Download SFY `08 – `09 Pharmacy Budget Initiatives

Governor’s Office of Health
Policy and Finance
MaineCare
Pharmacy Initiatives
1
PDL

Preferred Drugs:


By definition are usually Cost-Effective
Provide the best clinical outcome for the least
amount of money
2
PDL
What it’s not




A PDL is not a Formulary
Formulary is a limited list of drugs that are covered
In a PDL all Drugs continue to be covered
Members have access to Non-Preferred Drugs in a
variety of ways:




By
By
By
By
Prior Authorization
Step Therapy
Grandfathering in certain Drug Classes
Special Medical Conditions (Cancer)
3
Antipsychotics






Nearly $20 million (state + federal) spent
annually
11% of drug budget
Over 12,000 users
Presently, PDL only addresses high doses
and duplicate therapy
Can save over $1 million (state) by selecting
first-line drugs that won’t need PA
15 States currently PA in this Category
4
PA for Some Atypicals




Follow National Association of State
Mental Health Directors Guidelines
(see next 2 slides)
Many choices in first line medications
Established users not affected (about
50% over course of the year)
Only affects new starters
5
Antipsychotic PDL: Ensuring Appropriate
Access and Efficient Utilization (NASMHD)
All medications should be available.
Not all medications need be available on a first-line basis.
PA should be simple and flexible.
Choices of first-line medications at a minimum must include:











Clozapine (any approved formulation) [Treatment-resistance]
Risperidone or paliperidone [Atypical with long-acting
formulation]
Ziprasidone or aripiprazole [Weight-neutral atypical]
Olanzapine or quetiapine [Sedating atypical]
Haloperidol or fluphenazine [high potency typical and longacting formulation]
Perphenazine or thiothixene or other medium-potency typical
Chlorpromazine or other low-potency typical.
6
Antipsychotic PDL: Ensuring Appropriate
Access and Efficient Utilization (NASMHD)


Helps ensure that medications are prescribed
according to manufacturer indications
A prescription drug may be selected for prior
authorization if one of the following characteristics
apply:
 Clinically appropriate
 High ingredient cost
 Use is within a narrow member population
 Drugs with a high potential for inappropriate use
or abuse
 Agents that are best reserved for second or third
line therapies
7
What happens when a PA is needed?

But the doctor has not completed the PA request
 There was a one time override the pharmacist
could use to dispense a one month supply
during the PDL implementation phase.
The member always has access to a 96 hour
emergency supply.
Nearly 80% of PA’s submitted are approved
Completed PA receive a decision on average within
3 hours of submission



8
Draft PA Criteria






Grandfather existing users
Start of NP in Hospital setting will be grandfathered
3 week trial of an effective dose of a Preferred Drug
will meet approval criteria for a NP Drug
Documentation of good response to samples of NP
Drug
Documentation of significant side effects will meet
approval criteria for NP Drug
Doctor can always request a prior authorization
without having to use Preferred Drug if medical
necessity is documented
9
What happens when a PA is not approved?


Additional information documenting medical
necessity for a re-determination may be
submitted.
A member can appeal the decision by
requesting a Fair Hearing.
10
Safety Net Protections



Completed PA’s acted on within 24
hours of submission
Average time to review a completed PA
is 3 hours
96 hour supply of drug is available on
an emergency basis
11
4 Brand Name Per Month Limit


$1 Million savings (State)
Only for MaineCare members who are:



Will not apply to:





Not a dual eligible
Over 18 years of age
Cancer medications
HIV medications
Antipsychotics
Currently have 5 Brand limit for MaineCare
members living in certain settings
17 States currently have limits in place
12