Download CMS Annual DUR Report - 2010 - Michigan Department of Health

State of Michigan
Department of Community Health
MICHIGAN MEDICAID
DRUG UTILIZATION REVIEW
ANNUAL REPORT
Prospective and Retrospective
Drug Utilization Review
And
Cost Analysis
Federal Fiscal Year 2010
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
Table of Contents
I.
Program Background and History
1
II.
Prospective Drug Utilization Review (ProDUR)
4
III.
Retrospective Drug Utilization Review (RetroDUR)
9
IV.
Factors Affecting Program Drug Costs
13
V.
Generic Drug Substitution
16
VI.
E-Prescribing
18
VII.
Innovative Practices
20
VIII.
Tables
Table 1. ProDUR Message Report
22
Table 2. Top ProDUR Encounters by Problem Type
23
Table 3. Cost Avoidance Calculations
28
Table 4. RetroDUR Lettering
29
Table 5. Population Statistics
30
Table 6. Top 20 Therapeutic Classes
31
Table 7. Top 30 New Drugs by Total Cost
32
Table 8. Generic Drug Utilization
33
Appendix A. First Data Bank Bluebook Therapeutic Class Descriptions
34
IX.
DUR Board Meeting Minutes
36
X.
CMS Annual Report Survey
53
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
I. Program Background and History
The Medicaid Drug Utilization Review (DUR) Program was created by the
Omnibus Budget Reconciliation Act of 1990 (OBRA ’90). The main emphasis of
the program is to promote patient safety by an increased review and awareness
of outpatient prescribed drugs. States were encouraged by enhanced federal
funding to design and install point-of-sale (POS) electronic claims management
systems that interface with their Medicaid Management Information System
(MMIS) operations. The annual report requirement provides a measurement tool
to assess how well state Medicaid programs have implemented the DUR
program and the effect DUR has had on patient safety and provider prescribing
habits.
The purpose of Michigan’s DUR program is to improve the quality of
pharmaceutical care by ensuring that prescriptions are appropriate, medically
necessary, and that they are not likely to result in adverse medical results, in
accordance with OBRA ’90. DUR assesses data on drug use against
predetermined standards, consistent with peer-reviewed literature, and the
recommendations of the State’s DUR Board.
The major components of DUR are Prospective DUR (ProDUR) and
Retrospective DUR (RetroDUR). ProDUR provides for a review of drug therapy
before each prescription is filled or delivered to a recipient. The review must
include screening for items such as therapeutic appropriateness, over-utilization
and under-utilization, appropriate use of generic products, therapeutic
duplication, drug-disease contraindication, drug-drug interactions, incorrect drug
dosage or duration of drug treatment and clinical abuse/misuse.
This is accomplished by messages sent from the point-of-sale system to the
dispensing pharmacist when the claim is submitted for payment. The messages
may be “soft messages” – messages which are sent as information, but do not
stop the processing of the claim, or “hard messages” – messages which stop
processing and payment of the claim. Hard messages, or edits, are resolved in
one of two methods. Pharmacists may override a hard edit at point-of-sale by
submitting a code, which provides additional information about the patient. This
information is compared to criteria to allow for exception and payment. A
physician may have a hard edit overridden by calling and providing additional
clinical information to staff. If the information meets criteria for exception then an
authorization for payment is entered into the point-of-sale computer system.
RetroDUR retrospectively assesses data on drug use against explicit
predetermined standards and introduces appropriate remedial strategies to
improve the quality of care. This may be accomplished through a variety of
methods, including letters to specific providers about specific recipients,
educational mailings or personal visits to providers by pharmacists trained to
conduct educational visits.
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
A contract between the Michigan Department of Community Health (MDCH) and
First Health Services Corporation (FHSC) for ProDUR services and related
activities was begun as a point-of-sale system on July 5, 2000 in conjunction with
electronic claims adjudication. RetroDUR services and related activities were
begun in October 2000. The Michigan DUR Board meets on a quarterly basis to
review activities and reporting associated with both the ProDUR and RetroDUR.
All ProDUR and RetroDUR activities are carried out under the supervision of both
the MDCH and the Michigan DUR Board.
On December 19, 2002 FHSC began using the System Excellence (SX)
processing system for Michigan Medicaid point-of-sale (POS) claims processing,
which utilizes clinical criteria for ProDUR provided by First Data Bank
Corporation (FDB). This system was updated for Michigan Medicaid on August
16, 2003 to the NCPDP transmission standard 5.1 in compliance with Health
Insurance Portability and Accountability Act (HIPAA) regulations. RetroDUR
criteria utilized include proprietary FHSC RetroDUR clinical criteria as well as
custom criteria created specifically for the Michigan Medicaid program.
In 2009, FHSC was acquired by Magellan Health Services and on July 1, 2010,
officially changed the FHSC name to Magellan Medicaid Administration, Inc
(MMA, Inc). On April 1, 2010 a new contract between MDCH and MMA, Inc was
implemented for prescription benefit management (PBM) services.
This DUR program annual report encompasses the drug utilization review
activities and outcomes that have occurred during FFY 2010. Included are
ProDUR alerts and intervention statistics, RetroDUR alerts and intervention
statistics.
The Medicaid enrollment continues to grow, with an average total enrollment of
1,859,319 for FFY 2010, an 18.85% increase over FFY 2009. Presently, 65% of
the Medicaid patients are enrolled in Managed Care Organizations (MCOs). The
remaining 35% are in Fee for Service (FFS). The DUR Board reviews
prescribing patterns for primarily the FFS patient population.
In April 2010, full coverage of Medicaid Health Plan (MHP) Carve-Out
medications was transferred to FFS. Prior to this change, FFS covered 60% of
the cost of these medications and the MCOs covered 40%. The MHP Carve-Out
medications include antidepressants, antipsychotics, CNS stimulants,
anticonvulsants and antiretroviral agents.
While the DUR Program addresses patient safety, Michigan believes safe and
effective pharmaceutical prescribing results in cost effective medicine. The
Michigan Medicaid program has aggressively addressed pharmacy expenditures.
Other initiatives of our pharmacy program include daily Maximum Allowable Cost
(MAC) pricing review, use of quantity limits, dose optimization (dose
consolidation), e-prescribing and the multi state pooling initiative.
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
It is through these efforts Michigan continues to provide safe and effective
treatment of citizens served by the Medicaid program. E-prescribing was
initiated for Michigan Medicaid in September 2008. Utilization of electronic
prescriptions continues to grow among Michigan Medicaid prescribers. This ongoing program increases prescription drug safety by reducing errors due to
handwriting issues and by giving prescribers the opportunity to review a patient’s
medication history prior to ordering a new drug.
This report was prepared by Donna P. Johnson, PharmD, Clinical Account
Manager at Magellan Medicaid Administration, Inc. Questions regarding this
report should be directed to Debera H. Eggleston, M.D., Office of Medical Affairs,
Michigan Medical Services Administration at (517) 335-5181.
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
II. Prospective Drug Utilization Review (ProDUR)
The POS/ProDUR system provides Michigan Medicaid with the ability to minimize
potential drug interactions and drug-induced illness or side effects. Adverse reactions
from drugs occur more frequently when a recipient visits more than one physician and/or
more than one pharmacy to obtain medication. The dispensing pharmacist is provided
with access to a comprehensive patient/drug incompatibility database. Averting adverse
drug effects may result in the prevention of subsequent physician visits, hospitalizations
or additional drug therapy. ProDUR achieves this objective by reviewing all claims for
therapeutic appropriateness before a medication is dispensed, review of the recipient’s
available drug claims and history for incompatible or duplicative therapy and focusing on
those recipients at the highest level of risk for harmful outcome.
Utilization Analysis
Magellan Medicaid Administration’s ProDUR system assists the pharmacist with the
detection, evaluation and counseling components of predispensing drug therapy
screening by addressing ten different situations in which potential medication problems
may exist.
ProDUR messages and alerts are categorized as criteria-based or non-criteria-based.
Criteria-based alerts are based on standard drug criteria from First Data Bank
Corporation. Criteria-based alerts are separated into history and non-history alerts as
indicated below and in Figure 1 on page 6. History alerts require a drug claim in the
drug claim history to interface with the current claim. Non-history alerts are based on the
current claims information. Non-criteria-based alerts are the early refill (ER) messages.
The screening areas identified by ProDUR criteria are:
Criteria Based Alerts:
History Alerts:
•
Drug-Drug Interactions (DD) – Alert occurs when a drug to be dispensed
may interact with another drug filled within the previous eight weeks from
any participating pharmacy. Alerts are sent to pharmacies only on the
most clinically significant drug interactions.
•
Late Refill (LR) – Alert occurs when a patient has waited to refill their
maintenance medications beyond the specified days supply of the previous
fill. Late refill is also known as underutilization.
•
Plan Level Edits (PP) – Alert occurs when a drug is dispensed that meets
specific criteria established by the individual plan. Michigan Medicaid
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
currently uses this edit only for the ulcer medication edit to monitor acute
ulcer medication therapy beyond a specified number of days.
•
Therapeutic Duplication (TD) – Alert occurs when a drug to be dispensed
is in the same therapeutic class or is considered as having the same
action, but is not clinically synergistic, as another drug filled within a
specified time period. An example of this would be Oxycontin and Vicodin.
Non-History Alerts:
•
Drug-Age Contraindication (PA) – Alert occurs when a drug to be
dispensed is not recommended for use in the age group of the patient.
Severity is assigned by First Data Bank.
•
Drug to Inferred Disease (DC) – Alert occurs when a drug is dispensed
that may be contraindicated in a disease state which is inferred by drugs in
the recipient’s claim history. The inferred diseases are determined by First
Data Bank.
•
Drug to Gender (SX) – Alert occurs when a drug is dispensed that is not
recommended for use by the gender indicated on the recipient’s eligibility
file. Drug to gender is a criteria-based, non-history alert.
•
Excessive Drug Dosage (MAX) – Alert occurs when the calculated
milligram dose per day of a drug exceeds the recommended daily dosage.
The criteria for excessive daily dose may be age-specific.
•
Insufficient Daily Dose (MIN) – Alert occurs when the calculated milligram
dose per day of a drug is less than the minimum recommended dosage.
The criteria for insufficient daily dose may be age-specific.
Non-Criteria Based Alerts:
•
Early Refill (ER) – Alert occurs when a prescription for a non-controlled
substance is refilled before 75% of the previously filled prescription’s days supply
has elapsed. For controlled substances, an alert occurs when less than 90% of
the previously filled prescription’s days supply has elapsed. Early refill is a noncriteria based, non-history alert.
Michigan Medicaid denies claims for selected ProDUR messages, including early refill
(ER), selected therapeutic duplication (TD), drug interactions (DD), plan level edits (PP)
and drug to gender (SX). These denial edits were developed and approved by the
MDCH and the Michigan DUR Board. For FFY 2006, it was decided to discontinue
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
claim denials for ingredient duplication (ID), which was found to be less meaningful than
the therapeutic duplication (TD) edit. The denials for therapeutic duplication are for
drugs in the narcotic analgesic class only. For all denials involving DD and TD, the
pharmacist may override the edit by entering the appropriate override code as
established by the MDCH. Other denials may only be overridden after consultation by
the dispensing pharmacy or prescriber with the clinical personnel at MMA, Inc.
Figure 1: ProDUR Alert Categories
ProDUR Criteria Based Alert Categories
History Alerts
DD Drug-Drug Interactions
PG Pregnancy Conflict
TD Therapeutic Duplication
LR Late Refill
MC Drug-Disease
SX Drug to Gender
PP Plan Level Edits
Non-History Alerts
PA
MAX
MIN
DC
Drug-Age Conflict
Excessive Daily Dose
Insufficient Daily Dose
Drug to Inferred Disease
The reporting module of the POS/ProDUR system integrates information from the
therapeutic criteria, the pharmacy and medical claims history files and the
recipient/provider tracking files to create monthly reports. ProDUR reporting tracks cost
avoidance; frequency of ProDUR alerts by problem type, by drug and by number of
claims.
Reports summarizing the ProDUR alerts sent to pharmacies are presented to Michigan
Medicaid and to the Michigan Medicaid DUR Board at each quarterly meeting. Table 1
(see Section VIII. Tables) includes a summary of all ProDUR alerts by problem type.
During an average month, MMA, Inc processed 657,005 paid POS pharmacy claims
(range 603,249 – 766,600). This is a 4.59% increase in the average number of paid
POS claims per month from FFY 2009. The average cost per claims increased from
$74.03 in FY 2009 to $76.24 in FY 2010, an increase of 2.98%. This is a much higher
increase than the 0.3% increase seen from FFY 2008 – FFY 2009. There was also an
8.6% increase in the total number of ProDUR messages sent in FFY 2010 from FFY
2009. In addition, there was an average of 1.27 ProDUR messages per claim that
received a ProDUR message during FFY 2010, compared with 1.17 during FFY 2009.
Overall, this increase in messages is primarily due to an increased number of claims due
to increased enrollment as well as the inclusion of the Medicaid Health Plan Carve-Out
medications for the Medicaid managed care beneficiaries.
An analysis of the top ProDUR alerts -- by problem type -- with the number of POS
claims paid (and denied) receiving an alert for each drug, is included as Table 2 (see
Section VIII, Tables). Please note the following information extracted from this table:
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
•
•
•
•
•
•
•
•
•
•
The drugs most frequently noted for drug to inferred disease (DC) interactions
were fluticasone/salmeterol, haloperidol, insulin aspartame and bupropion.
Bupropion has replaced budesonide in the top four alerts for this category in FFY
2009.
The drugs most frequently involved in drug-drug interactions (DD) were
ziprasidone, oxybutynin, paliperidone and potassium chloride. This is similar to
the top drug-drug interactions in FFY 2009.
The most frequent early refills (ER) noted were alprazolam, hydrocodone,
quetiapine and clonazepam. This is the exact same top four alerts in this category
as in FFY 2009 and FFY 2008.
The most frequent excessive dose (MAX) alerts noted were fluticasone,
hydrocodone, cyanocobalamin and escitalopram. This is exactly the same as
those seen in FFY 2009.
The most frequent underutilization (LR) alerts noted were amphetamine salts,
albuterol, clonazepam, and sertraline. This is the same top four as in FFY 2009.
The most frequent drug-age (PA) alerts for geriatric recipients noted were
diazepam, benztropine, amitriptyline, and butalbital/acetaminophen/caffeine
combination. Chlordiazepoxide remains as number five on the list as it was in
FFY 2009.
The most frequent drug-age alerts for pediatric patients were
dextromethorphan/phenylephrine/chlorpheniramine, amphetamine salts,
lamotrigine and zonisamide. Dextromethorphan combination products are not
covered in the Michigan Medicaid program and these alerts occurred primarily on
denied claims. Amphetamine salts replaced lamotrigine as the number two drug
on this list.
The most frequent plan protocol units (PP – anti-ulcer edit) alerts were
lansoprazole, esomeprazole, omeprazole and pantoprazole. These positions
remain the same as in FFY 2009.
The most frequent drug to gender (SX) alerts was for tamsulosin, tadalafil,
letrozole and anastrozole. Miconazole vaginal and sildenafil have dropped to
numbers 5 and 6, respectively. Except for tamsulosin, the total number of alerts
for each of these drugs is a small percentage of their total use.
The drugs most frequently cited for therapeutic duplications (TD) alerts were
quetiapine, methylphenidate, hydrocodone, and amphetamine salts. This is the
same list as FFY 2009 and FFY 2008.
ProDUR Analysis
ProDUR cost avoidance for the Michigan Medicaid prescription drug program is the sum
of the claims that were reversed or denied and not resubmitted. An example of the first
type of claim is a paid claim for a diuretic, such as furosemide, which got a therapeutic
duplication message because the recipient had a recent claim for another diuretic, such
as hydrochlorothiazide. The dispensing pharmacist then reversed out the paid
furosemide claim and did not resubmit it. An example of the second type of cost
avoidance is a claim which denied for a level one severity drug interaction, such as a
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
claim for aspirin where the recipient has a claim in their history for warfarin, and the
dispensing pharmacist did not resubmit the claim with appropriate override codes in
order to receive a paid claim. This is illustrated in Figure 2 (below).
The ProDUR cost avoidance for FFY 2010 was $389,798,567. Table 3 (see Section VIII,
Tables) summarizes the FFY 2010 data. However, cost avoidance should not be
interpreted as true cost savings. While the ProDUR edit may have resulted in a claim
reversal or denial, it is not known what the complete impact this has on the program.
There are many prescriptions that are switched after point of sale to alternative
medications, which would have an improved therapeutic benefit to the patient and would
not generate a ProDUR edit. The cost of this alternative medication is not reflected in
the calculation of ProDUR cost avoidance. Another factor that influenced this calculation
was multiple claim submission for an individual beneficiary’s prescription. This would
result in a number of claims and ProDUR edits for one prescription. If the provider fails
to reverse the various claims, the calculations would be inflated. The inclusion of the
Medicaid Health Plan Carve-Out medications led to increased claims submissions as
pharmacy providers attempted to address the new alerts and edits that now impacted
these medications. These multiple submissions inflated the ProDUR cost avoidance for
FFY 2010.
Figure 2. Point of Sale Disposition of Claims
Cost avoidance associated with lack of
filling the prescription *
Claim Denied and Not Resubmitted
→
Claim Denied, then Resubmitted
and Paid
→
Claim Paid, no message sent
→
No cost avoidance
Claim Paid, message sent that does not cause
claim to reject
→
No cost avoidance
→
Cost avoidance not calculable due to
complexity of assessing impact.
→
Cost avoidance calculated as submitted
cost of the reversed claim *
Claim Paid, message sent that does not cause
claim to reject However, provider resubmits
with minor adjustments or other
information
Claim Paid, message sent that does not cause
claim to reject: however, provider reverses the
claim. No other claim in same
class submitted within calendar month
* Included in cost avoidance calculations
Page 8
Cost avoidance, if any, calculated as the
difference between the denied claim and
resubmitted claim. Only possible if claims
are in the same drug class
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
III. Retrospective Drug Utilization Review (RetroDUR)
The goal of the Michigan Medicaid RetroDUR Program is to promote appropriate
prescribing and use of medications. The RetroDUR utilization analysis, as described
below, provides information which assists in the identification of patterns of inappropriate
prescribing and/or medication use, alerts physicians and pharmacists to potential drug
therapy problems, identifies opportunities to improve drug therapy and makes
recommendations to avoid drug therapy problems.
Utilization Analysis
The on-going operation of the RetroDUR program is a shared responsibility of Magellan
Medicaid Administration and Michigan Medicaid. Each month, specific drug classes that
have been reviewed by the DUR Board are targeted for focused review under the
RetroDUR program. Magellan Medicaid Administration then applies the specified criteria
established by the Board to the prescription drug and health claims files and identifies
medication regimens that do not adhere to the criteria. Copies of individual medication
profiles that do not adhere to specific criteria are generated by Magellan Medicaid
Administration and sent to Michigan Medicaid Profile Reviewers for in-depth review. If,
based on the professional opinions of the Michigan clinical reviewers or the Magellan
Medicaid Administration Michigan Medicaid Clinical Manager, an aberrant pattern of
prescribing and/or utilization is indeed present, an educational letter is sent to the
prescribing physician and/or the dispensing pharmacist informing the provider of the
suspected problem and requesting further information to use in resolution of the issue.
After the review process is completed, the Magellan Medicaid Administration Michigan
Medicaid Clinical Manager decides which patient profiles should cause the generation of
physician or pharmacy letters. Magellan Medicaid Administration produces and mails
provider letters documenting the therapeutic effects of the RetroDUR program and tracks
provider responses and cost savings associated with the interventions.
The Michigan Medicaid DUR Board meets quarterly to review drug criteria in specific
therapeutic classes and/or drug criteria for new drugs approved by the FDA.
A total of 7,561 patient profiles, or an average of 630 profiles per month, reflecting these
RetroDUR exceptions were subsequently reviewed by Michigan Medicaid Profile
Reviewers. They then recommended a total of 2,404 intervention letters be sent to
physicians and/or pharmacist providers in FFY 2010 concerning criteria variances or
other medication related clinical issues. Table 4 (see Section VIII, Tables) summarizes
the profiles produced and lettered.
Among the problem types addressed in the intervention letters were therapeutic
duplication, overutilization, underutilization and appropriate use for age and for
diagnosis. Letters were also sent to physicians based on new FDA warnings or changes
in production labeling. The RetroDUR activities for February and March 2010 addressed
the FDA’s warning that long-term or high-dose use of metoclopramide is associated with
an increased risk of developing tardive dyskinesia. The Michigan DUR Board also
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
selects RetroDUR topics and/or criteria on a quarterly basis on information in the
monthly ProDUR statistics or other clinically relevant topics from the medical literature.
For example, the reviews conducted in April, May and June 2010 were related to current
recommendations for monitoring blood glucose levels in patients receiving second
generation antipsychotics. These references included recommendations from the
American Diabetes Association, the American Psychiatric Association, the American
Association of Clinical Endocrinologists, and the North American Association for the
Study of Obesity.
RetroDUR responses from prescribers were tracked on a monthly basis. Details of the
responses are also found in Table 4 (see Section VIII. Tables). The average response
rate for FFY 2010 was 19%. This is a decrease from the response rate of 27% in FFY
2009. Figure 3 (below) graphically displays the RetroDUR response rate.
Figure 3. RetroDUR Response Rate FFY 2010
RetroDUR Cost Analysis
The provision of high quality drug therapy not only results in improved patient health but
may also result in program cost avoidance. It is important to quantify the effect of
interventions on the cost of drug therapy. Magellan Medicaid Administration uses a cost
analysis model developed by the Institute for Pharmacoeconomics of the Philadelphia
College of Pharmacy and Science to quantify cost avoidance. When fully applied, the
cost analysis model has the ability to capture not only cost avoidance that is a direct
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
result of the RetroDUR letter intervention process, but also avoidance due to indirect
effects. This indirect effect arises when a physician applies changes in prescribing
triggered by a letter intervention involving one patient to other patients in his/her practice.
The model also takes into account the impact of prescription drug inflation, new drugs
introduced into the market, and changes in utilization rates, recipient numbers and
demographics.
The cost analysis in this report was calculated based on changes in the prescription drug
costs for those patients whose profiles were identified through the RetroDUR program.
Cost avoidance is tracked over a 12-month period beginning six months after the
provider is sent a letter/intervention. Changes in prescription drug costs are totaled to
yield overall cost avoidance for the review period. The total cost avoidance, attributed to
RetroDUR, during FFY 2010 was $477,833. Cost avoidance attributed to RetroDUR
during FFY 2009 was $300,497.
Monthly cost avoidance may vary due to a variety of factors, including:
•
•
•
the class selection and problem type chosen for review
the lag time before the next physician visit when changes in drug therapy may be
made
the incremental educational and familiarity impact on the prescriber after receiving
intervention letters
Month-by-month cost avoidance for all active interventions (i.e. interventions which have
not completed twelve consecutive months of review/tracking) vary with intensity of
intervention activity. Intervention letters sent during the fiscal year, have not all
completed follow-up review for one year. Consequently, the cumulative cost avoidance
effect of intervention letters mailed during FFY 2010 will not be known until the end of
FFY 2011. One of the RetroDUR activities for FY10 was an underutilization review. The
desired outcome of this review is more appropriate utilization of the medications by
beneficiaries. This will result in an increased number of prescriptions, which is reflected
as a decrease in cost savings to the pharmacy program, though the ultimate impact to
the beneficiary’s health should reflect a positive outcome. Overall, the cost savings
increased for FFY 2010 due to the majority of the reviews targeting overutilization or
inappropriate use which hopefully decreased the number of prescriptions.
Academic Detailing
The Michigan DUR Board also oversees the activities of the MI Academic Detailing
Program. On a quarterly basis, trained pharmacists from the Michigan Pharmacists
Association (MPA) visit selected physician providers. These providers are selected
based on their prescribing patterns to receive educational information on current medical
topics. The topics are often selected based on information in the ProDUR or RetroDUR
reports. Topics during FFY 2010 in are listed in Figure 4 below. During FFY 2010, 308
Michigan Medicaid physician providers received a personal visit from a pharmacist
detailer. Of the providers targeted for academic detailing, 88% were visited. Most
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
commonly visits were not completed due to a physician refusal to make an appointment
or canceling of the appointment by the physician.
Figure 4. History of Academic Detailing Projects
Subject
Percentage
Number of Number of
Date
of
Physicians
Visits
Completed
Completed
Profiled Completed
Visits
Asthma
November
Management
2009
119
103
87
Smoking
Cessation
May 2010
107
97
91
Smoking
Cessation
October
2010
123
108
88
Description
The providers of high risk patients were
identified as the provider population. The
physician selection was based on having
a patient admitted to the hospital or seen
in the emergency room
Prescribers were selected based on
having patients with the diagnosis of
diabetes, COPD or kidney disease.
Prescribers were grouped by the number
of recipients that they were writing
prescriptions for in one of those diagnosis
groups. The top 60 prescribers from each
diagnosis group were selected.
Duplications from previous smoking
cessation activities were eliminated to get
our target list of prescribers.
This activity was divided and conducted
over the course of 2 quarters.
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IV.
Factors Affecting Program Drug Costs
Population Analysis
Overall utilization rates can be defined in a variety of ways. These include total quantity
consumed per member, number of individual prescriptions, total days supply, etc. An
alternative way to look at utilization rates is by considering the number of recipients
taking one particular drug for one month of time. This quantity is defined as a membermonth and can give a relative view of the amount of drug used by recipients over time.
Data for drug usage and overall cost by age groups have been abstracted from overall
claims data. The data are summarized for FFY 2010 in Table 5 (see Section VIII.
Tables).
The age group 0-12 utilized 22.5% of total program dollars (versus 20.3% in FFY 2009).
Member-months in this category decreased slightly to 14.8% from FFY 2009 levels
(15.1%). The major drug expenditures were associated with the following therapeutic
classes. The top classes are the same as in FFY 2009 although antidepressants and
bronchial dilators showed increased utilization in FFY 2010.
•
•
•
•
•
•
•
•
•
Unclassified Agents (primarily antihemophilic factors) – class 99
Ataractics/Tranquilizers – class 07
CNS Stimulants – class 10
Amphetamines – class 12
Anticonvulsants – class 48
Antidepressants – class 11
Bronchial Dilators – class 15
Antivirals – class 33
Glucocorticoids– class 51
The age group 13-18 utilized 18.0% of total program dollars (versus the 16.6% utilized in
FFY 2009). Member-months in this category remained the same as FFY 2009 at 11.3%.
The major drug expenditures were associated with the following therapeutic classes.
The top classes are the same as FFY 2009, but the anticonvulsant class has moved
down from the third to the sixth position.
•
•
•
•
•
•
•
•
Ataractics/Tranquilizers – class 07
Unclassified Agents (primarily antihemophilic factors) – class 99
CNS Stimulants – class 10
Amphetamines – class 12
Antidepressants – class 11
Anticonvulsants – class 48
Other Hormones (primarily growth and vasopressin hormones) – class 64
Diabetic Therapy – class 58
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Michigan Medicaid
Drug Utilization Review
2010 Annual Report
The age group 19-39 utilized 27.3% of total program dollars (versus 27.8% in FFY 2009).
Member-months in this category increased slightly 27.1% relative to FFY 2008 level of
26.5%. The major drug expenditures were associated with the following therapeutic
classes. The list is essentially the same as in FFY 2009 with antidepressants moving up
one in the ranking to third place and anticonvulsants falling from second place to fourth.
Bronchial dilators dropped to the tenth position and were replaced with amphetamines in
the eighth position.
•
•
•
•
•
•
•
•
•
Ataractics/Tranquilizers – class 07
Unclassified Agents (primarily immunosuppressants) – class 99
Antidepressants – class 11
Anticonvulsants – class 48
Antivirals – class 33
Narcotic Analgesics – class 40
Contraceptives, oral- class 63
Amphetamines – class 12
Diabetic Therapy - class 58
The age group 40-65 utilized 31.6% of total program dollars, a decrease relative to FFY
2009 (34.4%). Member-months in this category decreased slightly to 39.8% from FFY
2009 levels (40.5%). The major drug expenditures were associated with the following
therapeutic classes. The top classes in FFY 2010 were consistent with those seen in
FFY 2009. Antidepressants rose from the fourth position to the third switching places
with anticonvulsants.
•
•
•
•
•
•
•
•
•
Ataractics/Tranquilizers – class 07
Antivirals – class 33
Antidepressants – class 11
Anticonvulsants – class 48
Unclassified Agents (primarily benign prostatic hypertrophy [BPH], osteoporosis and
immunosuppressant agents) – class 99
Narcotic Analgesics – class 40
Diabetic Therapy – class 58
Bronchodilators – class 15
Antineoplastics – class 30
The age group > 65 utilized 0.6% of total program dollars (versus 0.7% in FFY 2009).
Member-months in this category increased slightly to 7.0% from FFY 2009 levels (6.7%).
The major drug expenditures were associated with the following therapeutic classes.
Class 71, hypotensives, has moved up to the seventh position from the fifteenth position
for this age group.
•
•
•
Ataractics/Tranquilizers – class 07
Analgesics, non-narcotic, general - class 41
Antihistamines - class 14
Page 14
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
•
•
•
•
•
•
Anti-Ulcer/Other GI Agents – class 01
Unclassified Agents (primarily BPH, osteoporosis and immunosuppressant agents) –
class 99
Other Hypotensives – class 71
Hematinics – class 88
Water Soluble Vitamins – class 81
Laxatives – class 06
The twenty top therapeutic classes, contributing most to cost for each age category, are
listed in Table 6 (see Section VIII. Tables).
New Drugs
Another factor, which must be considered when analyzing yearly drug expenditures, is
the impact of new FDA-approved drugs and dosage forms. These new agents represent
costs which sometimes cannot be anticipated and have the potential to inflate drug
budgets, especially if the agents are high cost. The top new drugs, listed in Table 7 (see
Section VIII, Tables), contributed $2,466,473 to the Michigan Medicaid drug costs for
FFY 2010. Both the costs of the top 30 new drugs and total drug costs for the program
have risen significantly over the FFY 2009 level. The percentage of the costs of the new
drugs has jumped to 0.41% from 0.17% in FFY 2009. This illustrates the dramatic price
increases for new products in recent years.
Page 15
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
V.
Generic Drug Substitution
The Michigan Medicaid prescription drug program uses various methods to encourage
generic drug utilization and cost containment. These methods include:
•
Brand medically necessary edit: This edit requires that physicians indicate that
a multi-source brand drug is required for their patient. This edit is based on the
MDCH-specific definition of brand and generic drugs. Claims for multi-source
brand drugs will be paid at the MAC price if available unless the prescriber
requests a prior authorization (PA) for the priced as brand multi-source product.
Based on the Michigan Medicaid definition of their brand versus generic pricing,
the average rate of generic utilization is seventy-four percent (74%). This
includes both the fee-for-service claims as well as those for behavioral health drug
claims carved out for the managed care organizations (MCOs).
•
Maximum Allowable Cost (MAC): MAC reimbursement levels for Michigan
Medicaid are established and managed by MMA, Inc. MAC reimbursement levels
are generally applied to multi-source brand and generic products. However, MAC
reimbursement may also be applied to single source drugs or drug classifications
where appropriate (e.g. antihemophilic factors).
•
Preferred Drug List (PDL): The PDL drives market shift to the generic drugs
when the pricing is less than the brand pricing net of CMS and supplemental
rebates. The patents of the original brand drugs in many of the therapeutic
classes have expired. These older drugs have been replaced with several
generic versions that are now priced at MAC.
•
Tiered copays for brand/generic drugs: Michigan Medicaid requires $1
copayment for each generic drug dispensed, and a $3 copayment for each brand
name drug dispensed, in general, for Medicaid beneficiaries age 21 years and
older.
CMS has developed an extract file from the Medicaid Drug Rebate Program Drug
Product Data File identifying each NDC along with sourcing status of each drug. These
sourcing status indicators are identified as follows:
•
•
•
Single-Source (S) - Drugs that have an FDA New Drug Application (NDA)
approval for which there are no generic alternatives available on the market.
Non-Innovator Multiple-Source (N) - Drugs that have an FDA Abbreviated New
Drug Application (ANDA) approval and for which there exists generic alternatives
on the market.
Innovator Multiple-Source (I) - Drugs which have an NDA and no longer have
patent exclusivity.
Page 16
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
Utilizing these indicators to determine generic utilization will allow for consistent reporting
across all states. Based on calculations using these indicators, Michigan Medicaid has a
generic utilization of 68.47% for all outpatient claims comprising 12.12% of total drug
expenditures. The claim counts and expenditures for each indicator are listed in Table 8
(Section VIII, Tables).
Page 17
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
VI.
E-Prescribing
The Michigan Medicaid first implemented e-prescribing in 2008. This initial phase
allowed prescribers and pharmacies to search the Michigan Pharmaceutical Product List
(MPPL) of covered products.
In 2010, Michigan Medicaid and MMA, Inc implemented a second phase of e-prescribing
with SureScripts/RxHub that offers physicians access to the beneficiary’s drug plan
information in real time during the office visit. Automation of the outpatient prescribing
process offers many potential benefits to different healthcare stakeholders, especially
patients, physicians, and pharmacy providers, because the processes employed by eprescribing allows the creation of an “informed prescription” that takes into consideration
patient plan coverage, formulary preferences, and medication history. Putting formulary
and eligibility information at a physician’s fingertips eliminates many of the questions that
often require pharmacists to place multiple telephone calls to a physician’s office. This
improves beneficiary care and saves time for both beneficiaries and providers.
The MMA, Inc e-prescribing program supports a model for beneficiary demographics,
eligibility, PDL/Formulary, and medication history. MMA, Inc sends beneficiary,
formulary and medication history files to SureScripts/RxHub weekly. Program
capabilities include:
•
Prescriber requests for beneficiary eligibility using an ASC X12 270 format.
SureScripts/RxHub will validate the transaction format and locate the beneficiary
based on MMA, Inc’s demographics file and unique identifiers of the beneficiary to
determine if the requested beneficiary information is housed and available.
SureScripts/RxHub responds back to the requesting prescriber with the
beneficiary’s Eligibility response (ASCX12 271).
•
PDL/Formulary Lookups. The prescriber can locate the beneficiary’s
PDL/Formulary information in their practice management system. The
PDL/Formulary lookup will help inform the prescriber, based on the beneficiary’s
coverage, if the medication is covered, non-covered, or requires prior
authorization. After receiving formulary files, SureScripts/RxHub will validate it to
NCPDP specifications and provide the Michigan PDL/Formulary information to the
prescriber’s practice management system.
•
Prescriber requests for beneficiary medication history from
SureScripts/RxHub using the NCPDP SCRIPT 8.1 format. This request can be
limited to specific date ranges or, if no date is entered, defaults to the entire drug
history (a rolling maximum of 13 months) for the beneficiary. SureScripts/RxHub
validates the beneficiary elements on the request against a stored PBM dataset.
MMA, Inc supplies the beneficiary medication history and SureScripts/RxHub
completes interaction/DUR checks. The beneficiary medication history from MMA,
Inc is routed to the requesting prescriber through SureScripts/RxHub.
Page 18
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
•
Real‐time electronic scripts. Once all validation is completed,
SureScripts/RxHub forwards a real‐time electronic copy of the prescriber’s
prescription to the identified pharmacy.
•
Pharmacy approvals. The pharmacy submits the claim using the NCPDP origin
code to MMA, Inc for adjudication. The origin code indentifies the claim as an
electronic prescription.
The transaction activity of the e-prescribing program is routinely monitored.
SureScripts/RxHub provides monthly reports of the number of inquiries for eligibility,
medication history and formulary. In addition, MMA, Inc provides daily and monthly
reports of the prescribers that are using the application. In March 2008, Michigan
Medicaid began requiring that pharmacy providers submit the NCPDP Origin Code on all
claims. This allows the number of prescriptions processed via e-prescribing to be
monitored. Figure 5, below, shows the e-prescribing activity for FFY 2010 compared
with that of FFY 2009. The percentage of e-prescribed claims has risen from 4% to 16%
of all paid claims. There has also been an increase in the number prescribers utilizing eprescribing from 30% to 43% of active prescribers.
Figure 5. Comparison of Annual E-Prescribing Activity
FFY
Nbr
e-Prescribed
Paid Claims
2010
1,222,321
7,884,055
16%
19,264
45,214
43%
2009
309,472
7,535,342
4%
13,117
43,969
30%
Total
Paid Claims
% of
Total Paid
Claims
Nbr
e-Prescribers
Total
Unique
Prescribers
%
Total
Prescribers
Page 19
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
VII. Innovative Practices
Michigan Medicaid has been leading the way to control healthcare spending for years.
They were one of the first states in the nation to implement supplemental rebate
contracting to create a preferred drug list (PDL). Michigan Medicaid also employs an
aggressive reimbursement pricing algorithm, dose optimization, quantity limits, clinical
edits and a maximum allowable cost (MAC) program. As part of their DUR program,
Michigan Medicaid conducts academic detailing activities utilizing pharmacists from the
Michigan Pharmacy Association to educate prescribers on current evidence-based
guidelines and prescribing patterns.
Each year Michigan Medicaid strives to enhance their program to maximize both cost
containment as well as operational efficiencies. In FFY 2010, a number of automated
prior authorizations (AutoPAs) were implemented to optimize claims processing for the
pharmacy provider, the MMA, Inc call center as well as the beneficiary. These AutoPAs
utilize the beneficiaries’ medication and diagnosis history to verify that the edit criteria
are met allowing the claim to pay. The current AutoPAs involve criteria for such classes
as ADHD medications, diabetic therapy, proton pump inhibitors (PPIs), sedatives,
antihistamines, antibiotics, antihypertensives, immunosuppressants and anticonvulsants.
In 2011, a new prescriber file called HCIdea™ will be deployed in the POS system. This
new file will enhance the prescriber demographic database to include taxonomy codes
that will allow for AutoPAs for clinical edits based on prescriber specialty.
In addition to the enhanced e-prescribing program implemented in 2010, MMA, Inc also
implemented a web-based Drug Lookup application that allows the user to inquire about
the coverage of specific drug names or national drug codes (NDCs). The drug
information is tied directly to the claims adjudication tables within the POS system. The
POS table updates are loaded to the application weekly. This new application can be
accessed through Michigan Medicaid’s Magellan Medicaid Administration website
(https://michigan.fhsc.com) and is available to the public.
Page 20
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
VIII. Tables
Page 21
Michigan Medicaid
Table 1
ProDUR Message Report
FFY 2010
ProDUR
Message
ProDUR
Severity
Message
Count
Acute To Maintenance
1
102,061
$20,432,493.93
Drug To Drug
1
35,945
$11,057,267.85
Drug To Gender
1
4,354
$1,125,341.67
Drug To Geriatric
1
122,786
$5,345,527.58
Drug To Inferred Dis
1
530,662
$79,742,624.95
Drug To Pediatric
1
78,463
$12,896,513.55
Duplicate Therapy
0
4,265,256
$1,251,972,622.19
Min Max
0
1,043,844
$263,486,900.48
Too Late
0
2,374,691
$512,206,497.10
Too Soon Clinical
0
1,737,790
$382,245,147.37
10,295,852
$2,540,510,936.67
ALL
Message
Amount
Total Number of Claims with Messages: 8,083,127
Average ProDUR Message Per Claim:
1.27
ProDUR Severity 1 = High Importance
Severity Rating is assigned by First Data Bank, Inc.
CMS FFY 2010
Page 22
Table 1
Michigan Medicaid
Table 2
ProDUR Encounters by problem type
FFY 2010
Problem Type
Drug
Acute To Maintenance LANSOPRAZOLE
ESOMEPRAZOLE MAG TRIHYDRATE
(PP)
OMEPRAZOLE
LANSOPRAZOLE
OMEPRAZOLE MAGNESIUM
ESOMEPRAZOLE MAG TRIHYDRATE
PANTOPRAZOLE SODIUM
OMEPRAZOLE
OMEPRAZOLE MAGNESIUM
LANSOPRAZOLE
ESOMEPRAZOLE MAG TRIHYDRATE
OMEPRAZOLE MAGNESIUM
PANTOPRAZOLE SODIUM
OMEPRAZOLE MAGNESIUM
RABEPRAZOLE SODIUM
OMEPRAZOLE
OMEPRAZOLE
OMEPRAZOLE MAGNESIUM
OMEPRAZOLE
LANSOPRAZOLE
Problem Type
Drug To Drug
(DD)
CMS FFY 2010
Drug
ZIPRASIDONE HCL
OXYBUTYNIN CHLORIDE
PALIPERIDONE
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
GEMFIBROZIL
TOLTERODINE TARTRATE
SIMVASTATIN
POTASSIUM CHLORIDE
BENZTROPINE MESYLATE
CHLORPROMAZINE HCL
CIPROFLOXACIN HCL
DIPHENOXYLATE HCL/ATROP SULF
DICYCLOMINE HCL
ZIPRASIDONE HCL
KETOROLAC TROMETHAMINE
THIORIDAZINE HCL
POTASSIUM CHLORIDE
THIORIDAZINE HCL
SCOPOLAMINE HYDROBROMIDE
History
MAX DOSE 0.001 Each/DAY
MAX DOSE 0.001 Each/DAY
MAX DOSE 0.001 Each/DAY
ACUTE DOSE - 12 DAYS REMAIN
MAX DOSE 1.000 Each/DAY
ACUTE DOSE - 12 DAYS REMAIN
MAX DOSE 0.001 Each/DAY
ACUTE DOSE - 12 DAYS REMAIN
ACUTE DOSE - 12 DAYS REMAIN
MAX DOSE 1.000 Each/DAY
MAX DOSE 1.000 Each/DAY
ACUTE DOSE - 18 DAYS REMAIN
ACUTE DOSE - 12 DAYS REMAIN
ACUTE DOSE - 4 DAYS REMAIN
MAX DOSE 1.000 Each/DAY
ACUTE DOSE - 72 DAYS REMAIN
ACUTE DOSE - 18 DAYS REMAIN
ACUTE DOSE - 14 DAYS REMAIN
ACUTE DOSE - 4 DAYS REMAIN
ACUTE DOSE - 4 DAYS REMAIN
History
PALIPERIDONE
POTASSIUM CHLORIDE
ZIPRASIDONE HCL
TOLTERODINE TARTRATE
OXYBUTYNIN CHLORIDE
SIMVASTATIN
POTASSIUM CHLORIDE
GEMFIBROZIL
BENZTROPINE MESYLATE
POTASSIUM CHLORIDE
ZIPRASIDONE HCL
TIZANIDINE HCL
POTASSIUM CHLORIDE
POTASSIUM CHLORIDE
CHLORPROMAZINE HCL
IBUPROFEN
PAROXETINE HCL
DICYCLOMINE HCL
FLUOXETINE HCL
POTASSIUM CHLORIDE
Page 23
# Claims # Alerts
80,648
37,187
107,894
80,648
60,771
37,187
18,974
107,894
60,771
80,648
37,187
60,771
18,974
60,771
2,229
107,894
107,894
60,771
107,894
80,648
26,729
18,613
12,224
7,096
6,700
5,055
4,495
3,628
3,062
2,834
1,495
977
684
521
323
261
225
220
194
190
# Claims # Alerts
57,192
19,704
23,107
34,271
34,271
9,386
9,027
88,995
34,271
75,974
7,619
41,908
4,410
10,406
57,192
5,315
3,796
34,271
3,796
4,664
1,586
1,529
1,486
1,119
1,112
1,079
1,050
1,006
906
874
801
653
650
617
601
515
512
502
459
448
Alert %
33.14%
50.05%
11.33%
8.80%
11.02%
13.59%
23.69%
3.36%
5.04%
3.51%
4.02%
1.61%
3.60%
0.86%
14.49%
0.24%
0.21%
0.36%
0.18%
0.24%
Alert %
2.77%
7.76%
6.43%
3.27%
3.24%
11.50%
11.63%
1.13%
2.64%
1.15%
10.51%
1.56%
14.74%
5.93%
1.05%
9.69%
13.49%
1.46%
12.09%
9.61%
# Denial
Alerts
20,999
14,114
10,857
6,732
5,557
4,844
3,444
3,455
3,005
2,083
1,125
953
611
505
231
261
218
212
190
183
# Paid
Alerts
5,730
4,499
1,367
364
1,143
211
1,051
173
57
751
370
24
73
16
92
0
7
8
4
7
# Denial
Alerts
986
1,022
900
689
680
737
617
693
604
561
482
450
410
430
373
387
340
342
308
268
# Paid
Alerts
600
507
586
430
432
342
433
313
302
313
319
203
240
187
228
128
172
160
151
180
Table 2
Michigan Medicaid
Table 2
ProDUR Encounters by problem type
FFY 2010
Problem Type
Drug To Gender
(SX)
Problem Type
Drug To Geriatric
(PA)
CMS FFY 2010
Drug
TAMSULOSIN HCL
TADALAFIL
LETROZOLE
ANASTROZOLE
MICONAZOLE NITRATE
SILDENAFIL CITRATE
MEDROXYPROGESTERONE ACET
CLOTRIMAZOLE
LUBIPROSTONE
NORGESTIMATE-ETHINYL ESTRADIOL
FINASTERIDE
LEUPROLIDE ACETATE
TESTOSTERONE
ALFUZOSIN HCL
LEVONORGESTREL-ETH ESTRA
ETONOGESTREL/ETHINYL ESTRADIOL
ESTROGENS,CONJUGATED
BICALUTAMIDE
ESTRADIOL
TERCONAZOLE
Drug
DIAZEPAM
BENZTROPINE MESYLATE
AMITRIPTYLINE HCL
BUTALB/ACETAMINOPHEN/CAFFEINE
CHLORDIAZEPOXIDE HCL
CYCLOBENZAPRINE HCL
HYOSCYAMINE SULFATE
CLOZAPINE
CLORAZEPATE DIPOTASSIUM
CARISOPRODOL
DOXEPIN HCL
NORTRIPTYLINE HCL
CHLORDIAZEPOXIDE/CLIDINIUM BR
AMPHET ASP/AMPHET/D-AMPHET
DICYCLOMINE HCL
TRIAZOLAM
NITROFURANTOIN/NITROFURAN MAC
BUTALBITAL/ASPIRIN/CAFFEINE
PHENOBARB/HYOSCY/ATROPIN/SCOP
METHOCARBAMOL
History
Used exclusively in men
Used exclusively in men
Used exclusively in women
Used exclusively in women
Used exclusively in women
Used exclusively in men
Used exclusively in women
Used exclusively in women
Used exclusively in women
Used exclusively in women
Used exclusively in men
Used exclusively in men
Used exclusively in men
Used exclusively in men
Used exclusively in women
Used exclusively in women
Used exclusively in women
Used exclusively in men
Used exclusively in women
Used exclusively in women
History
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Page 24
# Claims # Alerts
9,927
2,981
2,010
4,025
10,314
4,613
19,959
25,759
2,174
82,289
1,744
1,663
2,069
654
36,487
24,685
6,377
308
7,218
6,744
2,265
230
217
198
196
194
147
111
75
64
57
57
47
42
37
27
26
25
25
25
# Claims # Alerts
223,856
75,974
101,919
25,951
12,056
65,752
8,132
33,665
4,776
25,379
13,650
20,615
1,744
343,936
10,406
4,667
16,351
3,069
2,770
10,435
42,251
9,038
8,333
8,119
7,001
6,910
3,295
3,095
2,619
2,535
2,442
2,201
2,012
1,710
1,652
1,322
1,263
1,256
1,232
1,210
Alert %
22.82%
7.72%
10.80%
4.92%
1.90%
4.21%
0.74%
0.43%
3.45%
0.08%
3.27%
3.43%
2.27%
6.42%
0.10%
0.11%
0.41%
8.12%
0.35%
0.37%
Alert %
18.87%
11.90%
8.18%
31.29%
58.07%
10.51%
40.52%
9.19%
54.84%
9.99%
17.89%
10.68%
115.37%
0.50%
15.88%
28.33%
7.72%
40.93%
44.48%
11.60%
# Denial
Alerts
2,200
190
166
155
196
190
141
111
68
63
54
54
47
40
37
27
25
23
25
25
# Paid
Alerts
65
40
51
43
0
4
6
0
7
1
3
3
0
2
0
0
1
2
0
0
# Denial
Alerts
20,962
2,378
1,523
1,867
3,030
4,532
2,787
811
589
2,535
478
484
1,962
1,161
1,061
1,153
843
219
1,232
728
# Paid
Alerts
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Table 2
Michigan Medicaid
Table 2
ProDUR Encounters by problem type
FFY 2010
Problem Type
Drug To Inferred Dis
(DC)
Problem Type
Drug To Pediatric
(PA)
CMS FFY 2010
Drug
FLUTICASONE/SALMETEROL
HALOPERIDOL
INSULIN ASPART
BUPROPION HCL
METFORMIN HCL
BUDESONIDE
INSULIN GLARGINE,HUM.REC.ANLOG
IBUPROFEN
FLUTICASONE PROPIONATE
LEVOTHYROXINE SODIUM
BUPROPION HCL
MORPHINE SULFATE
BUPROPION HCL
METOPROLOL TARTRATE
INSULIN LISPRO
LISINOPRIL
FENTANYL
BUDESONIDE/FORMOTEROL FUMAR
METFORMIN HCL
CYCLOBENZAPRINE HCL
Drug
DM/PHENYLEPH/CHLORPHENIRAMINE
AMPHET ASP/AMPHET/D-AMPHET
LAMOTRIGINE
ZONISAMIDE
D-METHORPHAN HB/P-EPD HCL/BPM
DEXMETHYLPHENIDATE HCL
PHENYLEPHRINE HCL/CHLOR-MAL
GUAIFENESIN/D-METHORPHAN HB
ASPIRIN
LISDEXAMFETAMINE DIMESYLATE
D-METHORPHAN HB/PROMETH HCL
DEXCHLORPHENIRAMINE MALEATE
GUAIFENESIN/CODEINE PHOS
CODEINE/PROMETHAZINE HCL
PHENYLEPHRINE/CHLOR-TAN
GUAIFENESIN
PROMETHAZINE HCL
MODAFINIL
LORATADINE/PSEUDOEPHEDRINE
SERTRALINE HCL
History
ALBUTEROL SULFATE
BENZTROPINE MESYLATE
GLUCAGON,HUMAN RECOMB
FLUOXETINE HCL
LISINOPRIL
ALBUTEROL SULFATE
GLUCAGON,HUMAN RECOMB
PRENATAL VIT/FE FUMARATE/FA
ALBUTEROL SULFATE
LISINOPRIL
GABAPENTIN
ALBUTEROL SULFATE
LAMOTRIGINE
FUROSEMIDE
GLUCAGON,HUMAN RECOMB
PREDNISONE
ALBUTEROL SULFATE
ALBUTEROL SULFATE
FUROSEMIDE
LISINOPRIL
History
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Drug therapy should be changed
Page 25
# Claims # Alerts
48,841
31,618
52,445
167,659
60,562
44,145
54,116
194,929
93,463
90,651
167,659
44,057
167,659
45,829
18,250
92,210
31,106
12,582
60,562
65,752
40,270
28,123
23,198
20,292
17,415
17,151
16,281
11,344
11,056
8,067
7,829
7,590
7,534
7,458
6,783
6,384
6,355
5,988
5,753
5,746
# Claims # Alerts
19,589
343,936
145,218
16,702
2,517
63,044
2,561
8,471
229,013
110,564
7,104
2,427
17,769
23,673
1,695
8,348
38,355
9,090
10,564
243,105
37,040
10,448
8,954
7,571
4,782
4,591
4,270
3,072
2,977
2,670
2,639
1,641
1,439
952
767
760
738
526
481
452
Alert %
82.45%
88.95%
44.23%
12.10%
28.76%
38.85%
30.09%
5.82%
11.83%
8.90%
4.67%
17.23%
4.49%
16.27%
37.17%
6.92%
20.43%
47.59%
9.50%
8.74%
Alert %
189.09%
3.04%
6.17%
45.33%
189.99%
7.28%
166.73%
36.26%
1.30%
2.41%
37.15%
67.61%
8.10%
4.02%
45.25%
9.10%
1.92%
5.79%
4.55%
0.19%
# Denial
Alerts
12,404
5,492
8,114
3,313
5,442
5,753
5,105
5,856
3,564
2,441
951
4,261
1,256
1,956
2,416
1,826
4,565
1,820
1,559
1,777
# Paid
Alerts
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
# Denial
Alerts
37,034
5,019
3,061
2,726
4,782
2,231
4,270
3,072
1,140
1,371
2,639
581
1,439
952
739
760
351
348
481
129
# Paid
Alerts
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Table 2
Michigan Medicaid
Table 2
ProDUR Encounters by problem type
FFY 2010
Problem Type
Duplicate Therapy
(TD)
Problem Type
Min Max
(HD)
CMS FFY 2010
Drug
QUETIAPINE FUMARATE
METHYLPHENIDATE HCL
HYDROCODONE BIT/ACETAMINOPHEN
AMPHET ASP/AMPHET/D-AMPHET
ALPRAZOLAM
RISPERIDONE
FLUOXETINE HCL
VENLAFAXINE HCL
DULOXETINE HCL
SERTRALINE HCL
DIVALPROEX SODIUM
CITALOPRAM HYDROBROMIDE
LAMOTRIGINE
BUPROPION HCL
ARIPIPRAZOLE
CLONAZEPAM
OLANZAPINE
ATOMOXETINE HCL
ALBUTEROL SULFATE
ALBUTEROL SULFATE
History
QUETIAPINE FUMARATE
METHYLPHENIDATE HCL
HYDROCODONE BIT/ACETAMINOPHEN
AMPHET ASP/AMPHET/D-AMPHET
ALPRAZOLAM
RISPERIDONE
FLUOXETINE HCL
VENLAFAXINE HCL
DULOXETINE HCL
SERTRALINE HCL
DIVALPROEX SODIUM
CITALOPRAM HYDROBROMIDE
LAMOTRIGINE
BUPROPION HCL
ARIPIPRAZOLE
CLONAZEPAM
OLANZAPINE
ATOMOXETINE HCL
FLUTICASONE/SALMETEROL
ALBUTEROL SULFATE
Drug
FLUTICASONE PROPIONATE
CYANOCOBALAMIN (VITAMIN B-12)
FLUTICASONE PROPIONATE
HYDROCODONE BIT/ACETAMINOPHEN
HYDROCODONE BIT/ACETAMINOPHEN
HYDROCODONE BIT/ACETAMINOPHEN
ESCITALOPRAM OXALATE
BUPRENORPHINE HCL/NALOXONE
DULOXETINE HCL
VENLAFAXINE HCL
ALBUTEROL SULFATE
PROPOXYPHENE/ACETAMINOPHEN
QUETIAPINE FUMARATE
ALBUTEROL SULFATE
DIAZEPAM
IBUPROFEN
ZOLPIDEM TARTRATE
OLANZAPINE
CYANOCOBALAMIN (VITAMIN B-12)
PHENYTOIN SODIUM EXTENDED
History
Pedi Max 0.532G
Geri Max 0.033ML
Adult Max 0.532G
Adult Max 5.000EA
Adult Max 6.000EA
Adult Max 8.000EA
Adult Max 1.000EA
Adult Max 2.000EA
Adult Max 1.000EA
Adult Max 1.000EA
Pedi Max 1.080G
Adult Max 6.000EA
Adult Max 2.000EA
Adult Max 1.080G
Geri Max 1.000EA
Adult Max 4.000EA
Geri Max 0.500EA
Adult Max 1.000EA
Adult Max 0.033ML
Adult Max 4.000EA
Page 26
# Claims # Alerts
319,183
412,622
522,596
343,936
691,065
226,902
218,067
94,770
143,069
243,105
189,892
213,652
145,218
167,659
197,245
349,484
100,863
93,601
293,693
293,693
181,423
157,698
112,328
111,069
77,420
66,226
65,156
62,531
61,148
59,669
56,697
51,234
49,728
43,473
39,987
38,695
38,462
37,748
37,684
37,628
# Claims # Alerts
93,463
31,751
93,463
522,596
522,596
522,596
143,088
64,368
143,069
94,770
293,693
49,164
319,183
293,693
223,856
194,929
132,589
100,863
31,751
56,880
48,529
40,924
37,966
32,604
29,890
24,995
20,054
19,123
17,580
16,331
13,718
13,384
12,198
11,610
11,053
10,004
8,851
8,665
8,310
7,959
Alert %
56.84%
38.22%
21.49%
32.29%
11.20%
29.19%
29.88%
65.98%
42.74%
24.54%
29.86%
23.98%
34.24%
25.93%
20.27%
11.07%
38.13%
40.33%
12.83%
12.81%
Alert %
51.92%
128.89%
40.62%
6.24%
5.72%
4.78%
14.02%
29.71%
12.29%
17.23%
4.67%
27.22%
3.82%
3.95%
4.94%
5.13%
6.68%
8.59%
26.17%
13.99%
# Denial
Alerts
35,919
23,958
84,577
19,146
18,902
13,444
15,908
6,994
7,652
10,138
9,341
8,512
10,241
6,102
7,240
7,692
6,993
10,532
13,191
12,321
# Paid
Alerts
N/A
N/A
27,751
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
# Denial
Alerts
24,369
9,638
20,803
32,180
19,718
24,994
4,563
13,553
3,893
3,516
6,971
13,335
3,208
6,479
4,264
5,923
4,276
2,035
3,081
1,706
# Paid
Alerts
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Table 2
Michigan Medicaid
Table 2
ProDUR Encounters by problem type
FFY 2010
Problem Type
Too Late
(LR)
Problem Type
Too Soon Clinical
(ER)
CMS FFY 2010
Drug
AMPHET ASP/AMPHET/D-AMPHET
ALBUTEROL SULFATE
CLONAZEPAM
SERTRALINE HCL
FLUOXETINE HCL
GABAPENTIN
TRAZODONE HCL
LISDEXAMFETAMINE DIMESYLATE
CITALOPRAM HYDROBROMIDE
DIVALPROEX SODIUM
BUPROPION HCL
ESCITALOPRAM OXALATE
DULOXETINE HCL
LAMOTRIGINE
PAROXETINE HCL
TOPIRAMATE
MONTELUKAST SODIUM
ATOMOXETINE HCL
LANSOPRAZOLE
OXCARBAZEPINE
Drug
ALPRAZOLAM
HYDROCODONE BIT/ACETAMINOPHEN
QUETIAPINE FUMARATE
CLONAZEPAM
LORAZEPAM
RISPERIDONE
ARIPIPRAZOLE
GABAPENTIN
DIAZEPAM
ASPIRIN
SERTRALINE HCL
LORATADINE
DIVALPROEX SODIUM
TRAZODONE HCL
ALBUTEROL SULFATE
FLUOXETINE HCL
OLANZAPINE
CITALOPRAM HYDROBROMIDE
LAMOTRIGINE
METHYLPHENIDATE HCL
History
AMPHET ASP/AMPHET/D-AMPHET
ALBUTEROL SULFATE
CLONAZEPAM
SERTRALINE HCL
FLUOXETINE HCL
GABAPENTIN
TRAZODONE HCL
LISDEXAMFETAMINE DIMESYLATE
CITALOPRAM HYDROBROMIDE
DIVALPROEX SODIUM
BUPROPION HCL
ESCITALOPRAM OXALATE
DULOXETINE HCL
LAMOTRIGINE
PAROXETINE HCL
TOPIRAMATE
MONTELUKAST SODIUM
ATOMOXETINE HCL
LANSOPRAZOLE
OXCARBAZEPINE
History
ALPRAZOLAM
HYDROCODONE BIT/ACETAMINOPHEN
QUETIAPINE FUMARATE
CLONAZEPAM
LORAZEPAM
RISPERIDONE
ARIPIPRAZOLE
GABAPENTIN
DIAZEPAM
ASPIRIN
SERTRALINE HCL
LORATADINE
DIVALPROEX SODIUM
TRAZODONE HCL
ALBUTEROL SULFATE
FLUOXETINE HCL
OLANZAPINE
CITALOPRAM HYDROBROMIDE
LAMOTRIGINE
METHYLPHENIDATE HCL
Page 27
# Claims # Alerts
343,936
293,693
349,484
243,105
218,067
233,019
198,982
110,564
213,652
189,892
167,659
143,088
143,069
145,218
122,838
121,768
90,870
93,601
80,648
95,096
204,481
105,411
95,380
72,121
68,436
63,757
60,803
59,061
56,727
55,040
53,221
48,722
43,592
41,649
38,542
36,929
34,018
31,478
30,451
29,937
# Claims # Alerts
691,065
522,596
319,183
349,484
306,047
226,902
197,245
233,019
223,856
229,013
243,105
260,384
189,892
198,982
293,693
218,067
100,863
213,652
145,218
412,622
118,459
78,554
78,252
67,616
60,740
53,601
42,631
31,330
28,506
27,522
26,170
25,474
24,985
24,336
23,611
23,407
22,371
20,776
20,449
18,887
Alert %
59.45%
35.89%
27.29%
29.67%
31.38%
27.36%
30.56%
53.42%
26.55%
28.98%
31.74%
34.05%
30.47%
28.68%
31.38%
30.33%
37.44%
33.63%
37.76%
31.48%
Alert %
17.14%
15.03%
24.52%
19.35%
19.85%
23.62%
21.61%
13.45%
12.73%
12.02%
10.76%
9.78%
13.16%
12.23%
8.04%
10.73%
22.18%
9.72%
14.08%
4.58%
# Denial
Alerts
47,103
36,932
14,656
12,133
10,788
7,522
8,586
15,356
8,951
10,093
7,914
7,412
5,974
8,512
5,656
6,123
12,565
7,698
18,506
5,870
# Paid
Alerts
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
# Denial
Alerts
110,937
75,014
75,548
62,269
55,711
51,148
41,129
27,661
26,583
27,483
23,607
25,084
22,362
21,741
23,035
20,158
21,836
18,937
18,019
16,889
# Paid
Alerts
7,522
3,540
2,704
5,347
5,029
2,453
1,502
3,669
1,923
39
2,563
390
2,623
2,595
576
3,249
535
1,839
2,430
1,998
Table 2
Michigan Medicaid
Table 3
Cost Avoidance Calculations
FFY 2010
Cost Avoidance Calculations
Paid Claims
Reversed and Not Resubmitted
$33,699,387*
Denied Claims
Not Resubmitted
$355,798,567♦
+
=
$389,497,954
Calculation Details
*Paid Claims Cost Avoidance
Count
Paid Claims: reversed
Paid claims: Resubmitted
(within 72 hours)
Amount
613,695
$87,950,271
(298,459)
($54,250,884)
315,236
$33,699,387*
Total Calculated Cost
Avoidance from Paid Claims
* Paid Claims Cost Avoidance is calculated by taking the paid dollar amount of claims with a
ProDUR message that paid, but were subsequently reversed and subtracting the paid
amount the claims resubmitted within 72 hours.
♦Denied Claims Cost Avoidance
Count
Denied Claims
Resubmitted claims
(within calendar month in
same drug class)
Total Calculated Cost
Avoidance from Denied Claims
Amount
3,678,654
$512,551,447
(1,525,582)
($156,752,880)
2,153,072
$355,798,567♦
♦Denied Claims Cost Avoidance is calculated by taking the submitted dollar value of the
claims that were initially denied and had a ProDUR message and subtracting any of those
claims that were then resubmitted within the same calendar month and then paid.
CMS FFY 2010
Page 28
Table 3
Michigan Medicaid
Table 4
RetroDUR Lettering
FFY 2010
Month
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Topic
Albuterol inhalers - more than 2 inhalers in 6 month period
Albuterol inhalers - more than 2 inhalers in 6 month period
ACE Inhibitor underutilization
Singular use without a diagnosis of asthma
Metoclopramide use over 90 Days
Metoclopramide use over 90 Days
Second generation antipsychotics and monitoring
Second generation antipsychotics and monitoring
Long-acting beta agonist use without inhaled corticosteroid
Second generation antipsychotics and monitoring
Hydrocodone combination products with other narcotics
Long-acting narcotics with long-acting narcotics
Long-acting fentanyl with long-acting morphine
Long-acting benzodiazepine use in older adults
Long-acting benzodiazepine use in older adults
Totals
CMS FFY 2010
Number
Number
Number
Response
Profiles
Responses
Letters Sent
%
Reviewed
Received
604
345
92
27%
600
292
60
21%
529
152
44
29%
700
132
33
25%
626
107
24
22%
600
77
22
29%
722
233
32
14%
668
218
35
17%
124
6
3
50%
625
201
21
11%
123
7
2
29%
84
10
3
30%
17
5
0
0%
726
317
25
8%
813
302
59
20%
7561
Page 29
2404
455
19%
Table 4
Michigan Medicaid
Table 5
Population Statistics
FFY 2010
Age
(Yrs)
Drug Quantity
Percent
Total
Quantity
Ingredient Cost
Percent
Ingredient
Cost
Total # of
Claims
Percent
Total
Claims
Paid Amount
Member
Months
Utilization
Percent
Member
Months
Avg. Amt.
Paid Per
Claim
0 - 12
118,927,917
21.48%
$148,984,656
22.53%
1,251,101
16.08%
$124,355,143
1,036,687
14.82%
$119.08
13 - 18
70,064,912
12.65%
$118,694,061
17.95%
885,126
11.38%
$99,586,796
792,124
11.32%
$134.10
19 - 39
148,124,418
26.75%
$180,413,932
27.28%
2,123,500
27.30%
$165,966,721
1,895,605
27.09%
$84.96
40 - 65
189,253,773
34.18%
$208,901,367
31.59%
2,979,843
38.31%
$202,700,943
2,786,357
39.82%
$70.10
65+
27,285,056
4.93%
$4,233,848
0.64%
539,026
6.93%
$4,371,904
486,102
6.95%
$7.85
Totals
553,656,076
100.00%
100.00%
7,778,596
100.00%
6,996,874
100.00%
CMS FFY 2010
$661,227,864
Page 30
$596,981,507
$76.75
Table 5
Michigan Medicaid
Table 6
Top 20 Therapeutic Classes For FFY 2010
Sorted By Cost For Each Age Category
Age 0 - 12
Class
Total
Cost
Age 13 - 18
Total
Count
Class
Total
Cost
Age 19 - 39
Total
Count
Class
Total
Cost
Age 40 - 65
Total
Count
Class
Total
Cost
Age > 65
Total
Count
Class
Total
Cost
Total
Count
99
$21,817,896
19,496
07
$29,742,081
122,118
07
$67,156,222
464,252
07
$88,744,794
720,466
07
$576,569
104,614
07
$19,114,403
99,301
99
$19,018,415
9,978
99
$21,334,452
13,757
33
$23,793,524
31,570
41
$362,563
107,812
10
$18,682,749
202,274
10
$9,772,094
91,450
11
$18,475,482
477,426
11
$23,556,364
592,154
14
$248,286
39,641
12
$13,260,889
134,003
12
$9,483,321
86,453
48
$14,617,927
348,878
48
$14,700,326
458,477
01
$240,334
12,158
48
$7,755,411
81,394
11
$5,481,688
148,999
33
$11,880,547
20,870
99
$12,709,484
22,044
99
$228,769
3,189
11
$5,191,129
95,793
48
$5,007,952
86,140
40
$4,716,606
108,164
40
$4,317,921
110,657
71
$202,760
3,568
15
$4,852,011
83,727
64
$4,526,405
4,187
63
$3,952,514
91,411
58
$4,124,326
48,247
88
$193,277
35,591
33
$4,533,316
7,217
58
$3,409,672
22,661
12
$2,716,585
29,748
15
$3,640,552
39,376
81
$169,032
29,004
51
$4,354,123
67,150
15
$2,277,525
33,668
58
$2,372,047
20,681
30
$3,518,890
8,299
06
$167,254
40,815
64
$4,009,814
6,426
33
$1,189,461
4,703
15
$2,045,208
28,322
77
$2,729,621
19,936
80
$166,196
21,646
58
$2,661,646
20,270
42
$1,070,778
16,144
10
$1,639,930
21,896
01
$2,116,597
47,970
48
$154,611
19,563
50
$2,349,882
47
01
$743,100
15,136
01
$1,270,086
27,554
71
$1,941,813
49,449
58
$151,599
3,219
01
$1,876,041
30,094
51
$740,770
18,444
77
$1,226,382
4,013
65
$1,641,114
47,398
77
$151,210
1,095
23
$1,850,029
1,154
63
$736,302
22,764
27
$1,061,699
14,376
42
$1,167,984
29,011
87
$148,576
34,080
69
$1,012,075
2,420
23
$724,032
702
69
$1,035,656
1,365
88
$1,018,367
26,193
15
$137,059
1,640
19
$1,003,246
25,497
69
$601,990
758
42
$1,001,162
36,077
47
$816,958
76,419
20
$133,248
15,752
88
$906,362
4,627
88
$558,457
3,367
23
$859,563
924
27
$757,173
11,394
65
$124,404
3,435
22
$768,682
63,893
27
$533,403
9,869
30
$761,065
1,508
76
$756,524
54,188
30
$117,511
405
42
$767,480
13,250
19
$407,866
10,442
41
$646,993
16,654
41
$748,374
84,919
83
$87,475
22,755
26
$608,533
11,053
90
$403,768
320
51
$627,324
20,304
90
$702,172
554
93
$86,670
4,345
* Class descriptions found in Appendix A
CMS FFY 2010
Page 31
Table 6
Michigan Medicaid
Table 7
Top 30 New Drugs by Total Cost
FFY 2010
Class
27
99
10
99
69
63
07
30
69
99
58
69
07
48
07
07
69
69
07
11
99
69
42
69
95
01
27
07
07
95
Brand Name Strength Form
CAYSTON 75 MG/ML VIAL-NEB
FEIBA NF 1750-3250 VIAL
FOCALIN XR 30 MG CPMP 50-50
FEIBA NF 651-1200 U VIAL
ZENPEP 20-68-109K CAPSULE DR
GIANVI 0.02-3(24) TABLET
FANAPT 6 MG TABLET
VOTRIENT 200 MG TABLET
ZENPEP 15-51-82K CAPSULE DR
AMPYRA 10 MG TAB ER 12H
BYETTA 10MCG/0.04 PEN INJCTR
ZENPEP 10-34-55K CAPSULE DR
FANAPT 8 MG TABLET
VIMPAT 10 MG/ML SOLUTION
FANAPT 2 MG TABLET
FANAPT 4 MG TABLET
ZENPEP 5K-17K-27K CAPSULE DR
PANCREAZE 21-37-61K CAPSULE DR
FANAPT 1 MG TABLET
EMSAM 9MG/24HR PATCH TD24
FEIBA NF 400-650 U VIAL
PANCREAZE 16.8-40-70 CAPSULE DR
PENNSAID 1.5 % DROPS
PANCRELIPASE 5,000 5K-17K-27K CAPSULE DR
DOVONEX 0.005% CREAM (G)
DEXILANT 60 MG CAP DR MP
XIFAXAN 550 MG TABLET
FANAPT 12 MG TABLET
FANAPT 10 MG TABLET
DOVONEX 0.005% CREAM (G)
Generic Name
AZTREONAM LYSINE
ANTI-INHIBITOR COAGULANT COMP.
DEXMETHYLPHENIDATE HCL
ANTI-INHIBITOR COAGULANT COMP.
LIPASE/PROTEASE/AMYLASE
ETHINYL ESTRADIOL/DROSPIRENONE
ILOPERIDONE
PAZOPANIB HYDROCHLORIDE
LIPASE/PROTEASE/AMYLASE
DALFAMPRIDINE
EXENATIDE
LIPASE/PROTEASE/AMYLASE
ILOPERIDONE
LACOSAMIDE
ILOPERIDONE
ILOPERIDONE
LIPASE/PROTEASE/AMYLASE
LIPASE/PROTEASE/AMYLASE
ILOPERIDONE
SELEGILINE
ANTI-INHIBITOR COAGULANT COMP.
LIPASE/PROTEASE/AMYLASE
DICLOFENAC SODIUM
LIPASE/PROTEASE/AMYLASE
CALCIPOTRIENE
DEXLANSOPRAZOLE
RIFAXIMIN
ILOPERIDONE
ILOPERIDONE
CALCIPOTRIENE
FFY 2010 Cost
$498,710
$410,196
$352,886
$271,923
$207,834
$195,047
$87,093
$56,013
$47,126
$43,441
$42,946
$42,568
$35,001
$20,261
$17,366
$16,682
$13,414
$12,313
$12,059
$11,725
$9,263
$8,866
$7,836
$7,719
$7,669
$7,557
$7,194
$5,666
$5,110
$4,991
Total FFY 2010 Top 30 New Product Costs:
$2,466,473
Total FFY 2010 All New Product Costs:
$22,302,586
Percent of Total Program Costs for FFY 2009 ($601,621,783):
0.41%
* Class descriptions located in Appendix A
CMS FFY 2010
Page 32
Table 7
Michigan Medicaid
Table 8
Generic Drug Utilization
FFY 2010
Non-Innovator (N) Drugs
Single-Source (S) Drugs
Total Number of Total Reimbursement
Amount Less Co-Pay
Claims
1,743,319
Total Number of
Claims
$451,770,421
Total Reimbursement
Amount Less Co-Pay
5,242,321
$72,215,475
All Drugs (S, N, I)
Total Number of
Claims
7,656,049
Innovator Multi-Source (I) Drugs
Total Number of
Claims
670,409
Total Reimbursement
Amount Less Co-Pay
$71,870,885
Generic Utilization Percentages
Total Reimbursement
Amount Less Co-Pay
Generic Utilization
Percentage
$595,856,781
68.47%
Generic Percentage
of All Drug Total
Expenditures
12.12%
KEY:
Single-Source (S) - Drugs that have an FDA New Drug Application (NDA) approval for which there are no generic alternatives available on the market.
Non-Innovator Multiple-Source (N) - Drugs that have an FDA Abbreviated New Drug Application (ANDA) approval and for which there exists generic alternatives on the
market.
Innovator Multiple-Source (I) - Drugs which have an NDA and no longer have patent exclusivity.
CMS FFY 2010
Page 33
Table 8
Appendix A
First Data Bank Bluebook Therapeutic Class Descriptions
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
CMS FFY 2010
Anti-Ulcer/Other GI Agents
Emetics
Antidiarrheal Agents
Antispasmodics/Anticholinergics
Bile Therapy
Laxatives
Ataractics/Tranquilizers
Muscle Relaxants
Antiparkinson
CNS Stimulants
Psychostimulants/Antidepressants
Amphetamines
Other Anti-obesity Agents
Antihistamines
Bronchial Dilators
Cough Preps/Expectorants
Cold and Cough Agents
Adrenergics
Topical Nasal and Otic Agents
Ophthalmic Agents
Tetracyclines
Penicillins
Streptomycins
Sulfonamides
Erythromycins
Cephalosporins
Other Antibiotics
Urinary Antibacterials
Chloramphenicol
Antineoplastics
Antiparasitics
Antimalarials
Antivirals
TB Preparations
Trimethoprim
Topical Contraceptives
Vaginal Cleansers
Antibacterials and Antiseptics
Diagnostics
Narcotic Analgesics
Non-Narcotic Analgesics
NSAIDs
Anesthetics, General Inhalant
Anesthetics, General Injectable
Anesthetics, Topical
Sedatives, Barbiturates
Sedatives, Non-Barbiturates
Anticonvulsants
Antinauseants
Corticotropins
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
Page 34
Glucocorticoids
Mineralocorticoids
Aldosterone Antagonists
Antidotes
Thyroid Preps
Antithyroid Preps
Iodine Therapy
Diabetic Therapy
Anabolics
Androgens
Estrogens
Progesterone
Oral Contraceptives
Other Hormones
Lipotropics
Cholesterol Reducers
Digestants
Protein Lysates
Enzymes
Rauwolfias
Other Hypotensives
Vasodilators, Coronary
Vasodilators, Peripheral
Digitalis Preps.
Xanthine Derivatives
Other Cardiovascular Agents
Anticoagulants
Hemostatics
Diuretics
Fat Soluble Vitamins
Water Soluble Vitamins
Multivitamins
Folic Acid Preps.
B Complex w/Vitamin C Agents
Vitamin K Agents
Infant Formulas
Electrolytes & Nutrients
Hematinics
Allergens
Biologicals
Antipruritics
Coal Tar Preps.
Emollients & Protectives
Fungicides
Dermatologicals, All Other
Hemorrhoidal Preps.
Oxytocics
Parasympathetic Agents
Unclassified Therapeutics
Appendix A
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
X. DUR Board Minutes
Page 35
Drug Utilization Review (DUR) Board
MEETING MINUTES
December 1, 2009
DUR Members Attending:
Members Absent:
MDCH/FHSC/MPA in
Attendance:
Steven Bernstein, MD, MPH , Chair
Bob DeYoung, Pharm D
James Forshee, M.D.
Carrie Germain, R. Ph, Vice Chair
Dawn Parsons, R. Ph, MBA
Sahar Swidan, Pharm D
Jonathan Henry, MD
Debera Eggleston, MD
Annette Paul, R. Ph
Giovanino Perri, MD
Carla Patrick-Fagan
Heather Slawinski
Helen Walley
Tom Welch
Donna Johnson, R. Ph
Karen Jonas, R. Ph
Guests:
Molly Bodenschatz
Melanie Crain
Glenn Cornish
Kelly Dingle
Chris Doyle
William Dozier
Paul Ford
Nancy Graeter
Dannie Guccaro
Mike Holmes
Don Iacobellis
Mary Ianni Summers
Michael Lafond
Joseph Marchant
Ellen Maxwell
Michelle Mischley
Shelly O’Connor
Kelly Olson
Diane Racicot
Tom Reis
Ken Riddldle
Gianna Rigoni
Ryan Segroves
Jim Sharp
Dave Skibicki
Sheila Sprague
John Valenti
John Verbanac
Jason Verbrusche
Mark Veerman
Chris Voyecett
Gregory Warren
Nancy Wilson
Joe Wizelski
Ruth Winfrey
Dr. Bernstein called the meeting to order at 3:04 p.m.
The minutes were reviewed. The minutes were approved with noted corrections.
The agenda was presented as follows:
Topic: Department Business Issues
Eligibility numbers: Medicaid Eligibility Reports were presented. The total number of
Medicaid eligible beneficiaries during the month of October, 2009 was 1,731,454. The
number of children enrolled in Children Special Health Services (CSHCS) only was
11,461. There were 19,066 in CSHCS and Medicaid. The total managed care
Page 36
enrolment for October 1, 2009 was 1, 107,671 compared to August 1, 2009 enrollment of
1,101,880.
Pharmacy Quality Improvement Project (PQIP): A one year extension for the PQIP
contract is being finalized.
Pharmacy &Therapeutic Committee (P&T):
The Analgesics and Central Nervous System (CNS) Classes will be reviewed at the
December, 2009 meeting of the P & T Committee. The subcommittees recommended no
changes to these Preferred Drug List (PDL) classes.
The ad hoc report of “Recipients Receiving Hypotensives in More Than One Class” was
reviewed. The age break down of recipients was requested. It is believed the younger
individuals will most likely receive fewer drugs and be easier to control. The numbers
were felt to be low. In discussion the Board was reminded this represents the Fee for
Service population (~ 700, 000) composed of primarily children and pregnant women. In
addition Part D recipients would not be included. Combination Drugs should be counted
more than once to reflect the number of antihypertensives in the tablets. Should an
academic detailing project result from this review, it was suggested the detailers obtain
patients’ BP readings at the visit. This report will be analyzed further and presented at
the next DUR Board meeting.
Utilization numbers were reviewed for the Asthma- Allergy and Anti- infectives drug
categories in anticipation of their review by the P & T committee in June, 2010. The
Board asked the preferred agents be distinguished from the non preferred in future
reports.
At this point an extensive discussion of how the P & T committee reviews drug
categories. The Department suggested separate meeting to address this topic.
Action: At the next Board meeting the utilization of Antibiotics and Asthma medications
will be reviewed. Utilization of antihypertensives will be presented.
DUR Business: Discussion of 2010 Board Meetings occurred. Coordination with P & T
will be attempted. Members will be notified of the decision with the dates posted at the
Web site.
Topic: Brand Generic Metric Report
The Brand /Generic Utilization and Program Metrics report was reviewed.
Page 37
Topic: RetroDUR
The Retro DUR topics as listed in the agenda were reviewed.
Areas of further discussion included the effectiveness of the START software looking at
adherence. The program requires a lengthy enrollment, which is not always true for Fee
for Service (FFS) Medicaid patients. Often they are transitioned to managed care and are
lost to analysis requiring lengthy enrollment. The behavioral health drugs might be best
reviewed with this software since these drugs are reimbursed on the FFS side.
The FDA has issued an alert regarding the Proton Pump Inhibitors prescribed to patients
on Plavix. A clear message is still elusive. The Board pointed out the risk of dying with a
Gastrointestinal Bleed is quit high and would seem to be greater than the risk related to
the stent reclotting when a PPI and Plavix are used simultaneously. This subject is
tabled at this time.
The risk of developing tardive dyskinesia after use of metoclopramide was raised. It
appears the risk is greatest after 3 months use of Reglan. The Department will run a
utilization report on Reglan for the next meeting.
Suggested topics

Metabolic syndrome surveillance with use of Second Generation Antipsychotics
(SGAs).

Frequent use of Short Acting Beta Agonists

ACE Inhibitor medication possession

Singular use in patients without a diagnosis of asthma.

Metoclopramide (Reglan) use of greater than 3 months and the development of
tardive dyskinesia.

Relationship of Hepatitis C treatment and monitoring of CD4 counts
Action:

Suggested retro DUR topics will be selected from above
Topic: Academic Detailing
Due to time constraints, academic detailing was tabled.
Action: The Department will provide an update of the Asthma and Smoking AD activity at
the March meeting.
Page 38
Public Comments Period
None
The meeting was adjourned at 4:50 Pm
The next DUR Board meeting is scheduled for
Date:
Tuesday, March 9, 2010
Time:
3 to 5 pm
Location: Kellogg Center, East Lansing, Michigan
Page 39
Drug Utilization Review (DUR) Board
MEETING MINUTES
March 9, 2010
DUR Members Attending:
Members Absent:
MDCH/FHSC/MPA in
Attendance:
Steven Bernstein, MD, MPH , Chairman
Bob DeYoung, Pharm D
Carrie Germain, R. Ph, Vice Chair
Sahar Swidan, Pharm D
James Forshee, M.D.
Jonathan Henry, MD Dawn
Parsons, R. Ph, MBA
Debera Eggleston, MD
Giovanino Perri, MD
Sue Moran, Bureau
Chief/MSA
Carla Patrick-Fagan
Helen Walley
Annette Paul, R. Ph
Donna Johnson, R. Ph
Karen Jonas, R. Ph
Guests:
Molly Bodenschatz
Kathy Bovid
Glenn Cornish
Chris Doyle
Paul Ford
Nancy Graeter
Jeanna Guthrie
Greg Gwinnup
David Heisch
Don Iacobellis
Michael Lafond
Bob Lewis
Joseph Marchant
Ellen Maxwell
Michelle Mischley
Jim Murray
Page Nardi
Kendra Prince
Diane Racicot
Gianna Rigoni
Ryan Segroves
Dave Skibicki
Ron Smollen
Allen Tubbs
Mark Veerman
David Wickard
Bob Young
Dr. Bernstein called the meeting to order at 3:02 p.m.
The minutes were reviewed. The minutes were approved as written.
The agenda was presented as follows:
Topic: Department Business Issues
Eligibility numbers: Deferred for this meeting.
Pharmacy Quality Improvement Project (PQIP): PQIP contract was renewed for the
calendar year 2010 (January 1- December 31, 2010).
Page 40
Pharmacy & Therapeutic Committee (P&T):
The cardiac and ophthalmic classes will be reviewed tonight at the March 9, 2010 P & T
Committee meeting. The subcommittees recommended no changes to these Preferred
Drug List (PDL) classes.
The ad hoc report of “Recipients Receiving Hypotensives in More Than One Class” was
reviewed again. The age breakdown of recipients and inclusion of diuretics was provided
in this current report. The number of adult beneficiaries on one to seven drugs was
reviewed as well. The large number of adult recipients on a single agent was noted and
discussed. The Board requested further analyses of the top diagnoses per class for the
beta blockers, calcium channel blockers, and diuretics. However, those patients with the
diagnosis of migraine will be excluded as that may be an appropriate condition for the
use of beta blockers. The report reflecting medication with age breakdown raised the
issue of treating children with antihypertensives. Pediatricians from Michigan
Department of Community Health indicated children are most often treated by
subspecialists for hypertension. The first line medications for treating children for
hypertension are ACEIs and CCB. The Board requested further analysis for children and
diagnoses.
In anticipation of their review by the P & T committee in September, 2010, utilization
numbers were reviewed for the Diabetes and Gastrointestinal drug categories.
Action: The most common diagnoses for those adult patients treated with
antihypertensives will be presented at the next meeting. The Board will also examine the
most common diagnoses in children ages 12-19 years old on antihypertensives by
gender. Those children with known renal disease, congenital heart disease and
congestive heart failure will be excluded form this analysis.
At the next Board meeting the utilization of Analgesics and CNS medications will be
reviewed. Utilization data for the P & T drug categories will have the preferred agents
bolded and include non-PDL drugs for these categories.
DUR Business:
Topic: Brand Generic Metric Report
The Brand /Generic Utilization and Program Metrics report was reviewed.
Topic: RetroDUR
The Retro DUR topics as listed in the agenda were reviewed and discussed. The retro
DUR letter addressing monitoring of second generation antipsychotics is still not
capturing the intent of the Board. Monitoring for the patient’s blood glucose as a risk
factor is most important as opposed to monitoring for the metabolic syndrome.
Page 41
Suggested topics for future retro DUR letters are as follows:

Metabolic syndrome surveillance with use of Second Generation
Antipsychotics (SGAs).

Monotherapy with Long Acting Beta Agonists in asthmatic patients

Risk of Tardive Dyskinesia when using Metoclopramide longer than three
months
Action:
•
Suggested retro DUR topics will be selected from above
•
The SGA letter will be rewritten
Topic: Academic Detailing
Betsy Waselivech presented the asthma 2008 academic detailing analysis. While the
number of responding prescribers was low, the data showed intent to change prescribing
but did not show an actual change in prescribing. There is further analysis to be done,
which includes adding five prescribers to the analysis. Five prescribers were excluded
due to missing intervention dates.
Action: Betsy will be provided the dates of intervention by detailers for the remaining five
excluded prescribers. This will allow completion of the data analysis. She will also provide
an analysis of the specific beneficiaries identified for this project.
Smoking cessation will be the next Academic Detailing project.
Public Comments Period
None
The meeting was adjourned at 4:50 Pm
The next DUR Board meeting is scheduled for
Date:
Tuesday, June 8, 2010
Time:
3 to 5 pm
Location: Kellogg Center, East Lansing, Michigan
Page 42
Drug Utilization Review (DUR) Board
MEETING MINUTES
June 8, 2010
DUR Members Attending:
Members Absent:
MDCH/FHSC/MPA in
Attendance:
Guests:
Steven Bernstein, MD, MPH
James Forshee, MD
Carrie Germain, RPh
Sahar Swidan, Pharm D
Bob DeYoung, Pharm D
Dawn Parsons, RPh,
MBA
Debera Eggleston, MD
Giovanino Perri, MD
Sue Moran
Helen Walley
Carla Patrick-Fagan
Annette Paul, RPh
Molly Bodenschatz
Kathy Bovid
Steve Bremer
Kathy Detloff
William Dozier
Christi Fields
Mark Gagneau
Greg Gwinnup
David Heisch
Don Iacobellis
Michael Lafond
Michael Lucy
Greg McDonald
Rick Mancedo
Joseph Marchant
Michelle Mischley
Jim Murray
Paige Nardi
Shelly O’Connor
Jeff Pouba
Gianna Rigoni
Phil Stead
Paul Titus
Bill Young
Karen Jonas, RPh
Donna Johnson, PharmD
Dr. Bernstein called the meeting to order at 3:03p.m.
The minutes were reviewed and approved with corrections.
The agenda was presented as follows:
Topic: Department Business Issues
Department Update: On May 1, 2010, the Michigan Department of Community
Health (MDCH) converted the drugs known as the 60/40 drug carve out to the 100%
carve out drugs. Those medications are now paid at point of sale. They no longer
will be paid by the health plans and then submitted to First Health for
reimbursement. This may result in larger utilization numbers initially.
Page 43
Eligibility numbers: The monthly eligibility numbers for Medicaid were presented
covering July, 2009 through May, 2010. The total number of Medicaid eligible
beneficiaries has climbed to 1,840,781. The number of children enrolled in
Children Special Health Services (CSHCS) only are 11,957. There are 20,222 in
CSHCS and Medicaid. Managed Care Organizations provide services to 65% of the
Medicaid beneficiaries with a total of 1,192,288.
PQIP: PQIP mailings were suspended for three months (February-April, 2010)
during validity testing of Michigan Department of Community Health’s (MDCH’s) new
computer systems, Bridges and CHAMPS.
P&T: The asthma and antibiotic drug class will be reviewed at this evening’s
meeting.
While there are no suggested changes, the asthma subcommittee did remind the
Department that Azmacort will be discontinued in the near future.
The antibiotic subcommittee recommended no changes.
New members of the P & T committee will be introduced tonight. The new members
include Dr. James Forshee and Dr. Daniel Ryan. Dr. Forshee, a member of the
DUR Board, is a family practitioner and the medical director of Molina Health Plan.
Dr. Ryan is a physiatrist from southeastern Michigan.
Ad HOC queries:
Several Ad hoc Queries were presented and discussed as follows:
•
Azmacort utilization was reviewed with the possibility of notifying patients’
providers of the phasing out of Azmacort. With the low utilization, it was felt
there was no need for further action.
•
Antihypertensives use under the age of 19 years of age was reviewed. First
the issue of polypharmacy was discussed. The Board asked the Department
to further analyze the number of medications the beneficiaries are on and
breaking out those patients with the diagnosis of Congestive Heart Failure,
Congenital Heart Disease or Renal Failure.
This table will be presented with two different populations. One will include
all patients under 19 and the second will exclude those on Children Special
Health Care Services. Magellan will identify the antihypertensives in this
report.
The top three diagnoses of Children under the age of 19 years of age were
presented by drug class - beta blockers, calcium channel blockers and
diuretics. Nothing unexpected was noted or required further analysis.
Page 44
•
Per request of the P & T committee, drugs indicated for treatment of
fibromyalgia were presented by age group and diagnosis. Again, nothing
unusual was noted. The Board suggested utilization data be run and
reviewed for the December, 2010 meeting.
•
The final group of ad hoc reports were run and presented per the P & T
committee’s request. With concern regarding the role of Zetia® (ezetimibe)
in treatment of hypercholesterolemia, the P & T committee requested the
Board review ezetimibe utilization. The 2010 first quarter’s claims data with
various hyperlipdemia diagnoses was presented. There were 129 unique
beneficiaries with expected diagnoses. Review of the individual patients and
the combination with other antihyperlipidemic agents was made. The Board
concluded the present data did not reflect anything alarming; however, future
analysis might focus on review of high-dose statins with the use of fibrates or
by themselves with particular attention to rhabdomyolysis.
Next the Board reviewed the analgesic and central nervous system drug categories
in preparation for the P & T December, 2010 meeting. Concern was voiced
regarding the use of the combination of alprazolam, hydrocodone and soma. The
Board suggested further investigation. Using benzodiazepines in the older adults
with its associated risk of falls was also discussed.
Action:
•
The Department will present the requested antihypertensive analysis of
children under age 19 years old at the next meeting. For the December
meeting the Department will present the utilization of medications with the
indication for fibromyalgia. This will include the recent report and data from a
subsequent quarter for comparison.
DUR Business: A replacement for Dr. Henry, our psychiatrist, is still being
considered.
Topic: Brand Generic Metric Report
The Brand /Generic Utilization and Program Metrics report was reviewed. No
significant changes were noted.
Dr. Forshee did indicate a greater use of generics by health plans. This will be
reviewed further.
Ms. Germaine requested the proportion of prescriptions and expenditures (dollars)
compared to total expenditures over a specific time period.
Page 45
Action:
•
Generic use by other First Health’s Medicaid clients will be reviewed and
presented at the next meeting.
•
The development and management of Preferred Drug List will be presented
at the September meeting.
•
The proportion of prescriptions and expenditures (dollars) compared to the
total expenditures over a specific time period will be presented.
•
Further description of the eligible population for Medicaid will be presented to
assist in greater understanding of the medication use of this population.
Topic: RetroDUR
The retro DUR topics which have resulted in lettering were presented and
discussed. Dr. Bernstein suggested in limiting future mailings to a smaller number
of providers to explore other methods of intervention.
Suggested topics for future Retro DUR initiatives are as follows:

SGAs and metabolic syndrome/hyperglycemia,

Risk of using Alprazolam, hydrocodone and soma in combination and,

The use of benzodiazepines in older adults and its associated risks, such as
falls.
Action:
•
Suggested retro DUR topics will be selected from above
Topic: Academic Detailing:
The Board was updated on the progress of the Asthma Academic Detailing project.
The Michigan Pharmacists Association (MPA) Smoking Cessation status report was
presented.
Educating providers about the Michigan Automated Prescription System (MAPS)
was a suggested topic for the future. The second topic was an asthma focused
intervention.
Action:
•
MPA will continue with the Smoking Cessation initiative. The providers will be
selected by identifying patients over the age of 19 with the diagnosis of
diabetes, COPD, and /or kidney disease. The providers will be rank ordered
by the number of patients they have with those diagnoses. Providers will be
Page 46
visited in order based on their rankings. The provider with the most patients
will be visited first.
•
The Department will contact licensure which oversees MAPS and coordinate
an educational effort.
Public Comments Period
None
The meeting was adjourned at 5:05 pm.
The next DUR Board meeting is scheduled for
Date:
Tuesday, September 14, 2010
Time:
3 to 5 pm
Location: Kellogg Center, East Lansing, Michigan
Page 47
Drug Utilization Review (DUR) Board
MEETING MINUTES
September 14, 2010
DUR Members Attending:
MDCH/MMA/MPA in Attendance:
Guests:
Steven Bernstein, MD, MPH
Debera Eggleston, MD
James Forshee, MD
Carrie Germain, RPh
Bob DeYoung, Pharm D
Giovanino Perri, MD
Sue Moran
Trish O’Keefe
Helen Walley
Carla Patrick-Fagan
Karen Jonas, RPh
Donna Johnson, PharmD
Molly Bodenschatz
Kathy Bovid
Glennn Cornish
Kathy Detloff
Christi Fields
Kevin Gallagher
Lisa Goetz
Mike Hebron
Ed Huckabone
Don Iacobellis
Michael Lafond
Michael Lucy
Greg McDonald
Cathy McGeehan
Joseph Marchant
Michelle Mischley
Jeff Pouba
Diane Racicot
Gianna Rigoni
Susanna Robinson
David Skibickt
Guii Tefferi
John Verbanac
Bill Young
Members Absent:
Sahar Swidan, Pharm D
Dr. Bernstein called the meeting to order at 3:02p.m.
The minutes were reviewed and approved.
The agenda was presented as follows:
Topic: Department Business Issues
Eligibility numbers: A PowerPoint presentation of recent Medicaid eligibility numbers
and Medicaid program descriptions was made by Trish O’Keefe, Medicaid Pharmacy
Operations section manager.
ACTION: Distribute electronically the complete PowerPoint presentation.
Page 48
PQIP: The DUR Board was informed PQIP is in evolution. The present project
seems to have run its natural course. At this point the Department is determining
what aspects should be sustained and internalized. This will mean the three way
agreement with Eli Lilly, Care Management Technologies and MDCH will not be
renewed at the end of November 2010. PQIP has provided an opportunity to discuss
and promote evidenced based best practices. It is anticipated the DUR Board will
assume the responsibility of retrospective review for behavioral health medications.
ACTION: Dr. Bernstein did request an update by the Department of the PQIP
accomplishments and what the expectations are of the Board with respect to
Behavioral Health drugs.
P&T: The Preferred Drug List (PDL) drug classes of Diabetes, Gastrointestinal and
Miscellaneous will be reviewed at the evening’s P & T committee meeting.
The Diabetes workgroup did not recommend any changes in this category. They did
question the utilization of insulin vials vs. pens.
The Gastrointestinal workgroup recommended no changes in this category. They
recommended continuing the clinical edit on continuous high dose use of Proton Pump
Inhibitors. Lansoprazole delayed release generic capsules were to be added to list of
drugs available without prior authorization.
The Miscellaneous Drug class had no recommended changes. The workgroup did ask
the Board to review the use of calcium & vitamin D in patients prescribed
bisphosphonates.
Ad HOC queries:
Ad hoc Queries were presented and discussed as follows:
•
Comparison of the use of insulin vials vs. pens was evaluated. The Board
determined no further action was required.
•
Use of Calcium and vitamin D by patients prescribed bisphosphonates was
reviewed. The data suggested there could be underutilization of products by
this patient population. This was felt to be an area which would warrant further
review and possible intervention.
•
In follow up of the June, 2010 DUR board meeting, further utilization data for
simultaneous use of Spiriva and Combivent was presented. The patient
population was small. Board members questioned the value of an intervention.
It was argued simultaneous use of these products could lead to hospitalizations
and warrant further review. The Department agreed to pull these few patients’
profiles for additional evaluation.
•
Utilization data of concurrent use of statins and gemfibrozil was presented.
Prior to the Board meeting Dr. Bernstein had reviewed the data and requested
the report clarify use of high doses of statins with gemfibrozil. He provided the
Veteran’s Administrations (VA) policy regarding use of statins and gemfibrozil
Page 49
and associated risk of rhabdomyolysis. This will be forwarded to the Board
members by e-mail. In general the Board felt this could be an area of possible
concern and intervention.
•
Utilization numbers of the top diagnoses in fee for service population was
presented. The number of beneficiaries with the diagnosis of Diabetes seemed
inordinately high compared to the number of beneficiaries utilizing insulin. The
Department will review the development of this data to determine an
explanation.
•
In follow up to the concern previously voiced regarding combination use of
alprazolam, hydrocodone and Soma, the Department reported that data for
Soma was not available as paid claims nor thought the Michigan Automated
Prescription System (MAPS). One suggestion was for the Department to see if
it could obtain denied claims for Soma, which would allow further analysis of
this problem. Patients with diagnoses such as cerebral palsy or quadriplegia
should be excluded.
Action:
The Department will address the following:
•
Review patient profiles of patients on both Combivent and Spiriva .
•
Retro DUR intervention to providers prescribing bisphophonates without
evidence of vitamin D and /or Calcium
•
Forward VA policy of simultaneous use of a high dose statin with
gemfibrozil to Board members
•
Magellan Medicaid will review the denied claims data for Soma.
•
Utilization numbers of beneficiaries on insulin compared to beneficiaries
with the diagnosis of diabetes will be further analyzed.
Topic: RetroDUR
The retro DUR topics that have resulted in lettering were presented and discussed. In
reviewing the metoclopramide use greater than 90 days, Board members questioned
the need for PA when used for 90 more days due to increased risk of tardive
dyskinesia. This will be presented to the P & T for consideration. Dr. Bernstein asked
for the per cent of the paid claims for metoclopramide use of 90 days or more be
broken out by age. Dr. Nedd suggested adding provider comparison data in letters.
Use of 2 or more oral hypoglycemics was discussed. Dr. Forshee questioned the
Department’s ability to obtain HbA1C. Ms. O’Keefe suggested the future ability to
acquire this information once EHR is fully implemented.
Page 50
Action:
•
Retrospective DUR topics selected include:
1. Duplication of Serotonergic agents,
2. Use of calcium and Vitamin D with bisphosphonate therapy
3. Frequent use of SABA.
•
Utilization of Metoclopramide use greater than 90 days by age group will be
provided at the next DUR Board meeting.
•
Ability to obtain HbA1C to be explored by Department.
Topic: Academic Detailing:
Next two topics for intervention will be smoking cessation followed with frequent
SABA use.
Educating providers about the Michigan Automated Prescription System (MAPS) will
be planned for after the first of the year.
Action:
Academic detailing will be implemented as noted.
National Medicaid Pooling Initiative (NMPI):
Dr. Perri presented a PowerPoint presentation of the NMPI.
Due to time constraints the following topics were deferred at this time:
•
Brand/Generic Metrics
•
Utilization data for March P & T /Cardiac & Ophthalmics.
•
DUR Business
Public Comments Period
None
The meeting was adjourned at 4:59 pm.
The next DUR Board meeting is scheduled for
Date:
Tuesday, December 14, 2010
Time:
3 to 5 pm
Location: Kellogg Center, East Lansing, Michigan
Page 51
Michigan Medicaid
Drug Utilization Review
2010 Annual Report
X. CMS Annual Report Survey
Page 52
OMB approved #: 0938-0659
MEDICAID DRUG UTILIZATION REVIEW
ANNUAL REPORT
FEDERAL FISCAL YEAR __2010__
Section 1927 (g) (3) (D) of the Social Security Act requires each State to submit an annual report on
the operation of its Medicaid Drug Utilization Review (DUR) program. Such reports are to include:
descriptions of the nature and scope of the prospective and retrospective DUR programs; a summary
of the interventions used in retrospective DUR and an assessment of the education program; a
description of DUR Board activities; and an assessment of the DUR program’s impact on quality of
care as well as any cost savings generated by the program.
This report covers the period October 1, 2009 to September 30, 2010 and is due for submission to
your CMS Regional Office by no later than June 30, 2011. Answering the attached questions
and returning the requested materials as attachments to the report will constitute compliance
with the above-mentioned statutory requirement.
To locate your Regional Office, go to the
Centers for Medicare and Medicaid Services (CMS) website at
http://www.cms.hhs.gov/RegionalOffices/
If you have any questions regarding this survey instrument or the DUR Annual Report please contact
CMS: [email protected].
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information
unless it displays a valid O.M.B. control number. The valid O.M.B. control number for this information collection is
0938-0659. The time required to complete this information collection is estimated to average 30 hours per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: Paperwork Reduction Act Reports Clearance
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
CMS-R-153 (mm/yyyy)
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MEDICAID DRUG UTILIZATION REVIEW
ANNUAL REPORT
FEDERAL FISCAL YEAR _2010___
I.
STATE NAME ABBREVIATION
_MI___________________________
II.
MEDICAID AGENCY INFORMATION
1. Identify State person responsible for DUR Annual Report Preparation.
Name:
_Debera H. Eggleston, MD___________
Street Address:
_400 S. Pine Street
City/State/Zip Code:
_Lansing, MI 48909-7979____________
Area Code/Phone Number: __(517) 335-5181__________________
2. Identify pharmacy POS vendor - (contractor, state-operated, other).
_Magellan Medicaid Administration, Inc (MMA, Inc)__________
3. If not state-operated, is the POS vendor also the MMIS fiscal agent?
____ Yes
III.
_X__No
PROSPECTIVE DUR
1. Identify prospective DUR criteria source.
__X_ First Data Bank ____ Other (specify): __________________________
2. Are new prospective DUR criteria approved by the DUR Board?
__X__ Yes
____ No
If answer above is “No,” please explain:
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3. When the pharmacist receives prospective DUR messages that deny the claim, does your
system:
a) ____ Require preauthorization
b) ____ Allow the pharmacist to override with the correct “conflict,” “intervention,”
and “outcome” codes?
c) __X__ a) and/or b) above - depending on the situation. Please explain:
4. Early Refill:
a) At what percent threshold do you set your system to edit?
i) Non-controlled drugs:
__75_%
ii) Controlled drugs:
__90_%
b) When an early refill message occurs, does the state require prior authorization?
i) Non-controlled drugs:
____ Yes
ii) Controlled drugs:
__X_ Yes
_X _ No
____ No
c) For non-controlled drugs, if the answer to 4 (b) above is “Yes,” who obtains
authorization?
____ Pharmacist
____ Prescriber
____ Either
d) For controlled drugs, if the answer to 4 (b) above is “Yes,” who obtains
authorization?
____ Pharmacist
____ Prescriber
__X_ Either
e) For non-controlled drugs, if the answer to 4 (b) above is “No,” can the pharmacist
override at the point of service?
__X_ Yes
____ No
f) For controlled drugs, if the answer to 4 (b) above is “No,” can the pharmacist
override at the point of service?
____ Yes
_X __ No
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5. Therapeutic Duplication:
a) When there is therapeutic duplication, does the State require prior authorization
for:
i) Non-controlled drugs:
____ Yes
__X_ No
___ Sometimes
If answer above is “Sometimes,” please explain:
ii) Controlled drugs:
_X__ Yes
____ No
___Sometimes
If answer above is “Sometimes,” please explain:
b) If the answer to 5 (a) above is “Yes,” who obtains authorization?
i) Non-controlled drugs:
____ Pharmacist
____ Prescriber
____ Either
ii) Controlled drugs:
____ Pharmacist
__X Prescriber
____ Either
c) If the answer to 5 (a) above is “No,” can the pharmacist override at the point of
service?
i) Non-controlled drugs:
_X_ Yes
___ No
ii) Controlled drugs:
____ Yes
_X__ No
Additional Comment:
6. State has provided DUR criteria data requested on Table 1 - Pro DUR Criteria Reviewed
by DUR Board 1, indicating by problem type those criteria with the most significant
severity level reviewed in-depth by the DUR Board in this reporting period.
____ Yes
_X _ No (NOTE: ProDUR criteria automatically loaded into POS
system. MI DUR Board selected specific problem types to deny or message at POS.)
7. State has included Attachment 1 – Prospective DUR Review Summary 2.
_X__ Yes
1
2
__ No (See TABLE 1 in Annual Report)
Please see Instruction for Table 1 on page 13
Please see Explanation for Attachment 1 on page 10
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8. State has included Attachment 2 – Prospective DUR Pharmacy Compliance Report 3, a
report on State efforts to monitor pharmacy compliance with the oral counseling
requirement.
IV.
____ Yes
_X__ No
(NOTE: The recently awarded RFP for pharmacy audit
activites includes addressing the issue of oral Counseling.)
RETROSPECTIVE DUR
1. Identify the vendor that performed your retrospective DUR activities during the time
period covered by this report (company, academic institution, or other organization).
_Magellan Medicaid Administration, Inc__________________________________
a) Is the retrospective DUR vendor also the Medicaid fiscal agent?
____ Yes
__X_ No
b) Is the retrospective DUR vendor also the developer/supplier of your retrospective
DUR criteria?
_X__ Yes
____ No
If “No,” please explain:
2. Does the DUR Board approve the retrospective DUR criteria supplied by the criteria
source?
_X__ Yes
____ No
3. State has provided the DUR Board approved criteria requested on Table 2 - Retrospective
DUR Approved Criteria 4 .
_X__ Yes
____ No
4. State has included Attachment 3 - Retrospective DUR Screening and Intervention
Summary Report 5. (NOTE: See TABLE 4 in Annual Report)
_X_ Yes
___ No
3
Please see Explanation for Attachment 2 on page 10
Please see Instruction for Table 2 on page 13
5
Please see Explanation for Attachment 3 on page 11
4
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V.
PHYSICIAN ADMINISTERED DRUGS
The Deficit Reduction Act required collection of NDC numbers for covered outpatient
physician administered drugs. These drugs are paid through the physician and hospital
programs. Has your MMIS been designed to incorporate this data into your DUR criteria for
both prospective DUR and retrospective DUR?
_X__ Yes
____ No
If “No,” when do you plan to include this information in your DUR criteria? mm/dd/yyyy
VI.
DUR BOARD ACTIVITY
1. State has included a summary report of DUR Board activities and meeting minutes
during the time period covered by this report as Attachment 4 - Summary of DUR Board
Activities 6.
_X__ Yes
____ No
2. Does your state have a Disease Management Program?
____ Yes
_X__ No
If “Yes,” is your DUR Board involved with this program?
____ Yes
____ No
3. Does your state have a Medication Therapy Management Program?
____ Yes
_X__ No
If “Yes,” is your DUR Board involved with this program?
____ Yes
VII.
____ No
GENERIC POLICY AND UTILIZATION DATA
1. State has included a description of new policies used to encourage the use of
therapeutically equivalent generic drugs as Attachment 5 - Generic Drug Substitution
Policies 7.
_X__ Yes
6
7
____ No
Please see Explanation for Attachment 4 on page 11
Please see Explanation for Attachment 5 on page 12
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2. Indicate the generic utilization percentage for all covered outpatient drugs paid during
this reporting period, using the computation instructions in Table 3 - Generic Utilization
Data 8. (NOTE: Also see TABLE 8 in Annual Report)
Number of Generic Claims:
_5,242,321______
Total Number of Claims:
_7,656,049______
Generic Utilization Percentage: _68.47%________
3. Indicate the percentage dollars paid for generic covered outpatient drugs in relation to all
covered outpatient drug claims paid during this reporting period using the computation
instructions in Table 3 - Generic Utilization Data 9.
Generic Dollars:
_$72,215,475____
Total Dollars:
_$595,856,781___
Generic Expenditure Percentage: __12.12%_______
VIII. PROGRAM EVALUATION / COST SAVINGS
1. Did your state conduct a DUR program evaluation/cost savings estimate?
_X__ Yes
____ No
2. Who conducted your program evaluation/cost savings estimate (company, academic
institution, other institution)?
_Magellan Medicaid Administration Inc ___________________________________
3. State has provided the Medicaid program evaluation/cost savings estimate as Attachment
6 - Cost Savings Estimate 10.
_X__ Yes
____ No
4. Please provide the total net cost savings estimate.
$390,276,400____
5. Please provide the estimated percent impact of your state’s cost savings program
compared to total drug expenditures for covered outpatient drugs. Divide the estimated
net savings amount provided in Section VIII, Question 4 above by the total dollar amount
provided in Section VII, Question 3. Then multiply this number by 100.
Estimated Net Savings Amount ÷ Total Dollar Amount × 100 = _______65.5%
(NOTE: Savings is greatly inflated due to factors affecting ProDUR savings. See page 8
in Annual Report for explanation.)
8
Please see Instruction for Table 3 on page 13
Please see Instruction for Table 3 on page 13
10
Please see Explanation for Attachment 6 on page 12
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IX.
FRAUD, WASTE, AND ABUSE DETECTION
1. Do you have a process in place that identifies potential fraud or abuse of controlled drugs
by recipients?
_X__ Yes
____ No
If “Yes,” what action(s) does this process initiate? Check all that apply.
a. _X__ Deny claim and require pre-authorization
b. _X__ Refer recipient to lock-in program
c. _X___ Refer to Medicaid Fraud Control Unit (MFCU) or Program Integrity
d. ____ Other - please explain:
2. Do you have a process in place that identifies possible fraud or abuse of controlled drugs
by prescribers?
_X__ Yes
____ No
If “Yes,” what actions does this process initiate? Check all that apply.
a. ____ Deny claims written by this prescriber
b. _X__ Refer to MFCU or Program Integrity
c. _X__ Refer to the appropriate Medical Board
d. _X__ Other - please explain: Prescribers may be suspended from the program.
3. Do you have a process in place that identifies potential fraud or abuse of controlled drugs
by pharmacy providers?
_X__ Yes
____ No
If “Yes,” what actions does this process initiate? Check all that apply.
a. ____ Deny claim
b. _X__ Refer to MFCU or Program Integrity
c. _X__ Refer to Board of Pharmacy
d. _X___ Other - please explain: Pharmacy may be suspended from the program.
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4. Does your state have a Prescription Drug Monitoring Program (PDMP)? See Attachment
7 - Prescription Drug Monitoring Program 11 for a description of this program.
_X___ Yes
____ No
If “Yes,” please explain how the State applies this information to control fraud and abuse.
Each prescriber has web access at the time the Rx is written to review the beneficiary's
medication history. The information is rapidly available to the prescriber.
If “No,” does your State plan to establish a PDMP?
____ Yes
X.
____ No
INNOVATIVE PRACTICES
Have you developed any innovative practices during the past year which you have included
in Attachment 8 - Innovative Practices 12? (NOTE: Refer to page 20 in Annual Report.)
_X__ Yes
XI.
____ No
E-PRESCRIBING
1. Has your state implemented e-prescribing?
_X__ Yes
____ No
If “Yes,” please respond to Questions 2 and 3 below. If “No,” are you planning to
develop this capability?
____ Yes
____ No
2. Does your system use the NCPDP Origin Code that indicates the prescription source?
_X__ Yes
____ No
3. Does your program system (MMIS or pharmacy vendor) have the capability to
electronically provide a prescriber, upon inquiry, patient drug history data and pharmacy
coverage limitations prior to prescribing?
_X__ Yes
____ No
a) If “Yes,” do you have a methodology to evaluate the effectiveness of providing
drug information and medication history prior to prescribing?
_X__ Yes
11
12
____ No
Please see Explanation for Attachment 7 on page 12
Please see Explanation for Attachment 8 on page 12
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b) If “Yes,” please explain the evaluation methodology in Attachment 9 - EPrescribing Activity Summary 13. (NOTE: Refer to pages 18-19 in Annual Report.)
c) If “No,” are you planning to develop this capability?
____ Yes
13
____ No
Please see Explanation for Attachment 9 on page 12
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TABLE 2
RETROSPECTIVE DUR CRITERIA
(Check All Relevant Boxes)
DRUG PROBLEM TYPE
THERAPEUTIC CATEGORY
ACE Inhibitors
Beta Adrenergics: short-acting)
Beta Adrenergics: long-acting)
Benzodiazepines
Leukotriene Receptor Antagon.
Narcotics
Second Gen. Atnipsychotics
PROBLEM TYPE KEY
ID = Insufficient Dose
IDU = Incorrect Duration
OU = Over Utilization
UU = Under Utilization
O1, 2, 3 = Other Problem Type
Specify (1) Inappropriate Use
ID
IDU
OU
UU
X
DDI
DDC
TD
AG
O1
O2
O3
X
X
X
X
X
X
DDI = Drug/ Drug Interaction
DDC = Drug/ Disease Contradiction
TD = Therapeutic Duplication
AG = Appropriate Use of Generics
(2) Metabolic Monitoring
(3)
______________
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