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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. Page 1 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. Page 2 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. Page 3 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 Page 4 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 Page 5 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: Page 6 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 Page 7 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 Page 9 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 Page 10 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 Page 11 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. Page 12 Michigan Medicaid Drug Utilization Review 2010 Annual Report 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 Page 13 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) OMB approved #: 0938-0659 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: 1 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 2 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 3 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 4 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 5 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 9 CMS-R-153 (mm/yyyy) 6 OMB approved #: 0938-0659 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. 7 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 8 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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 9 CMS-R-153 (mm/yyyy) OMB approved #: 0938-0659 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) ______________ 15 CMS-R-153b (mm/yyyy)