU

RE

%

AV

ER

AG

E

STA

TE

SH

AR

E

AV

ER

AG

E

STA

TE

SH

AR

E

AV

ER

AG

E

STA

TE

SH

AR

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AV

ER

AG

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XP

EN

DIT

UR

E

%E

XP

EN

DIT

UR

E

%

72

TA

BL

E 6

.3P

AC

EN

ET

CL

AIM

S A

ND

EX

PE

ND

ITU

RE

S B

Y P

RO

VID

ER

TY

PE

JAN

UA

RY

- D

EC

EM

BE

R 2

013

CO

PA

IDTO

TAL

CA

RD

HO

LDE

RO

THE

R P

AY

ER

STA

TE S

HA

RE

TOTA

LC

LAIM

SC

LAIM

SE

XP

EN

DIT

UR

ES

EX

PE

ND

ITU

RE

SE

XP

EN

DIT

UR

ES

EX

PE

ND

ITU

RE

S

IND

EP

EN

DE

NT

PH

AR

MA

CIE

S1,

000

914

341,

426

1,27

8,40

91,

619,

835

28.1

$15,

635,

871

$63,

353,

128

$33,

434,

697

$112

,423

,696

27.1

DIS

PE

NS

ING

P

HY

SIC

IAN

S94

2929

550

579

0.0

$7,7

00$1

,107

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$212

,544

$1,3

28,1

060.

3

INS

TITU

TIO

NA

L P

HA

RM

AC

IES

3027

2,18

712

,320

14,5

070.

3$1

14,6

15$7

74,3

38$3

67,2

54$1

,256

,207

0.3

CH

AIN

P

HA

RM

AC

IES

1,86

31,

849

716,

336

2,83

0,12

53,

546,

461

61.4

$35,

288,

384

$149

,205

,622

$71,

720,

627

$256

,214

,633

61.8

NU

RS

ING

H

OM

E

PH

AR

MA

CIE

S15

114

510

4,01

440

5,55

050

9,56

48.

8$4

,125

,842

$16,

213,

896

$7,5

19,1

55$2

7,85

8,89

36.

7

MA

IL O

RD

ER

P

HA

RM

AC

IES

4027

4,46

279

,193

83,6

551.

4$1

,185

,772

$12,

023,

950

$2,5

10,7

51$1

5,72

0,47

23.

8

TOTA

L (A

LL

PR

OV

IDE

RS

)3,

178

2,99

11,

168,

454

4,60

6,14

75,

774,

601

100.

0$5

6,35

8,18

4$2

42,6

78,7

95$1

15,7

65,0

27$4

14,8

02,0

0710

0.0

SO

UR

CE

: P

DA

/CLA

IMS

HIS

TOR

Y

NO

TE:

DA

TA IN

CLU

DE

OR

IGIN

AL,

PA

ID C

LAIM

S B

Y D

ATE

OF

PA

YM

EN

T.

PA

CE

NE

T C

AR

DH

OLD

ER

S W

HO

AR

E N

OT

EN

RO

LLE

D IN

PA

RT

D A

RE

RE

QU

IRE

D T

O P

AY

TH

E B

EN

CH

MA

RK

AM

OU

NT

PR

IOR

TO

AN

Y P

AC

EN

ET

CLA

IM C

OV

ER

AG

E.

EN

RO

LLE

D

EX

PE

ND

ITU

RE

S

PR

OV

IDE

R

TYP

E

PR

OV

IDE

RS

% O

FC

LAIM

SD

ED

UC

TIB

LEC

LAIM

S1

CLA

IMS

% O

F TO

TAL

EX

PE

ND

ITU

RE

SP

AR

TIC

I-P

ATI

NG

1 IN 2

013,

TH

E M

ON

THLY

PA

CE

NE

T D

ED

UC

TIB

LE W

AS

CH

AN

GE

D T

O $

36.5

7 TO

CO

INC

IDE

WIT

H T

HE

RE

GIO

NA

L M

ED

ICA

RE

PA

RT

D P

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MIU

M B

EN

CH

MA

RK

.

73

TABLE 6.4

PACENET CLAIMS VOLUME BY PHASE OF COVERAGE1, PRODUCT TYPE, AND PROVIDER TYPEJANUARY - DECEMBER 2013

PROVIDER TYPE NO. % NO. % NO. % NO. %

INDEPENDENT PHARMACIES 14,278 4.2 6,233 1.8 320,915 94.0 341,426 100.0

DISPENSING PHYSICIANS 2 6.9 1 3.4 26 89.7 29 100.0

INSTITUTIONAL PHARMACIES 73 3.3 90 4.1 2,024 92.5 2,187 100.0

CHAIN PHARMACIES 26,926 3.8 15,154 2.1 674,256 94.1 716,336 100.0

NURSING HOME PHARMACIES 4,632 4.5 2,050 2.0 97,332 93.6 104,014 100.0

MAIL ORDER PHARMACIES 349 7.8 91 2.0 4,022 90.1 4,462 100.0

TOTAL (ALL PROVIDERS) 46,260 4.0 23,619 2.0 1,098,575 94.0 1,168,454 100.0

PROVIDER TYPE NO. % NO. % NO. % NO. %

INDEPENDENT PHARMACIES 248,639 19.4 65,115 5.1 964,655 75.5 1,278,409 100.0

DISPENSING PHYSICIANS 304 55.3 35 6.4 211 38.4 550 100.0

INSTITUTIONAL PHARMACIES 1,429 11.6 717 5.8 10,174 82.6 12,320 100.0

CHAIN PHARMACIES 539,428 19.1 147,660 5.2 2,143,037 75.7 2,830,125 100.0

NURSING HOME PHARMACIES 66,134 16.3 17,422 4.3 321,994 79.4 405,550 100.0

MAIL ORDER PHARMACIES 11,659 14.7 3,385 4.3 64,149 81.0 79,193 100.0

TOTAL (ALL PROVIDERS) 867,593 18.8 234,334 5.1 3,504,220 76.1 4,606,147 100.0

SOURCE: PDA/CLAIMS HISTORYNOTE: DATA INCLUDE ORIGINAL, PAID CLAIMS BY DATE OF PAYMENT.

THE DEDUCTIBLE. GENERIC UTILIZATION RATES MAY THEREFORE BE HIGHER IN THE DEDUCTIBLE PHASE

FOR WHICH THE TOTAL PRICE IS LESS THAN THE $8 OR $15 COPAY ARE NOT NECESSARILY SUBMITTED DURING THE COPAYMENT PHASE, BUT MAY BE SUBMITTED DURING THE DEDUCTIBLE PHASE TO SATISFY

DUE TO THE OVER-REPRESENTATION OF LOW-PRICED GENERIC CLAIMS.

1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONALMEDICARE PART D PREMIUM BENCHMARK. PACENET CARDHOLDERS WHO ARE NOT ENROLLED IN PART D ARE REQUIRED TO PAY THE BENCHMARK AMOUNT PRIOR TO ANY PACENET CLAIM COVERAGE. THE DEDUCT-IBLE AND COPAYMENT PHASES DIFFER IN THE TYPES OF CLAIMS SUBMITTED. LOW-PRICED PRESCRIPTIONS

TOTAL(ALL PRODUCTS)

SINGLE-SOURCE MULTI-SOURCE GENERIC (ALL PRODUCTS)BRAND BRAND TOTAL

DEDUCTIBLE PHASE CLAIMS

COPAYMENT PHASE CLAIMS

SINGLE-SOURCE MULTI-SOURCE GENERICBRAND BRAND

74

TABLE 6.5PACENET EXPENDITURES BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPE


PAGE 1

A. DEDUCTIBLE PHASE CLAIMS1

PROVIDER TYPE AMOUNT % AMOUNT % AMOUNT % AMOUNT %

INDEPENDENT PHARMACIESCARDHOLDER EXPENDITURES $376,935 15.5 $104,334 4.3 $1,956,883 80.3 $2,438,152 100.0OTHER PAYER EXPENDITURES $1,819,921 34.4 $345,007 6.5 $3,127,753 59.1 $5,292,682 100.0STATE SHARE EXPENDITURES $2,436 82.2 $98 3.3 $429 14.5 $2,962 100.0TOTAL EXPENDITURES $2,199,292 28.4 $449,438 5.8 $5,085,065 65.8 $7,733,795 100.0

DISPENSING PHYSICIANSCARDHOLDER EXPENDITURES $49 21.7 $11 4.9 $166 73.4 $226 100.0OTHER PAYER EXPENDITURES $930 76.3 $212 17.4 $77 6.3 $1,219 100.0STATE SHARE EXPENDITURES $0 – $0 – $0 – $0 –

TOTAL EXPENDITURES $979 67.8 $223 15.5 $243 16.8 $1,445 100.0

INSTITUTIONAL PHARMACIESCARDHOLDER EXPENDITURES $1,440 9.2 $909 5.8 $13,363 85.1 $15,713 100.0OTHER PAYER EXPENDITURES $34,986 69.7 $1,570 3.1 $13,669 27.2 $50,225 100.0STATE SHARE EXPENDITURES $4,729 99.3 $0 0.0 $35 0.7 $4,764 100.0TOTAL EXPENDITURES $41,155 58.2 $2,479 3.5 $27,067 38.3 $70,702 100.0

CHAIN PHARMACIESCARDHOLDER EXPENDITURES $747,809 14.1 $241,220 4.5 $4,322,271 81.4 $5,311,301 100.0OTHER PAYER EXPENDITURES $3,658,982 34.3 $716,921 6.7 $6,299,543 59.0 $10,675,446 100.0STATE SHARE EXPENDITURES $2,232 86.6 $6 0.2 $340 13.2 $2,577 100.0TOTAL EXPENDITURES $4,409,022 27.6 $958,147 6.0 $10,622,154 66.4 $15,989,324 100.0

NURSING HOME PHARMACIESCARDHOLDER EXPENDITURES $98,019 16.3 $25,949 4.3 $477,786 79.4 $601,755 100.0OTHER PAYER EXPENDITURES $522,043 32.0 $112,902 6.9 $994,185 61.0 $1,629,130 100.0STATE SHARE EXPENDITURES $2,073 65.3 $87 2.7 $1,017 32.0 $3,176 100.0TOTAL EXPENDITURES $622,135 27.9 $138,938 6.2 $1,472,988 65.9 $2,234,061 100.0

MAIL ORDER PHARMACIESCARDHOLDER EXPENDITURES $2,780 11.6 $1,092 4.6 $20,103 83.9 $23,974 100.0OTHER PAYER EXPENDITURES $320,211 81.7 $13,234 3.4 $58,493 14.9 $391,938 100.0STATE SHARE EXPENDITURES $164 100.0 $0 0.0 $0 0.0 $164 100.0TOTAL EXPENDITURES $323,154 77.7 $14,325 3.4 $78,596 18.9 $416,076 100.0

TOTAL (ALL PROVIDERS)CARDHOLDER EXPENDITURES $1,227,033 14.6 $373,515 4.5 $6,790,572 80.9 $8,391,120 100.0OTHER PAYER EXPENDITURES $6,357,073 35.2 $1,189,847 6.6 $10,493,719 58.2 $18,040,639 100.0STATE SHARE EXPENDITURES $11,633 85.3 $190 1.4 $1,821 13.4 $13,643 100.0TOTAL EXPENDITURES $7,595,738 28.7 $1,563,552 5.9 $17,286,113 65.4 $26,445,403 100.0


1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONAL MEDICARE PART DBENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $36.57 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS

THE PRESCRIPTION.

BRAND BRANDSINGLE-SOURCE MULTI-SOURCE GENERIC ALL PRODUCTS

THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF

75

TABLE 6.5PACENET EXPENDITURES BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPE


PAGE 2

B. COPAYMENT PHASE CLAIMS

PROVIDER TYPE AMOUNT % AMOUNT % AMOUNT % AMOUNT %

INDEPENDENT PHARMACIESCARDHOLDER EXPENDITURES $5,173,353 39.2 $1,232,531 9.3 $6,791,836 51.5 $13,197,720 100.0OTHER PAYER EXPENDITURES $39,684,492 68.4 $6,050,218 10.4 $12,325,737 21.2 $58,060,447 100.0STATE SHARE EXPENDITURES $20,199,185 60.4 $4,296,728 12.9 $8,935,822 26.7 $33,431,735 100.0TOTAL EXPENDITURES $65,057,030 62.1 $11,579,477 11.1 $28,053,394 26.8 $104,689,901 100.0

DISPENSING PHYSICIANSCARDHOLDER EXPENDITURES $5,321 71.2 $797 10.7 $1,356 18.1 $7,474 100.0OTHER PAYER EXPENDITURES $1,046,369 94.6 $38,921 3.5 $21,352 1.9 $1,106,643 100.0STATE SHARE EXPENDITURES1 $197,019 92.7 $7,160 3.4 $8,364 3.9 $212,544 100.0TOTAL EXPENDITURES $1,248,710 94.1 $46,879 3.5 $31,072 2.3 $1,326,661 100.0

INSTITUTIONAL PHARMACIESCARDHOLDER EXPENDITURES $26,774 27.1 $10,568 10.7 $61,562 62.2 $98,903 100.0OTHER PAYER EXPENDITURES $561,670 77.6 $57,939 8.0 $104,504 14.4 $724,112 100.0STATE SHARE EXPENDITURES $215,582 59.5 $43,029 11.9 $103,878 28.7 $362,490 100.0TOTAL EXPENDITURES $804,026 67.8 $111,535 9.4 $269,944 22.8 $1,185,505 100.0

CHAIN PHARMACIESCARDHOLDER EXPENDITURES $11,689,561 39.0 $2,792,137 9.3 $15,495,386 51.7 $29,977,083 100.0OTHER PAYER EXPENDITURES $95,153,745 68.7 $14,428,742 10.4 $28,947,690 20.9 $138,530,176 100.0STATE SHARE EXPENDITURES $45,320,238 63.2 $9,205,960 12.8 $17,191,852 24.0 $71,718,050 100.0TOTAL EXPENDITURES $152,163,544 63.3 $26,426,838 11.0 $61,634,927 25.7 $240,225,309 100.0

NURSING HOME PHARMACIESCARDHOLDER EXPENDITURES $1,245,767 35.4 $293,290 8.3 $1,985,029 56.3 $3,524,087 100.0OTHER PAYER EXPENDITURES $9,041,494 62.0 $1,593,590 10.9 $3,949,682 27.1 $14,584,766 100.0STATE SHARE EXPENDITURES $4,253,077 56.6 $854,385 11.4 $2,408,517 32.1 $7,515,979 100.0TOTAL EXPENDITURES $14,540,338 56.7 $2,741,265 10.7 $8,343,228 32.6 $25,624,831 100.0

MAIL ORDER PHARMACIESCARDHOLDER EXPENDITURES $380,733 32.8 $89,736 7.7 $691,329 59.5 $1,161,798 100.0OTHER PAYER EXPENDITURES $8,668,187 74.5 $864,788 7.4 $2,099,036 18.1 $11,632,012 100.0STATE SHARE EXPENDITURES $2,104,861 83.8 $176,916 7.1 $228,810 9.1 $2,510,587 100.0TOTAL EXPENDITURES $11,153,781 72.9 $1,131,440 7.4 $3,019,175 19.7 $15,304,397 100.0

TOTAL (ALL PROVIDERS)CARDHOLDER EXPENDITURES $18,521,508 38.6 $4,419,059 9.2 $25,026,497 52.2 $47,967,064 100.0OTHER PAYER EXPENDITURES $154,155,957 68.6 $23,034,197 10.3 $47,448,002 21.1 $224,638,156 100.0STATE SHARE EXPENDITURES $72,289,963 62.5 $14,584,178 12.6 $28,877,243 25.0 $115,751,384 100.0TOTAL EXPENDITURES $244,967,428 63.1 $42,037,435 10.8 $101,351,741 26.1 $388,356,604 100.0


THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OFTHE PRESCRIPTION.

1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONAL MEDICARE PART D

BRAND BRANDSINGLE-SOURCE MULTI-SOURCE GENERIC ALL PRODUCTS

BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $36.57 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS

76

TABLE 6.6AVERAGE CARDHOLDER AND STATE SHARE COST PER PACENET CLAIM

BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPEJANUARY - DECEMBER 2013

BRAND BRAND BRAND BRANDSINGLE- MULTI- SINGLE- MULTI-SOURCE SOURCE GENERIC TOTAL SOURCE SOURCE GENERIC TOTAL

INDEPENDENT PHARMACIESAVERAGE CARDHOLDER SHARE2 $26.40 $16.74 $6.10 $7.14 $20.81 $18.93 $7.04 $10.32AVERAGE OTHER PAYER SHARE $127.46 $55.35 $9.75 $15.50 $159.61 $92.92 $12.78 $45.42AVERAGE STATE SHARE $0.17 $0.02 $0.00 $0.01 $81.24 $65.99 $9.26 $26.15AVERAGE TOTAL RX COST $154.03 $72.11 $15.85 $22.65 $261.65 $177.83 $29.08 $81.89

DISPENSING PHYSICIANSAVERAGE CARDHOLDER SHARE2 $24.47 $11.16 $6.37 $7.78 $17.50 $22.78 $6.42 $13.59AVERAGE OTHER PAYER SHARE $464.93 $212.14 $2.96 $42.03 $3,442.00 $1,112.04 $101.20 $2,012.08AVERAGE STATE SHARE $0.00 $0.00 $0.00 $0.00 $648.09 $204.58 $39.64 $386.44AVERAGE TOTAL RX COST $489.39 $223.30 $9.33 $49.82 $4,107.60 $1,339.41 $147.26 $2,412.11

INSTITUTIONAL PHARMACIESAVERAGE CARDHOLDER SHARE2 $19.73 $10.10 $6.60 $7.18 $18.74 $14.74 $6.05 $8.03AVERAGE OTHER PAYER SHARE $479.26 $17.45 $6.75 $22.97 $393.05 $80.81 $10.27 $58.78AVERAGE STATE SHARE $64.78 $0.00 $0.02 $2.18 $150.86 $60.01 $10.21 $29.42AVERAGE TOTAL RX COST $563.77 $27.55 $13.37 $32.33 $562.65 $155.56 $26.53 $96.23

CHAIN PHARMACIESAVERAGE CARDHOLDER SHARE2 $27.77 $15.92 $6.41 $7.41 $21.67 $18.91 $7.23 $10.59AVERAGE OTHER PAYER SHARE $135.89 $47.31 $9.34 $14.90 $176.40 $97.72 $13.51 $48.95AVERAGE STATE SHARE $0.08 $0.00 $0.00 $0.00 $84.02 $62.35 $8.02 $25.34AVERAGE TOTAL RX COST $163.75 $63.23 $15.75 $22.32 $282.08 $178.97 $28.76 $84.88

NURSING HOME PHARMACIESAVERAGE CARDHOLDER SHARE2 $21.16 $12.66 $4.91 $5.79 $18.84 $16.83 $6.16 $8.69AVERAGE OTHER PAYER SHARE $112.70 $55.07 $10.21 $15.66 $136.71 $91.47 $12.27 $35.96AVERAGE STATE SHARE $0.45 $0.04 $0.01 $0.03 $64.31 $49.04 $7.48 $18.53AVERAGE TOTAL RX COST $134.31 $67.77 $15.13 $21.48 $219.86 $157.35 $25.91 $63.19

MAIL ORDER PHARMACIESAVERAGE CARDHOLDER SHARE2 $7.96 $12.00 $5.00 $5.37 $32.66 $26.51 $10.78 $14.67AVERAGE OTHER PAYER SHARE $917.51 $145.43 $14.54 $87.84 $743.48 $255.48 $32.72 $146.88AVERAGE STATE SHARE $0.47 $0.00 $0.00 $0.04 $180.54 $52.26 $3.57 $31.70AVERAGE TOTAL RX COST $925.94 $157.42 $19.54 $93.25 $956.67 $334.25 $47.07 $193.25

TOTAL (ALL PROVIDERS)AVERAGE CARDHOLDER SHARE2 $26.52 $15.81 $6.18 $7.18 $21.35 $18.86 $7.14 $10.41AVERAGE OTHER PAYER SHARE $137.42 $50.38 $9.55 $15.44 $177.68 $98.30 $13.54 $48.77AVERAGE STATE SHARE $0.25 $0.01 $0.00 $0.01 $83.32 $62.24 $8.24 $25.13AVERAGE TOTAL RX COST $164.20 $66.20 $15.74 $22.63 $282.35 $179.39 $28.92 $84.31


PAYMENTS IF BRAND IS CHOSEN OVER GENERIC. THE CARDHOLDER SHARE DURING THE COPAYMENT PHASE MAYTHEREFORE EXCEED THE $8 OR $15 COPAYMENT.

DEDUCTIBLE PHASE1 COPAYMENT PHASE

PROVIDER TYPE

2THE CARDHOLDER SHARE INCLUDES THE DEDUCTIBLE PAYMENTS, COPAYMENTS, AND GENERIC DIFFERENTIAL

1IN 2013, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $36.57 TO COINCIDE WITH THE REGIONAL MEDICARE PART D BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $36.57 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF THE PRESCRIPTION.

77

SECTION 7

THERAPEUTIC CLASS DATA

AND DRUG UTILIZATION

REVIEW DATA

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SECTION 8

PENNSYLVANIA PATIENT

ASSISTANCE CLEARINGHOUSE

89

PENNSYLVANIA PATIENT ASSISTANCE PROGRAM CLEARINGHOUSE (PA PAP) In January 2001, the PACE Program began a referral program to assist Pennsylvanians ages 60 through 64 that facilitated contact between the Area Agency on Aging offices and the patient assistance programs offered by pharmaceutical manufacturers. That Program has evolved in recent years, and, as a result, the Program now accepts applications from individual patients, physician offices, social workers and other agencies throughout the Commonwealth. In late 2004, the name of the Program changed to reflect the Program’s current objectives; it became the Pennsylvania Patient Assistance Program Clearinghouse (PA PAP). The Pharmaceutical Research and Manufacturers of America (PhRMA) represents the country’s leading research-based pharmaceutical and biotechnology companies. Some of these manufacturers offer limited prescription drug assistance to persons who are not eligible for other forms of pharmaceutical coverage and who cannot afford the cost of one or more of their medications. The PA PAP coordinator provides the expertise necessary to determine the likelihood of eligibility for persons seeking assistance from manufacturers’ medication programs, gathers the patient information required to complete the pharmacy assistance applications, offers guidance and assistance to the patient throughout the application and—if successful—reorder processes. In 2006, the Clearinghouse extended assistance to all adult Pennsylvania residents who appear to meet the selected guidelines, without regard to age. Pharmaceutical manufacturers which offer pharmacy assistance programs set their income and eligibility guidelines as individual companies; they limit the products and the length of time for assistance. Typically, the gross household income should be at or below 200% of federal poverty level guidelines, but many manufacturers will consider circumstances of hardship that fall outside their usual guidelines. Household income is one factor of many criteria used by the manufacturers to determine eligibility for medication. Manufacturers require a wide range of information on company-specific forms which further complicates the application and review process. A substantial amount of coordination needs to occur between the PA PAP coordinator, the patient, and the patient’s physician. Since the inception of Medicare Part D, some manufacturers have instituted programs to assist cardholders while they are in the Part D coverage gap. The requirements for the Medicare Part D coverage gap programs differ from the base programs offered by the manufacturers. As a result of different settlements from the Pennsylvania Attorney General’s office, the Pennsylvania Patient Assistance Program Clearinghouse has been able to offer assistance for specific medications to patients who are not eligible for the manufacturer’s assistance programs. Eligible patients can receive a 30-day supply of medication for which they are charged varying copayments based on the program they are enrolled in. At the end of 2013 the Clearinghouse successfully enrolled 362 additional patients into this program. Despite the inherent difficulties of application, the lengthy wait for approval from the manufacturer, and the strictly limited amount of medication granted with each approval, the collaborative efforts of the local and central coordinators responded to inquiries from 26,086 patients after ten years of operation. At the end of 2013, 48% (12,627 persons) were receiving medication assistance through the PA PAP Clearinghouse. The Program successfully referred persons to the PACE Program (1,116), PACENET Program (2,788), VA benefits (60), or other insurance (229). Among the remaining inactive patients, 65 were over the income limits set by the manufacturers and were not eligible for PACE or PACENET benefits. Among the 12,627 persons receiving assistance through the PA PAP Clearinghouse, a total of 41,656 medications were obtained. Current initiatives include continuing to process manufacturers’ pharmacy assistance applications for cardholders who are uninsured, cardholders with Medicare Part D, and to initiate new Programs that are the result of Attorney General lawsuit settlements.

91

APPENDIX A

THE PACE/PACENET MEDICAL EXCEPTION PROCESS BACKGROUND: Act 134-96, the State Lottery Law, requires publication and dissemination of the medical exception process used by the Department of Aging for the Pharmaceutical Assistance Contract for the Elderly (PACE) and for the Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET). Specifically, the legislation addresses the medical exception process with regard to generic substitution when an A-rated therapeutically equivalent medication is available. The law further requires that the Department of Aging distribute the medical exception process to providers and recipients in the Program. THE MEDICAL EXCEPTION PROCESS: Through the online claims processing system, the PACE/PACENET Program provides prospective therapeutic review of prescriptions before the pharmacist dispenses the medication to the cardholder. The review checks for potential drug interactions, duplicative therapies, over-utilization, under-utilization and other misutilization. The Department of Aging, of course, recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. A medical exception will be considered by the Program when the cardholder’s physician indicates the diagnosis, medical rationale, anticipated therapeutic outcomes, the expected length of exception therapy, and the last trial at alternative therapy. Act 134-96 requires a pharmacist to dispense the A-rated, therapeutically equivalent, generic drug to the cardholder if they have a prescription for a multi-source brand product. If a cardholder seeks an exception to this mandate, a pharmacist may request a short term medical exception at the time of dispensing by calling 1-800-835-4080. The PACE Program may grant a 30-day medical exception if requested. Immediately following approval of the exception, the Program sends a follow-up letter to the cardholder’s prescribing physician. This letter serves as notice that the Program granted a temporary medical exception to the mandatory substitution requirement. The letter seeks the therapeutic rationale for continuing the medical exception. The Program allows 30 days for the return of the written medical exception request from the prescriber. If the Program does not receive written documentation, the short term medical exception will expire. If the prescriber does respond to the letter and provides appropriate information, the Program may grant a longer medical exception period. The cardholder may continue to obtain the brand medication without paying the extra cost of a generic differential. The Program may refer a request to a physician consultant or to a therapeutics committee for special review and consideration. The cardholder will receive a short term medical exception until completion of the review process. If the Program denies a request for a medical exception to the mandatory generic requirement, the cardholder may opt to continue using the brand multi-source product and, then, pay the generic differential. If this occurs, the pharmacist must collect the copay for the brand name product plus 70 percent of the average wholesale price of the brand name product from the cardholder. Please direct questions regarding the implementation of the medical exception process to 1-800-835-4080 or in writing to: Mr. Thomas M. Snedden Director, Bureau of Pharmaceutical Assistance Pennsylvania Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919 Source: Pennsylvania Bulletin, Vol. 26, No. 52, December 28, 1996; address change December 8, 1997.

93

APPENDIX B AMERICAN HOSPITAL FORMULARY SERVICE (AHFS) CLASSIFICATIONS

FOR THERAPEUTIC CLASSES USED IN REPORT The American Hospital Formulary Service (AHFS) provides a universal standard of drug classification. Listed below are the AHFS classifications corresponding to the drug classes reported in the tables and figures of this report.

Name of Therapeutic Class AHFS Classification Anti-infective agents 08 Quinolones 08:12.18 Cephalosporins 08:12.06 Antineoplastic agents 10 Autonomic drugs 12 Anticholinergics 12:08 Adrenergic agents 12:12 Blood formation and coagulation agents 20 Cardiovascular drugs 24 Cardiac drugs 24:04 or any below Angiotensin receptor blockers 24:32.08 ACE inhibitors 24:32.04 Cardiac glycosides 24:04.08 Antiarrhythmic agents 24:04.04 Beta blockers 24:24 Calcium channel blockers 24:28 Lipid-lowering agents 24:06 Antihypertensive agents 24:08, 20 Vasodilating agents 24:12 Analgesics/antipyretics 28:08 NSAID's/COX-2 Inhibitors 28:08.04 Opiate agonists 28:08.08 Psychotropic drugs 28:12,16, 20, 24, 28 Anxiolytics, sedatives, hypnotics 28:24 Antidepressants 28:16.04 Antipsychotic agents 28:16.08 Replacement solutions 40:12 Diuretics 40:28, 24:32.20, 52:40.12 Loop diuretics 40:28.08 Thiazide diuretics 40:28.20, 24 Potassium-sparing diuretics 40:28.16, 24:32.20 Respiratory tract agents 48 Eye, ear, nose and throat preparations 52 Gastrointestinal agents 56 H2-receptor antagonists (H2RA's) 56:28.12 Proton pump inhibitors 56:28.36 Miscellaneous anti-ulcer agents 56:28.28, 56:28.32 Hormones and synthetic substances 68 Adrenals and comb. 68:04 Estrogens and comb. 68:16.04 and selected other products Antidiabetic agents (including insulin) 68:20 Thyroid and antithyroid agents 68:36 Drugs for osteoporosis multiple classes (68:16.12, 68:24, 92:24) Theophylline and related smooth muscle relaxants 86:16

SOURCE: AHFS Drug Information

94

APPENDIX C

PACE

PROSPECTIVE DRUG

UTILIZATION REVIEW

CRITERIA

Updated 10/8/2014

95

Angiotensin Converting Enzyme Inhibitors - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose

MG Per Day Date Begun MG Per Day Date Begun Class Date Begun

Angiotensin II Receptor Antagonists - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose Duplicate Therapy

MG Per Day Date Begun MG Per Day Date Begun Class Date Begun

Candesartan (Atacand) No Criteria --- Less than or equal to

32 mg/day 05/19/99 No Criteria ---

Irbesartan (Avapro) No Criteria --- Less than or equal to


Eprosartan (Teveten) No Criteria --- Less than or equal to


Telmisartan (Micardis) No Criteria --- Less than or equal to


Olmesartan (Benicar) No Criteria --- Less than or equal to


Ramipril (Altace)

Moexipril (Univasc)

Perindopril (Aceon)

Less than or equal to 30 mg/day


Benazepril (Lotensin)

Captopril (Capoten)

Enalapril (Vasotec)

Fosinopril (Monopril)

Lisinopril (Prinivil)





---

Quinapril (Accupril)


---

---

No Criteria

No Criteria

No Criteria

No Criteria

---

---



10/18/95

05/13/02

01/12/98

Concurrent with other ACE Inhibitors


05/15/99

05/15/99

No Criteria

No Criteria

No Criteria

No Criteria

Drug Name Generic (Brand)

---

---

No Criteria ---

---

No Criteria

---

---

---

Valsartan (Diovan)

Losartan (Cozaar) No Criteria --- Less than or equal to

100 mg/day 04/22/98


10/22/96

05/13/02

Concurrent with other ACE Inhibitors 01/12/98

10/18/95

10/18/95

10/18/95

10/18/95

10/22/96

10/22/96Concurrent with other ACE Inhibitors

10/22/96

10/22/96


Duplicate Therapy




No Criteria

No Criteria

Less than or equal to 320 mg/day 08/18/97


96

Beta Blockers - Criteria Elements and Implementation Dates

Drug NameGeneric(Brand) MG Per Day Date Begun MG Per Day Date Begun Class Date Begun

Cardiac Glycosides - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose Duplicate TherapyMG Per Day MG Per Day Date Begun Class Date Begun

10/18/95No Criteria



---

No Criteria

No Criteria

---

---

Bisoprolol (Zebeta)

Carvedilol (Coreg)

Digoxin (Lanoxin)

Propranolol (Inderal)

Propranolol LA (Inderal LA)

Metoprolol (Toprol XL)

Nadolol (Corgard)




Propranolol extended release

(Innopran XL)

Sotalol (Betapace)

Timolol (Blocadren)

Atenolol (Tenormin)

Betaxolol (Kerlone)

Carteolol (Cartrol)






Penbutolol (Levatol)

Pindolol (Visken)

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria



---

---

---

---

---

---

---

---

---

10/18/95

10/18/95

08/18/97

---

---

---

---

---



10/18/95

10/18/95

10/18/95

03/29/04

10/18/95

10/18/95

10/18/95

10/18/95

10/18/95



Labetalol (Normodyne)

Metoprolol (Lopressor)

10/18/95


10/18/95

10/18/95Concurrent with other Beta Blockers

No Criteria

No Criteria

Acebutolol (Sectral)

10/18/95

Concurrent with other Beta Blockers

No Criteria ---

10/18/95

10/18/95

10/18/95

10/18/95

10/18/95

Concurrent with other Beta Blockers 10/18/95




10/18/95

10/18/95



Concurrent with other Beta Blockers 12/09/9505/15/99No Criteria Less than or equal to

1200 mg/day

10/18/95



Concurrent with other other Beta Blockers 03/29/04







Less than or equal to .375 mg/day

97

Calcium Channel Blockers - Criteria Elements and Implementation Dates

Drug NameGeneric Maximum Initial Dose Maximum Daily Dose(Brand) MG Per Day Date Begun MG Per Day Date Begun Class Date Begun

Nisoldipine (Sular)

Amlodipine & Atorvastatin

(Caduet)

Nifedipine (Procardia)

Verapamil (Calan, Isoptin)

Felodipine (Plendil)

Isradipine (DynaCirc)

Nicardipine (Cardene)

Diltiazem (Cardizem)

Diltiazem CD (Cardizem CD) 05/15/99





10/18/95---

---

02/14/05

10/18/95

10/18/95

10/18/95

10/18/95

10/18/95

02/14/05

Concurrent with Other Calcium Channel

Blockers

08/18/97

10/18/95



10/18/95

10/18/95

08/18/97


Blockers


Blockers


Blockers

---

---

No Criteria

No Criteria

No Criteria

Less than or equal to 80 mg/day (based on

Atorvastatin)

No Criteria Less than or equal to 120 mg/day---

---

---

---



Less than or equal to 120 mg/day 10/18/95

---


Blockers


Blockers

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria ---


Blockers

---

10/18/95

12/09/95

10/18/95

10/18/95

10/15/95

Bepridil (Vascor)

No Criteria

Duplicate Therapy


Blockers


Blockers


Blockers


Blockers

10/18/95

No Criteria

12/09/95Amlodipine (Norvasc)

98

Lipid Lowering Agents - Criteria Elements and Implementation Dates

MG per Date DateDay Begun MG Per Day Begun

No Criteria

Antiplatelet Agents - Criteria Elements and Implementation Dates

MG per Date Date Date Day Begun MG Per Day Begun Begun Period

Cilostazol (Pletal)

No Criteria --- Less than or equal to 200 mg/day

04/10/00 No Criteria ---

Ticlopidine (Ticlid)



Clopidogrel bisulfate (Plavix)



Aspirin/ dipyridamole (Aggrenox)

No Criteria --- Less than or equal to 50 mg/400 mg/day







---

---

--- 04/15/97

04/15/97

04/15/97

Concurrent HMG-Co A Reductase

Inhibitors

04/15/97


Inhibitors


Inhibitors

02/14/05Less than or equal to 40 mg/day

Class---

No Criteria

---

---

02/14/05

---

12/04/9712/04/97

---

---

No Criteria

No Criteria

No Criteria

No Criteria

Date Begun

No Criteria

---

Duration of Therapy

--- No Criteria


Inhibitors

Duplicate Therapy

04/15/97 ---

---

---


Inhibitors

---


Fluvastatin (Lescol)

No Criteria

No CriteriaSimvastatin (Zocor)

05/15/99

04/15/97Less than or equal to 80 mg/day

Max. Initial Dose Maximum Daily Dose Duration of Therapy

ClassDate

BegunDate

Begun

No Criteria

---

Period

Max. Initial Dose Maximum Daily Dose

--- 03/29/04


Inhibitors

---

04/15/97

No Criteria

No Criteria

Rosuvastatin (Crestor)

Ezetimibe (Zetia)


Duplicate Therapy

No Criteria

02/14/05

Lovastatin (Mevacor)

Pravastatin (Pravachol)

Atorvastatin (Lipitor)

No Criteria

No Criteria

No Criteria

No Criteria

Less than or equal to 5 mg

99

Oral Antihyperglycemic Agents - Criteria Elements and Implementation Dates

MG per Date Date Date Day Begun MG Per Day Begun Begun Period

Thioglitazones – Criteria Elements and Implementation Dates

Date Begun

1/6/2009

1/6/2009

Anticonvulsant – Criteria Elements and Implementation Dates

Date Begun


Oxcarbazepine extended release (Oxtellar XR)

Previous therapy required with immediate release oxcarbazepine (Trileptal)

Step Therapy

Step Therapy

Medical exception required

Previous therapy required with a sulfonylurea, metformin or insulin.


Rosiglitazone and combinations (Avandia, Avandamet, Avandaryl)

Pioglitazone (Actos)

06/02/09---

---

---

---

---


ClassNew therapy denied for

reimbursement

No Criteria

No Criteria

Plan Protocol

---

01/06/09

No Criteria

---No Criteria

---

---

---

---

---Prior therapy with either metformin, a sulfonylurea or

insulin in the previous 60 days.

1/6/2009

---No Criteria --- No Criteria

Rosiglitazone (Avandia)


No Criteria

Max. Initial Dose

--- 04/10/00Less than or equal to 8 mg/day



Maximum Daily Dose

--- 04/10/00

--- 04/10/00

Metformin (Glucophage)

No Criteria --- 04/10/00Less than or equal to 2550 mg/day

No Criteria

Acarbose (Precose)

No Criteria

Repaglinide (Prandin)

No Criteria

No Criteria ------10/08/01 No Criteria No CriteriaLess than or equal to 20 mg/2000 mg/day

---

No Criteria



No Criteria

No Criteria

10/08/01

10/08/01

04/10/00Miglitol (Glyset)

No Criteria


Nateglinide (Starlix)

No Criteria

Pioglitazone (Actos)

No Criteria

Pioglitazone/ glimepride (Duetact)

No Criteria

Glyburide/ metformin

(Glucovance)

Date Begun

Duplicate Therapy

---

---

---

---

No Criteria

No Criteria

No Criteria

No Criteria

Sagliptin (Onglyza)


---12/14/10 No Criteria --- No Criteria

1/6/2009 No Criteria ---Sitagliptin (Januvia)

No Criteria --- --- 04/01/11 Prior therapy with either metformin, a sulfonylurea or

insulin in the previous 60 days.

100

Maximum Daily Dose Duplicate TherapyDate Begun Period Date Begun Class Date Begun

Aspirin (Legend) 08/06/94 No Criteria --- 08/16/92(Easprin, Zorprin)

Choline Magnesium 10/28/94 No Criteria --- 10/28/94Sulfate (Trilisate)

Diclofenac (Voltaren) 03/29/95 No Criteria --- 08/16/92(Normal Release)

Diclofenac (Cataflam) 10/28/94 No Criteria --- 10/28/94(Quick Release)

Diflunisal 07/05/93 No Criteria --- 08/16/92(Dolobid)Etodolac 07/05/93 No Criteria --- 08/16/92(Lodine)

Fenoprofen 07/05/93 No Criteria --- 08/16/92(Nalfon)

Flurbiprofen 07/05/93 No Criteria --- 08/16/92(Ansaid)Ibuprofen 07/05/93 No Criteria --- 08/16/92(Motrin)

Indomethacin 07/05/93 No Criteria --- 08/16/92(Indocin)

Indomethacin SR 07/05/93 No Criteria --- 08/16/92(Indocin SR)Ketoprofen 07/05/93 No Criteria --- 08/16/92

(Orudis, Oruvail)Ketorolac (Toradol)

I.M. Therapy 7/15/1993 5 days/ 05/15/95 08/16/9230 days

Oral Therapy 07/05/93 5 days/ 05/15/95 08/16/9230 days

Meclofenamate 07/05/93 No Criteria --- 08/16/92(Meclomen)

Mefenamic Acid 07/05/93 No Criteria --- 08/16/92(Ponstel)

Nabumetone 07/05/93 No Criteria --- 08/16/92(Relafen)Naproxen 07/05/93 No Criteria --- 08/16/92

(Naprosyn)Naproxen Sodium 07/05/93 No Criteria --- 08/16/92

(Anaprox)Oxaprozin 07/05/93 No Criteria --- 08/16/92(Daypro)Piroxicam 07/05/93 No Criteria --- 08/16/92(Feldene)Salsalate 10/28/94 No Criteria --- 10/28/94(Disalcid)Sulindac 07/05/93 No Criteria --- 08/16/92(Clinoril)Tolmetin 07/05/93 No Criteria --- 08/16/92(Tolectin)

Meloxicam 05/13/02 No Criteria --- 05/13/02(Mobic)

Diclofenac Epolamine No Criteria --- 03/10/09(Flector Patch)

Diclofenac Potassium 12/14/10 No Criteria --- 12/14/10(Zipsor)

------Diclofenac (Zorvolex)

Step TherapyRequires prior trial of generic diclofenac or other

generic NSAID

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

to 2000 mg/dayLess than or equal

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Concurrent NSAIDS

Less than or equalto 100 mg/day



to 15 mg/day









to 300 mg/day


Less than or equal


Less than or equal

Less than or equal

Less than or equal



to 200 mg/day


to 225 mg/day


to 3200 mg/day


to 3200 mg/day



Less than or equal

Less than or equal

Non-Steroidal Anti-Inflammatory Agents (NSAIDS) - Criteria Elements and Implementation Dates

MG Per DayMaximum Duration

101

COX-2 Inhibitors - Criteria Elements and Implementation Dates

Maximum Daily Dose Duplicate Therapy

Date Begun Period Date Begun Class Date Begun

Celecoxib 04/10/00 No Criteria --- 04/10/00(Celebrex)Valdecoxib 08/19/03 No Criteria --- 08/19/03

(Bextra)

Centrally Acting Analgesics - Criteria Elements and Implementation Dates


Date Begun Period Date Begun Class Date Begun12/04/97 No Criteria --- ---

Combination Analgesics - Criteria Elements and Implementation Dates



Hydrocodone and 04/22/98 10 days/ 04/22/98 ---Ibuprofen 30 days

(Vicoprofen)

Opiate Agonists - Criteria Elements and Implementation Dates



Tramadol/acetaminophen 08/20/03 5 days out 08/20/03 ---(Ultracet) of every 30

Agents to Treat Benign Prostatic Hyperplasia - Criteria Elements and Implementation Dates

Maximum Daily Dose Gender Edit

Date Begun MG Per Day Date Begun Male/ Female Date BegunTamsulosin HCI - No Criteria - 01/04/07

(Flomax)Dutasteride - No Criteria - 02/22/07(Avodart)

Finasteride - No Criteria - 02/22/07(Proscar)Alfuzosin - No Criteria - 02/22/07

(Uroxatral)

Inhaled Corticosteroids - Criteria Elements and Implementation Dates

Maximum Daily Dose Gender EditDate Begun MG Per Day Date Begun Male/ Female Date Begun

Budesonide 06/03/09 No Criteria - -(Pulmicort-Respules)

Concurrent NSAIDS

1 mg/day

Less than or equal

Concurrent NSAIDS

to 37.5 mg/day


No Criteria

Maximum Initial Dose

Tramadol (Ultram)


MG Per Day

400 mg daily if under 75 years of age

Maximum Duration

to 10mg/day

Less than or equalMG Per Day



Maximum Duration

300 mg daily if over 75 years of age

No Criteria


Duration of Therapy

MG Per Day

Less than or equal


Maximum Duration

MG Per Day


Maximum Initial DoseMG Per Day

MG Per DayMale OnlyNo Criteria

No Criteria

No Criteria

No Criteria

No CriteriaLess than or equal to

Male Only

Male Only

Male Only

No Criteriato 300 mg/day

102

Other Analgesics - Criteria Elements and Implementation Dates

Date Begun Drug

Date Begun Quantity

Date Begun Period Date Begun Quantity Date Begun

Propoxyphene HCl 05/13/02 No Criteria --- No Criteria --- No Criteria --- No Criteria ---(Darvon)

Propoxyphene napsylate 05/13/02 No Criteria --- No Criteria --- No Criteria --- No Criteria ---(Darvocet)

Acetaminophen/Codeine 05/13/02 No Criteria --- No Criteria --- 180 days out 10/18/04 No Criteria ---Combinations of 210

Morphine Sulfate No Criteria 10/18/04 No Criteria No Criteria No Criteria 10/18/04 No Criteria ---(Kadian, Various)

Fentanyl buccal --- 06/03/09 No Criteria --- No Criteria --- No Criteria ---(Fentora®)

Fentanyl Citrate No Criteria No Criteria 10/18/04 6 units 10/18/04 No Criteria --- 10/18/04(Actiq)

Fentanyl Transdermal No Criteria 10/27/04 No Criteria No Criteria 10/18/04 10/18/04(Duragesic)

Oxycontin 03/29/04 No Criteria No Criteria No Criteria No Criteria 180 days out of 210

10/18/04 No Criteria No Criteria

Tapentadol (Nucynta) 12/14/10 No Criteria No Criteria No Criteria No Criteria No Criteria No Criteria No Criteria No Criteria

Fentanyl Sublingual (Subsys)

--- --- --- Less than or equal to 100

mcg/day

5/14/2014 --- --- 4 doses/day 5/14/2014

Calcium Phosphate Binder - Criteria Elements and Implementation Dates

Date Begun Drug

Date Begun Quantity

Date Begun Period Date Begun Quantity Date Begun

Sevelamer Carbonate 04/21/08 No Criteria No Criteria No Criteria No Criteria --- --- No Criteria No Criteria(Renvela)

---

10 patches in a 30 day period. Dose increase will permit an additional 10

patches.


No Criteria

to 7200 mg/day

Maximum Duration Maximum Quantity

MG Per DayLess than or equal


Patches greater than 50 mcg

must show prior conversion with

opiate.


Maximum Daily Dose Plan Protocol Initial Quantity

Maximum Quantity

48 units in a 30 day period

Maximum Daily Dose


to 390 mg/day

No Criteria

No Criteria


No Criteria Tablets greater than 100/mg must show

conversion from Actiq

Less than or equal

Must show prior conversion with opiate before

reimbursement of 200 mg extended

release tab.

180 days out of 210

Maximum Duration

MG Per DayLess than or equal

Plan Protocol Initial Quantity

to 4000 mg/day

103

Histamine H2 Receptor Antagonists - Criteria Elements and Implementation Dates

Date Date DateMG Per Day Begun Period Begun Class Begun

Cimetidine (Tagamet)Maintenance 08/16/92 Unlimited 10/08/04 08/16/92

TherapyFamotidine (Pepcid)

Maintenance 08/16/92 Unlimited 10/08/04 08/16/92Therapy

Nizatidine (Axid)Maintenance 08/16/92 Unlimited 10/08/04 08/16/92

TherapyRanitidine (Zantac)

Maintenance 08/16/92 Unlimited 10/08/04 08/16/92Therapy

Dexlansoprazole(Dexilant) 12/14/10 Unlimited 03/30/10 12/14/10

Miscellaneous Gastrointestinal Agents - Criteria Elements and Implementation Dates

Date Date DateMG Per Day Begun Period Begun Class Begun

Metoclopramide(Reglan)

Misoprostol(Cytotec)

Omeprazole Proton Pump Inhibitors/(Prilosec) H2 Receptor AntagonistsSucralfate(Carafate)

Lansoprazole Proton Pump Inhibitors/(Prevacid) H2 Receptor Antagonists

Pantoprazole Proton Pump Inhibitors/(Protonix) H2 Receptor Antagonists

Esomeprazole Proton Pump Inhibitors/(Nexium) H2 Receptor Antagonists

Rabeprazole Proton Pump Inhibitors/(Aciphex) H2 Receptor Antagonists

Naproxen andLansoprazole

(Prevacid NapraPAC)

Agent to Treat Irritable Bowel - Criteria Elements and Implementation Dates

Date Date DateMG Per Day Begun mg/day Begun Male/Female Begun

Alosetron(Lotronex)

Antidiarrheal - Criteria and Implementation Dates

Aminosalicylate - Criteria Elements and Implementation Dates

Date Date DateMG Per Day Begun mg/day Begun Male/Female Begun

Balsalazide Disodium(Giazo) Male 12/13/12No Criteria --- No Criteria ---

Date Begun

Crofelemer (Fulyzaq)

10/22/14


Maximum Daily Dose Maximum Initial Dose Gender Edit

Step Therapy

Current use of an antiretroviral


20 mg/day

40 mg/day10/08/01 No Criteria --- 10/08/01


Less than or equal to


40 mg/day

Proton Pump Inhibitors and Concurrent H2.




No Criteria


08/28/95

Less than or equal to40 mg/day

30 mg/day

4000 mg/dayLess than or equal to

No Criteria 10/08/01

---

No Criteria

No Criteria

Duplicate Therapy

No Criteria

No Criteria


07/05/93

08/28/95

Maximum Daily Dose

---

---

10/28/94

07/05/93800 mcg/day


---


Duration of TherapyMaximum Daily Dose



Less than or equal to60 mg/day


Duplicate TherapyDuration of Therapy

07/05/93

10/08/01 10/08/01No Criteria

No Criteria

---

10/08/01 ---

Gender EditMaximum Daily Dose Maximum Initial Dose

Naproxen)---

No Criteria

1000 mg (based on

---

08/28/95

10/18/04

No Criteria

No Criteria No Criteria No Criteria Female only

02/14/05 No Criteria





---

---

---

---

No Criteria

No Criteria

104

Antipsychotics - Criteria Elements and Implementation Dates

Maximum Initial DoseDate Date

MG Per Day Begun MG Per Day Begun

Chlorpromazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Thorazine) 50 mg/day 200 mg/dayClozapine Less than or equal to 01/16/95 Less than or equal to 08/18/97 No Criteria(Clozaril) 25 mg/day 100 mg/day

Fluphenazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Prolixin) 1 mg/day 10 mg/day

Haloperidol Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Haldol) 1 mg/day 10 mg/dayLoxapine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Loxitane) 20 mg/day 100 mg/day

Mesoridazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Serentil) 30 mg/day 125 mg/day

Perphenazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Trilafon) 8 mg/day 24 mg/day

Risperidone 01/16/95 01/16/95 No Criteria(Risperdal & Risperdal-M)Thioridazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Mellaril) 50 mg/day 200 mg/dayThiothixene Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Navane) 4 mg/day 20 mg/day

Trifluoperazine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Stelazine) 2 mg/day 10 mg/dayQuetiapine Less than or equal to 04/22/98 Less than or equal to 04/22/98 No Criteria(Seroquel) 50 mg/day 400 mg/dayOlanzapine Less than or equal to 08/18/97 Less than or equal to 08/18/97 No Criteria(Zyprexa) 2.5 mg/day 10 mg/day

Ziprasidone No Criteria --- 160 mg per day Oral 08/19/03 No Criteria(Geodon) 40 mg/day IM

Aripiprazole No Criteria --- Less than or equal to 08/19/03 No Criteria(Abilify) 15 mg/day

Paliperidone No Criteria --- Less than or equal to 06/02/09 No Criteria(Invega) 12 mg/day

Aripiprazole, Ext. Release Injectible (Abilify Maintena)

Requires prior use of oral Aripiprazole 6/25/2014

---

Less than or equal to 0.5 mg/day


---

---

---

---

---

---

---

---

---

Drug Name Generic (Brand) Class

Maximum Daily Dose

---

---

---

---

Duplicate Therapy

Date Begun

---

---

105

Antidepressants (SSRI AND SSNRI) - Criteria Elements and Implementation Dates

Maximum Initial DoseDate Date

MG Per Day Begun MG Per Day BegunAmitriptyline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Elavil) 75 mg/day 250 mg/dayAmoxapine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Asendin) 75 mg/day 300 mg/dayBupropion Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Wellbutrin) 200 mg/day 450 mg/dayCitalopram Less than or equal to 05/15/99 Less than or equal to 05/15/99 No Criteria(Celexa) 20 mg/day 40 mg/day

Clomipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Anafranil) 50 mg/day 250 mg/day

Desipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Norpramin) 75 mg/day 250 mg/day

Doxepin Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Sinequan) 75 mg/day 250 mg/dayFluoxetine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Prozac) 20 mg/day 60 mg/day

Imipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Tofranil) 75 mg/day 250 mg/day

Isocarboxazid Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Marplan) 30 mg/day 50 mg/day

Maprotiline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Ludiomil) 50 mg/day 200 mg/day

Mirtazapine Less than or equal to 8/18/97 Less than or equal to 08/18/97 No Criteria(Remeron) 15 mg/day 45 mg/day

Nefazodone No Criteria --- Less than or equal to 08/28/95 No Criteria(Serzone) 600 mg/day

Nortriptyline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Pamelor) 50 mg/day 150 mg/dayParoxetine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Paxil) 20 mg/day 40 mg/dayPhenelzine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Nardil) 45 mg/day 90 mg/dayProtriptyline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Vivactil) 15 mg/day 40 mg/daySertraline Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Zoloft) 50 mg/day 200 mg/day

Tranylcypromine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Parnate) 30 mg/day 60 mg/day

Trazodone Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Desyrel) 150 mg/day 400 mg/day

Trimipramine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria(Surmontil) 75 mg/day 250 mg/dayVenlafaxine Less than or equal to 01/16/95 Less than or equal to 01/16/95 No Criteria

(Effexor) 75 mg/day 225 mg/dayParoxetine Less than or equal to 08/19/03 Less than or equal to 08/19/03 No Criteria(Paxil CR) 12.5 mg/day 50 mg/day

Escitalopram Less than or equal to 08/19/03 Less than or equal to 08/19/03 No Criteria(Lexapro) 10 mg/day 20 mg/dayBupropion Less than or equal to 02/06/97 Less than or equal to 02/06/97 No Criteria

(Wellbutrin XL) 300 mg/day 400 mg/dayFluoxetine

(Prozac weekly)Duloxetine No Criteria --- Less than or equal to 02/11/08 No Criteria(Cymbalta) 60 mg/day

Desvenlafaxine No Criteria No Criteria Less than or equal to 12/14/10 No Criteria(Pristiq) 50 mg/day

Bupropion Less than or equal to 12/16/10(Aplenzin) 348 mg/day

Milnacipran No Criteria --- Max dose 12/14/10 No Criteria(Savella) 200 mg/day

Vortioxetine No Criteria ---(Brintellix)

12/14/2010Step TherapyRequire pre-existing use of SSRI or SSNRI

---

---

---

---

---

---

---

---

---



Class Date Begun

---

Prior to Prozac weekly being approved, 90 days of therapy with Prozac daily is required

---

---

---

---

---

---

---

---

---

---

---

---

---

12/14/2010

---

Step TherapyPrevious therapy with bypropin tablets required

(not T12 or T24)

---

---

---

---

---

Desvenlafaxine Extended Release

(Khedezla)

Less than or equal to 50 mg/day No CriteriaNo Criteria ---

106

Benzodiazepines/Miscellaneous Sedative/Hypnotics - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose Duration of TherapyDate Date Date

MG Per Day Begun MG Per Day Begun Begun Class01/16/95 01/16/95 ---

01/16/95 01/16/95 ---

01/16/95 01/16/95 ---

03/01/94 03/01/94 03/01/94

01/31/92 01/31/92 01/31/92

01/16/95 01/16/95 ---

--- 02/19/07 ---

--- 11/01/05 ---

--- 02/19/07 ---

--- 02/19/07 No Criteria ---

Benzodiazepines - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose Duration of TherapyDate Date

Begun BegunAlprazolam 01/16/95 01/16/95 No Criteria Concurrent

(Xanax)Alprazolam 03/29/04 03/29/04(Xanax XR)

Chlordiazepoxide 01/16/95 01/16/95 No Criteria Concurrent (Librium)

Clonazepam 01/16/95 01/16/95 No Criteria Concurrent (Klonopin)

Clorazepate 01/16/95 01/16/95 No Criteria Concurrent (Tranxene)Diazepam 01/16/95 01/16/95 No Criteria Concurrent (Valium)

Halazepam 01/16/95 01/16/95 No Criteria Concurrent (Paxipam)Lorazepam 01/16/95 01/16/95 No Criteria Concurrent

(Ativan)Oxazepam 01/16/95 01/16/95 No Criteria Concurrent

(Serax)

Obsessive-Compulsive Disorder Agent - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose Duration of TherapyDate Date

MG Per Day Begun MG Per Day Begun

Fluvoxamine 08/28/95 08/28/95 No Criteria No Criteria ---(Luvox)

Duplicate Therapy

Period

Date Begun

Duplicate Therapy

Class

240 mg/6 mos

PeriodDate

Begun

No Criteria

10/25/05

Drug Name Generic (Brand) MG Per Day MG Per Day


Less than or equal

to 30 mg/day

to 2 mg/day

to 40 mg/day

to 5 mg/day

Less than or equal

to 50 mg/day Less than or equal

to 300 mg/day

Date Begun

---

---

03/13/00

03/13/00

4 mg/6 mos

No Criteria

---

No Criteria


No Criteria

No Criteria

No Criteria




Period




---

03/13/00

03/13/00

03/13/00

03/13/00

03/13/00

---

---

Date BegunClass

---

---

Only for Panic Disorder

Date Begun

--- 03/13/00

Ramelteon (Rozerem)

Eszopiclone (Lunesta)

Duplicate Therapy

Estazolam (Prosom)

Flurazepam (Dalmane)

Quazepam (Doral)

Temazepam (Restoril)




Less than or equal

Less than or equalto .75 mg/day

No Criteria

No Criteria

No Criteria

Less than or equal


Less than or equal

Less than or equal

to 60 mg/day

to 40 mg/day

to 40 mg/day

to 15 mg/day

to 1 mg/day

to 20 mg/day

to 0.5 mg/day

Less than or equal

Less than or equal

Less than or equal


to 4 mg/day

Less than or equal

to 60 mg/day Less than or equal

Less than or equal

Less than or equal

Less than or equal

Less than or equal

to 6 mg/day

Less than or equal

to 3 mg/day

Concurrent Benzodiazepines and Misc Sed/Hypnotics

03/13/00

03/13/00

03/13/00



03/13/00

03/13/00

10/25/05

12/14/10

10/25/05

10/25/05

No Criteria




10/25/05Less than or equal to 6.25 mg/day

Zolpidem (Edluar)

Step Therapy

Documentation required as to need for sublingual dosage formLess than or equal

to 10 mg/day Concurrent

Benzodiazepines and Misc Sed/Hypnotics

No CriteriaZaleplon (Sonata)

Zolpidem (Ambien CR)




Zolpidem (Ambien)






Triazolam (Halcion)

107

Miscellaneous Sedative/Hypnotics - Criteria Elements and Implementation Dates

Maximum Initial Dose Maximum Daily Dose Duration of Therapy Duplicate TherapyDate Date Date Date

Begun MG Per Day Begun Period Begun Class BegunAmobarbital No Criteria --- Less than or equal to 06/07/00 14 days out 06/07/00 No Criteria ---

(Amytal) 200 mg/day of every 180Butabarbital No Criteria --- Less than or equal to 11/26/97 14 days out 04/20/98 No Criteria ---

(Butisol) 90 mg/day of every 180Chloral Hydrate No Criteria --- Less than or equal to 11/26/97 14 days out 04/20/98 No Criteria ---

(Somnote) 1 gm/day of every 180Ethchlorvynol No Criteria --- Less than or equal to 11/26/97 14 days out 06/01/98 No Criteria ---

(Placidyl) 500 mg/day of every 180Secobarbital No Criteria --- Less than or equal to 11/26/97 14 days out 06/01/98 No Criteria ---

(Seconal) 100 mg/day of every 180Amobarbital/Secobarbital No Criteria --- Less than or equal to 11/26/97 14 days out 04/20/98 No Criteria ---

(Tuinal) 50 mg/day of every 180


Begun MG Per Day Begun Period Begun Class Begun

---

Phentermine/Topiramate (Qsymia)

Requires documentation of adherence to manufacturer recommendations for dose titration as well as weight loss related to use at each dose 08/28/13

---

1/21/2013

----


---

No Criteria

No Criteria

---

Document at least 5%

weight loss after 12 weeks

Lorcaserin HCL (Belviq)

Phentermine HCL (Suprenza) ---1/21/2013

Orlistat (Xenical) No Criteria --- Less than or equal to

360 mg/day 07/26/99 60 days out of every 90 08/09/99

No Criteria

---

---

Diethylpropion (Tenuate) No Criteria --- Less than or equal to

100 mg/day 07/26/99 60 days out of every 120 08/09/99 ---

Phendimetrazine (Bontril) No Criteria --- Less than or equal to

105 mg/day 07/26/99 60 days out of every 120

---

60 days out of every 120 08/09/99 ---

60 days out of every 90

Sibutramine (Meridia)

Phentermine HCL (Adipex-P) No Criteria --- Less than or equal to

37.5 mg/day

08/09/99

706 CH on 10/22/2014

07/26/99

No Criteria --- Less than or equal to 30 mg/day 07/26/99 08/09/99

---

concurrent with all other anti-obesity medications

No Criteria

No Criteria

No Criteria

No Criteria

No Criteria


Anti-Obesity Agents - Criteria Elements and Implementation Dates


MG Per Day

MG Per Day

Document at least 5%

weight loss after 12 weeks

concurrent with all other anti-obesity medications

108


Begun MG Per Day Begun Period Begun Class BegunAlendronate No Criteria --- Less than or equal to 08/19/03 No Criteria --- No Criteria ---(Fosamax) 10 mg/day

Risedronate No Criteria --- Less than or equal to 03/29/04 No Criteria --- No Criteria ---(Actonel) 5 mg/day

Teriparatide No Criteria --- Less than or equal to 03/29/04 24 months 12/14/10 No Criteria ---(Forteo) 5 mg/day





No CriteriaNo Criteria --- ---Suprep Bowel Kit --- --- 1 day out of every 365

--- No Criteria ---Cabozantinib (Cometriq) No Criteria --- Less than or equal to 180 mg/day 10/14/13 No Criteria

Drug Name Generic (Brand) MG Per Day

Criteria Elements and Implementation Dates

No Criteria ---

Sodium picosulfate, magnesium oxide and anhydrous citric acid

(Prepopik)

No Criteria --- --- ---

Antineoplastic Tyrosine Kinase Inhibitors - Criteria Elements and Implementation D

1 day out of every 365

Laxatives - Criteria Elements and Implementation Dates



Bisphosphonates and Recombinant Human Parathyroid Hormone Analog -

109

DateBegun

No Criteria --- Less than or equal 06/05/00 --- 21 daysto 1400 mg/day out of 30









Maximum Daily Dose Duplicate Therapy Maximum Duration

MG Per DayDate

Begun MG Per DayDate

Begun ClassDate

Begun Period Date BegunDonepezil (Aricept)


per day

05/15/99 Less than or equal to 10 mg per day

05/15/99 No Criteria --- No Criteria ---

Tacrine (Cognex)


per day



Rivastigmine (Exelon)


per day



Galantamine (Reminyl)


per day



Memantine (Namenda)




06/12/00

Tizanidine (Zanaflex)


06/12/00

Methocarbamol (Robaxin)


Metaxalone (Skelaxin)

Baclofen (Lioresal)


Orphenadrine Citrate (Norflex)

No Criteria

06/12/00

Dantrolene (Dantrium)


Cyclobenzaprine (Flexeril)

No Criteria

06/12/00

Chlorzoxazone (Parafon Forte)


Carisoprodol (Soma)

No Criteria

No Criteria

Duration of Therapy

MG Per Day MG Per DayDate

Begun ClassDate

Begun Period Date Begun

Skeletal Muscle Relaxants - Criteria and Implementation Dates

Maximum Initial Dose



Cholinesterase Inhibitors - Criteria Elements and Implementation Dates


110

ClassDate


BegunMale/

FemaleDate

Begun Period Date BegunSildenafil Citrate

(Viagra)Concurrent with other erectile

dysfunction agents

05/07/04 Less than or equal to 50 mg/day

06/01/98 Male 10/18/04 8 days out of every 30 01/04/99

Vardenafil (Levitra)

Concurrent with other erectile

dysfunction agents

05/07/04 No Criteria --- Male 10/18/04 8 days out of every 30 10/31/03

Tadalafil (Cialis)


dysfunction agents

04/29/08 Less than or equal to 20 mg/day

03/15/04 Male 10/18/04 8 days out of every 30 05/05/04

Alprostadil (Caverject)


dysfunction agents

05/07/04 No Criteria --- Male 02/11/08 8 days out of every 30 02/11/08

MG Per DayDate


Begun ClassDate

Begun Period Date BegunDoxycycline (Periostat)


05/13/02 No Criteria --- 9 months out of every 12

05/13/02

Rifaximin (Xifaxan)

No Criteria --- No Criteria --- No Criteria --- 3 days out of every 180

06/03/09



--- No Criteria ---

6/25/2014

Step Therapy

Previous therapy required with immediate release oxcarbazepine (Trileptal)

Perampanel (Fycompa) No Criteria --- Less than or equal

to 2 mg/day 10/22/2014 ---

Antiepileptic - Criteria Elements and Implementation Dates


Duplicate TherapyDrug Name Generic (Brand)


Maximum Daily Dose

Erectile Dysfunction Agents - Criteria Elements and Implementation Dates

Maximum DurationGender Edit

Oxcarbazepine extended release

(Oxtellar XR)

Maximum Initial Dose Maximum Daily Dose Maximum Duration

Antibiotics - Criteria Elements and Implementation Dates

Duplicate Therapy

111





10/22/2014

10/22/2014

Iloprost (Ventavis) No Criteria --- No Criteria --- --- --- Concurrent with other

Pulmonary Arterial 10/22/2014

Concurrent with other Pulmonary Arterial

Hypertension Agents10/22/2014

Epoprostenol (Veletri) No Criteria --- No Criteria --- --- ---


Hypertension Agents

---Concurrent with other

Pulmonary Arterial Hypertension Agents

10/22/2014

Tadalafil (Adcirca) No Criteria --- No Criteria --- --- ---

Macitentan (Opsumit) No Criteria --- No Criteria --- ---

10/22/2014

Sildenafil Citrate (Revatio) No Criteria --- No Criteria --- --- ---





Ambrisentan (Letairis) No Criteria --- No Criteria --- --- ---


Hypertension Agents

---Concurrent with other

Pulmonary Arterial Hypertension Agents

10/22/2014

Bosentan (Tracleer) No Criteria --- No Criteria --- --- ---

Pulmonary Arterial Hypertension - Criteria Elements and Implementation


MG Per Day

Riociquat (Adempas) No Criteria --- No Criteria --- ---

Naftifine hydrochloride --- --- Step Therapy

Requires a trial of a 1% naftifine product

Antifungals - Criteria Elements and Implementation Dates


MG Per Day

112

DateBegun

Cetirizine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Zyrtec, Zyrtec-D) to 10 mg/day

Desloratadine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Clarinex, Clarinex-D) to 5 mg/day

Fexofenadine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Allegra, Allegra-D) to 120 mg/day

Fexofenadine No Criteria --- Less than or equal 08/19/03 08/19/03 No Criteria(Allegra, 180 mg to 180 mg/daystrength tablet)

DateBegun

Zolmitriptan No Criteria --- Less than or equal 08/19/03 08/19/03 3 days out(Zomig, ZMT) to 10 mg/day of every 30Almatriptan No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out

(Axert) to 25 mg/day of every 30Methysergide No Criteria --- Less than or equal 08/19/03 08/19/03 150 days out

maleate to 8 mg/daily of every 180(Sansert)

Naratriptan(Amerge)

Frovatriptan No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out(Frova) to 7.5 mg/day of every 30

Dihydroergotamine No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out(Migranal) to 2 bottles daily of every 30Rizatriptan No Criteria --- Less than or equal 08/19/03 08/19/03 4 days out

(Maxalt, to 30 mg/day of every 30 Maxalt MLT)

Eletriptan No Criteria --- Less than or equal 03/29/04 03/29/04 3 days out(Relpax) to 40 mg/day of every 30

Sumitriptan and naproxen(Treximet)

DateBegun

Varenicline No Criteria --- No Criteria --- 12 weeks followed(Chantix) by another 12 weeks

if smoking cessation has been documented

Anaphylaxis Agent - Criteria and Implementation Dates


Step TherapyDate

Begun

Epinephrine Injection (AUVI-Q) Requires documentation as to why traditional Epi-Pen cannot be used.

Antihistamines - Criteria and Implementation Dates


Maximum Initial Dose Maximum Daily Dose Duplicate Therapy Duration of Therapy


Begun ClassDate

BegunConcurrent with other

antihistaminesConcurrent with other



antihistamines

---

Concurrent with other anti-migraines


Date Begun Period

Duration of Therapy

---

---

---

08/19/03

08/19/03


Begun ClassDate

Begun PeriodDate

Begun

02/19/07

Smoking Cessation Agent - Criteria and Implementation Dates


Maximum Initial Dose Maximum Daily Dose Duration of Therapy


Begun PeriodDate

Begun

Antimigraine Agents - Criteria and Implementation Dates







03/29/04

Not indicated in the elderly

08/19/03

08/19/03

08/19/03Concurrent with other anti-migraines

Not Recommended for the Elderly

08/19/03

113

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