Virginia Medicaid ProDUR Program Update Presented to: PDL/PA- Implementation Advisory Group

1. Virginia Medicaid ProDUR Program UpdatePresented to:PDL/PA- Implementation Advisory Group Javier Menendez, Pharmacy Manager Department of Medical Assistance Service June 22, 2004 Richmond, Virginia

2. Presentation Outline  • Background on the ProDUR Program • DUR Board • ProDUR enhancements

3. Background on the ProDUR Program ProDUR is a review by the pharmacist of the prescription medication order and the patient’s drug therapy before each prescription is filled. This review is for the health and safety of the Medicaid patient. The review includes an examination of the patient’s profile to determine the possibility of potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions, drug-allergy interactions, drug dosage or duration of drug treatment. ProDUR is used by commercial carriers, Medicaid managed care organizations and DMAS. This is in compliance of state regulations 12 VAC 30-130-280 through 130-410 and The Omnibus Reconciliation Act of 1990.

4. Presentation Outline • Background on the ProDUR Program  • DUR Board • ProDUR enhancements

5. DUR Board • 5 Physicians • 2 Nurses • 6 Pharmacists

6. Members of DUR Board MemberBackground • Geneva Briggs (PharmD) (Chairman) DUR Board • Kelly Goode (PharmD) Virginia Pharmacist Assoc. • Sandra Dawson (Rph) VaPha-Consultant Pharmacist • Mark Johnson (PharmD) Shenandoah University • Bill Rock (PharmD) VA Hospital • Jennifer Edwards (PharmD) Va. Assoc. Chain Drugs • Jane Settle (NP) Virginia Nurses Association • Elaine Ferray (MS) Virginia Nurses Association • Thomas Moffatt (MD) Medical Society of Virginia • Robert O Friedel (MD) Medical Society of Virginia • Matthew Goodman (MD) UVA School of Medicine • Catherine Kelso (MD) MCV • Jason Lynam (MD) UVA School of Medicine

7. DUR Board Quarterly Meetings • August 7th 2003 • November 6, 2003 • February 5th, 2004 • May 6, 2004

8. Presentation Outline • Background on the ProDUR Program • DUR Board  • ProDUR enhancements

9. ProDUR Enhancements • February 1st, 2004, certain edits enhanced from Message Only to Provider Level Override. • DD(drug-drug), MC(drug-disease), PG(pregnancy) and TD (therapeutic duplication)now require intervention and outcome codes. • FHSC has complete prescription history for all recipients, many recipients use multiple providers for prescription services

10. Anti-Ulcer Agents Ace Inhibitors Angiotensin II Receptor Blockers Antidepressants Benzodiazepine NSAIDS Calcium Channel Blockers Narcotics Thiazide Diuretics Loop Diuretics Potassium-Sparing Diuretics 11 Drug Classes Deny for Therapeutic Duplication

11. ProDUR Enhancements • June 14th, 2004, ER (early refill) edits enhanced from Provider Level Override With Intervention and Outcome Codes, to required telephone call. • The Early Refill (ER) alerts occur when the prescription is presented for refill before75% of the medication is used in compliance with the directions and quantity (days supply). • Requires POS/RPH to call FHSC for PA • FHSC has complete prescription history for all recipients

12. Early Refills 30 days x .75 = 23 days 23 days / 365 days = 15.8 scripts/year An Extra 3 scripts at $55/script (avg. Rx $) for 10% of the FFS population (23,000) would equal $3,795,000.00

13. Why enhance ER edit to telephone call required? • From January 2004 through May 2004 DMAS has made > $3,500,000.00 in override payments. • Most state Medicaid plans require a telephone call for this override (Tennessee, South Carolina, Missouri, Massachusetts, Maryland, Michigan, Ohio, Iowa, Alabama) • Most MCOs have this as standard including Sentara, Anthem, VA Premier, Unicare and CareNet. • Most commercial plans have this as standard ( Aetna, BCBS, Cigna, United Healthcare )

14. Pro-DUR Reason for Service (Conflict Code) NCPDP Field 439 Current Claims Disposition New Claims Disposition Professional Service (Intervention Code) NCPDP Field 440 942) Pro-DUR Result of Service (Outcome Code) NCPDP Field 441 Provider Override for 11 drug classes: Anti-Ulcer Agents ACE Inhibitors Angiotensin II Receptor Blockers Antidepressants Benzodiazepines NSAIDs (includes salicylates and COX-2s) Calcium Channel Blockers Thiazide Diuretics DD Message only Provider override AS = Patient assessment CC = Coordination of care DE = Dosing evaluation/ Determination MØ = Prescriber consulted MR = Medication Review PØ = Patient Consulted 1A 1B 1C 1D 1E 1F 1G 1H 1J 1K 2A 2B 3A 3B 3C 3D 3F 3G 3H 3J 3K 3M 3N Note: These are ALL of the Outcome Codes as defined by NCPDP (See definitions below) Loop Diuretics Potassium-Sparing Diuretics Narcotics *note: some of these classes are in the PDL ER2 Deny – provider override allowed Call in to FHSC Call in to FHSC 800xxxxxxxxx Call in to FHSC 800xxxxxxx MC Message only Provider override AS = Patient assessment CC = Coordination of care DE = Dosing evaluation/ Determination MØ = Prescriber consulted MR = Medication Review PØ = Patient Consulted 1A 1B 1C 1D 1E 1F 1G 1H 1J 1K 2A 2B 3A 3B 3C 3D 3F 3G 3H 3J 3K 3M 3N Note: These are ALL of the Outcome Codes as defined by NCPDP (See definitions below) TD (denials) Deny for 11 drug classes – provider override allowed AS = Patient assessment CC = Coordination of care DE = Dosing evaluation/ Determination MØ = Prescriber consulted MR = Medication Review PØ = Patient Consulted 1A 1B 1C 1D 1E 1F 1G 1H 1J 1K 2A 2B 3A 3B 3C 3D 3F 3G 3H 3J 3K 3M 3N Note: These are ALL of the Outcome Codes as defined by NCPDP (See definitions below) PG Message only Provider override AS = Patient assessment CC = Coordination of care DE = Dosing evaluation/ Determination MØ = Prescriber consulted MR = Medication Review PØ = Patient Consulted 1A 1B 1C 1D 1E 1F 1G 1H 1J 1K 2A 2B 3A 3B 3C 3D 3F 3G 3H 3J 3K 3M 3N Note: These are ALL of the Outcome Codes as defined by NCPDP (See definitions below)