Governor’s Office of Health Policy and Finance

1. Governor’s Office of Health Policy and Finance MaineCare Pharmacy Initiatives

2. PDL • Preferred Drugs: • By definition are usually Cost-Effective • Provide the best clinical outcome for the least amount of money

3. 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 Prior Authorization • By Step Therapy • By Grandfathering in certain Drug Classes • By Special Medical Conditions (Cancer)

4. 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

5. 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

6. 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 long-acting formulation] • Perphenazine or thiothixene or other medium-potency typical • Chlorpromazine or other low-potency typical.

7. 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

8. 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

9. 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

10. 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.

11. 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

12. 4 Brand Name Per Month Limit • $1 Million savings (State) • Only for MaineCare members who are: • Not a dual eligible • Over 18 years of age • Will not apply to: • Cancer medications • HIV medications • Antipsychotics • Currently have 5 Brand limit for MaineCare members living in certain settings • 17 States currently have limits in place