Naval Hospital Camp Lejeune Formulary Management

1. LT Megan E. Dahlke, Pharm.D. Assistant Head, Pharmacy Department Naval Hospital Camp Lejeune Formulary Management

2. Learning Objectives • Recognize the need for multidisciplinary efforts to comply with formulary requirements • Outline the process implemented by Naval Hospital Camp Lejeune • Identify future efforts that may improve formulary compliance • Recognize the time required to achieve formulary compliance.

3. Non-formulary medications verses formulary medications

4. January-March 2004 • Pharmacy spending was at a rate that could not be sustained • PEC Conference • NHCL P&T Committee • Test pilot with paper scripts accompanied by a preauthorization form that clinic DH had to sign • Turn off non-formulary keys in CHCS • Extensive class/formulary review and education

5. April-July 2004 • Averaging about 700 non-formulary preauthorizations a month. • Non formulary use was down to 7 percent of our budget and under 2 percent of our scripts • Continue extensive class/formulary review and education • Consult in CHCS for Pharmacy Special Drug Request • Print free text information on the drug, dose, directions, quantity, refills • Pharmacy reviews consults and notifies provider when completed

6. August 2004 • Developed clinical necessity criteria • Failed formulary drug • SE from formulary drug • No formulary agent available • Risk for changing patient to another medication • Continue extensive class/formulary review and education • Consult available for all providers as the only avenue for ordering non formulary medications • Non formulary use was down to 5 percent of our budget and 1.75 percent of our scripts

7. Ongoing initiatives • NHCL P&T committee reviews DoD P&T minutes • Patients on UF non-formulary medications are notified when the minutes are approved • Educated to contact their provider to: • Change to a formulary alternative • Obtain new prescription to fill through TMOP or retail. • If NHCL provider, may fill out medical necessity form and if meet approval may continue to obtain at NHCL. • Remaining refills are canceled to avoid accidental filling after cutoff date. • Providers educated on formulary changes.

8. Dear Patients of Naval Hospital Camp LeJeune (NHCL) Dear Patientsof Naval Hospital Camp Lejeune (NHCL) Due to a recent ruling by the DOD (Department of Defense), tamsulosin (Flomax) will only be available through TMOP (Tricare mail order pharmacy) or Retail Pharmacies. NHCL carries terazosin 1,2, 5 & 10mg, and alfuzosin (Uroxatral) 10mg SR in place of Flomax. Your provider may wish to switch you to one of these medications. Another option is to have your provider write you a new prescription for Flomax which you may have filled at a network retail pharmacy at a co-pay of $22 for a 30 day supply or through TMOP at a co-pay of $22 for a 90 day supply. If your provider deems it medically necessary for you to continue on Flomax and the proper medical necessity form is approved (www.tricare.osd.mil/pharmacy/medical-nonformulary.cfm.) then the co-pay drops to $9 for a 30 day supply or $9 for a 90 day supply respectively. If you have any questions, please feel free to contact your pharmacist at 450-4171 or healthcare provider. There have been several changes to the formulary in the past few months. Please take note to see if any of the changes affect you or your family members. Drugs added to NHCL Formulary Vytorin (all strengths) Levemir Pravastatin (all strengths) Sular (all strengths) Plan B Maxalt and Maxalt MLT tablets (all strengths) Claritin Syrup *If you are currently receiving any of these medications from another pharmacy, please see your doctor. Your doctor can provide you with a new prescription to be filled at Camp Lejeune. Handwritten prescriptions can be filled at the MCX Pharmacy. Drugs removed from NHCL Formulary Rondec Drops (removed due to FDA safety concerns) Imitrex tablets (replaced with Maxalt tablets) Zyrtec Syrup (replaced with Claritin Syrup) *If you are currently taking any of these medications, please see your doctor. Your doctor can provide you with a new prescription for a formulary item or for the same medication to continue to fill through TMOP or the retail network. Examples

9. Ongoing initiatives • Review NHCL formulary annually to ensure the appropriate medications are available. • Modify CHCS to alert providers which agents are preferred, which require consults, and which require medical necessity forms • Provide information to patients • Working on providing information to civilian partners

10. Pros • Excellent formulary/budget control • Cost savings have allowed additional medications to be added to our formulary • Providers are more aware of the formulary and what medications are available

11. Cons • Time • Provider-must type in script and give medical necessity criteria—estimate 5 minutes per consult • Pharmacist-must review consult and reply to provider—estimate 5-15 minutes depending on if clarification in necessary • 0.5 Full Time Employee just to manage consult • Turnaround of 1 day to 2 weeks depending on volume • Delay in treatment • Inhibit practice of medicine?

12. Contact Information LT Megan Dahlke Megan.dahlke@med.navy.mil