Idaho Medicaid Drug Utilization Review Program

1. Idaho Medicaid Drug Utilization Review Program 18 July 2013

2. Follow-up to Previous Reviews • Botulinumtoxin DUR • Hydrocodone/APAP DUR • Nystatin/triamcinolone Combo DUR

3. Botulinumtoxin DUR • Only payable on the medical side (not self-administered and not safe for patient to “brown bag” to physician’s office). • Prior authorization was instituted 7/1/2013. • Before June 2013: • Prior authorization requests received were returned to prescriber with a note that prior authorization was not required at this time but would be required starting 7/1/13.

4. Botulinumtoxin DUR • Starting June 1, 2013: • Prior authorization requests were processed. • Approvals were dated 7/1/13 with a note that prior to July, prior authorization was not required. • Denials were sent back with an explanation of why request was denied. Claims still paid through 6/30/13.

5. Botulinumtoxin DUR • Chronic daily headaches/migraines • New prior authorization form specifically for Botox for chronic daily headaches/migraines was written and posted on the website in June 2013. • Letter was sent in June with a copy of this prior authorization form to the Boise physician that was prescribing and administering the majority of Botox for this indication.

6. Botulinumtoxin DUR • Botox for indications other than chronic daily headaches/migraines • Another prior authorization form was created for all other indications.

7. Botulinumtoxin DUR • Therapeutic criteria for chronic daily headaches/migraines • At least 15 days per month • At least four hours per day (on average) • Prophylactic medication tried and failed • Abortive medications (e.g. triptans) filled monthly for at least 3 months

8. Botulinumtoxin DUR • Documentation provided by prescribers has dramatically improved after feedback from Idaho Medicaid on what information is needed. • Prescriber is now sending us a “Chronic Daily Headache” two page data collection sheet that the patient fills out. • Majority of requests received for this indication have been approved. • For new patients, two injections (12 weeks apart) are approved. This duration was chosen as in the licensing trial, reduction in headache frequency was seen by this length of time.

9. Botulinumtoxin DUR • For patients who have already received one dose prior to 7/1/13, a second dose will be approved if the patient meets the therapeutic criteria. • For patients with a positive response who have already received two or more doses, therapy will be approved for six months.

10. Hydrocodone/APAP DUR • What are the utilization numbers on the various hydrocodone/APAP products?

11. Hydrocodone/APAP DUR Idaho Medicaid paid pharmacy claims between 1/1/2013 and 4/30/2013

12. Nystatin/Triamcinolone Combo DUR • What are the utilization numbers on the various nystatin/triamcinolone combo products?

13. Nystatin/Triamcinolone Combo DUR

14. Nystatin/Triamcinolone Combo DUR

15. Current Interventions/Outcomes Studies • Hepatitis C DUR • Demographics of the Idaho Medicaid Utilizer of Rx’s Population • CHIC – Children’s Healthcare Improvement Collaboration • Geo‐Mapping Analysis • Utilization of Narcotic Analgesics (HIC3 = H3A)

16. Current Interventions/Outcomes Studies • P&T Committee Narcotic Analgesic Studies • Narcotic Analgesics in Chronic Non-Malignant Pain 2012 Update • Participants Receiving More Than 1 Long Acting at a Time • Suboxone and Participants Paying Cash for Other Opioids

17. Hepatitis C Agents • Incivek and Victrelis • Review past 6 months of data for usage • Are patients that started on therapy continuing therapy? • Will be requesting chart notes to determine why patients discontinued therapy (e.g. intolerable side effects vs. non-responders to therapy based on viral counts) vs. non-compliance. • Will look for trends in patients that discontinued therapy (e.g. does rate vary between practices or geographically) • Are patients on TRIPLE therapy with ribavirin and interferon?  Check for adherence to all three medications. • Audit for checking viral counts at appropriate time intervals

18. Hepatitis C Agents • Incivek and Victrelis • Look at quarterly trends in usage since Incivek/Victrelis were approved by the FDA in May 2011 as patients were not started on double therapy (ribavirin/interferon) as the specialists were waiting for triple therapy to be available. • In the future an all oral regimen is going to be available for treatment of Hepatitis C so there may be patient “warehousing” again.

19. Hepatitis C DUR

20. Hepatitis C DUR

21. Hepatitis C DUR

22. Hepatitis C DUR Review from 5/1/2012 thru 5/26/2013 Total of 53 patients prescribed Incivek or Victrelis • 36 Incivek • 17 Victrelis Mean age: 47 years (range: 18 – 61) Female: 26 Male: 27 **All patients had a diagnosis for Hepatitis C (ICD-9 code 070.4 or 070.5)

23. Hepatitis C DUR 36 Incivek Patients • Mean age: 46 years (range 28 – 61) • Female: 16 • Male: 20 29 completed treatment (3 months) 5 did not complete treatment • 1 patient was co-infected with HIV (2 months) 2 patients exceeded 3 months • 5 months(50 y/o male) • 4 months(28 y/o male)

24. Hepatitis C DUR Incivek Payment • Total payment $1,613,601.00 • Payment/month $18,000.00 • 6 monthsshould not havebeen submitted ($108,000.00) **All Incivek patients were started on Interferon and Ribavirin

25. Hepatitis C DUR 17 Victrelis patients Mean age: 47 years (range 18 – 60) Female: 10 Male: 7 8 completed treatment • Mean # of months: 7 2did not complete treatment 7 active treatment

26. Hepatitis C DUR Victrelis Payment • Total payment $355,187.00 • Payment/month $5074.00 **All Victrelis patients were on Interferon and Ribavirin for 4 weeks prior to Victrelis treatment

27. Hepatitis C DUR Letters sent out requesting the following information: • HCV Genotype • Baseline Laboratory values (CBC, LFT’s, SVR) • Follow-up Laboratory values while on Incivek or Victrelis (SVR, LFT’s) • Documentation/chart notes of follow-up treatment and response to treatment • If documented: Co-infection of HIV • If applicable: reason why therapy was discontinued (side effects, inadequate response, etc)

28. Demographics of the Idaho Medicaid Utilizer of Rx’s Population

29. Demographics of the Idaho Medicaid Utilizer of Rx’s Population

30. Demographics of the Idaho Medicaid Utilizer of Rx’s Population

31. Demographics of the Idaho Medicaid Utilizer of Rx’s Population

32. CHIC – Children’s Healthcare Improvement Collaboration Mental Health Learning Collaborative – Depression Screening in Adolescent Patients

33. CHIC • Target Prescribers: Pediatricians and Family Practice • Goal: Increase screening for depression in adolescent patients with appropriate follow-up for those patients with positive screenings • Psychosocial support including counseling • Medications (e.g. SSRIs) • Target Dates: • Learning session for enrolled providers in August 2013. Sessions to be held in Boise, Twin Falls, and Pocatello • Start tracking screenings and follow-up in October 2013 • Duration of project: 6 months

34. CHIC • Baseline Data for 2012 • 3265 unique patients age 12-17 years with at least one paid claim for an SSRI • 18,063 total paid claims for SSRIs • $265,842 • 4604 unique patients age 12-17 with at least one paid claim for any antidepressant • 30,198 total paid claims for all antidepressants • $467,419

35. Geo‐Mapping AnalysisUtilization of Narcotic Analgesics (HIC3 = H3A) Prepared by MMA 6/13/2013 Please refer to handout in Packet

36. P&T Committee Narcotic Analgesic Studies • Narcotic Analgesics in Chronic Non-Malignant Pain 2012 Update • Participants Receiving More Than 1 Long Acting at a Time

37. Narcotic Patterns of Use in Chronic Non-Malignant Pain Follow-Up from 2011 Study

38. Profile Review • Generated profiles for the top 150 recipients by total narcotic claim count from the recipients who had at least one narcotic claim in each of the 24 months of the period ending March 2013 • Time Period: October 1, 2012 through March 31, 2013 • Original study: May 1, 2011 through December 31, 2011 • Evaluated 142 Cancer Diagnosis found in 8 • All profiles were hand reviewed by Idaho Medicaid Pharmacists

39. Review Focus • Years of opioid use • Number of different opioids used • Daily morphine equivalents • Number of different prescribers • Other concurrent central acting/ potentially addictive drugs • Diagnosis or indication for chronic opioid use • Average days between refills • History of abuse diagnosis • Currently in lock-in program? • Additional opioid use paid outside of Medicaid

40. Length of Time for Continuous Opioid Use

41. Number of Different Opioids Includes different drugs or dosage forms May or may not be concurrent, but over course of therapy

42. Daily Morphine Equivalents Lowest = 14 mg Highest = 1340 mg

43. Number of Prescribers per Participant

45. Diagnosis/Indications Most patients had multiples diagnoses

46. Average Days Prior to Refill

47. Other Information Gathered • Number on Medicaid Pharmacy Lock-In • 5 currently on lock-in • Non-Medicaid Opioid Fills • From Board of Pharmacy Reports • Many gaps in Board of Pharmacy Reports • 34 of the 142 patients ( 24%) had fills not paid for by Medicaid • Concurrent Drug Abuse Diagnosis 66 (46%)

48. Comparison of Original and Follow-up Data

49. Evaluation of Participants Receiving More than One Long-Acting Narcotic Analgesic Concurrently

50. Long-Acting Narcotic Evaluation • Goal: To evaluate impact of planned change that would only allow one long-acting and one short-acting narcotic analgesic per participant without further prior authorization • Report was run and profiles generated for participants who had a claim for more than one unique long-acting narcotic analgesic between 12/1/2012 and 5/31/2013 • N = 65