Evidence-based Prescription Drug Program EBRx UAMS College of Pharmacy the Arkansas Department of Health and Human Ser

1. Evidence-based Prescription Drug Program (EBRx)UAMS College of Pharmacy& the Arkansas Department of Health and Human Services April 3, 2008 The state wanted to ensure that they could ensure: the current level of service to the state’s Medicaid recipients; while attempting to protect current reimbursement levels to pharmacists/physicians and other providers The state wanted to ensure that they could ensure: the current level of service to the state’s Medicaid recipients; while attempting to protect current reimbursement levels to pharmacists/physicians and other providers

2. The COP’s Role with DHHS Creation of a Preferred Drug List (PDL) Operation of a Prior Authorization (PA) Call Center Evaluation of Medicaid Data As I mentioned earlier, the state actually reached out to the College for help with the creation of a PDL for the Medicaid population….but the state didn’t just want a PDL, they also wanted: A process established to facilitate exceptions to the PDL A process to evaluate the long-term implications that our decisions have made.As I mentioned earlier, the state actually reached out to the College for help with the creation of a PDL for the Medicaid population….but the state didn’t just want a PDL, they also wanted: A process established to facilitate exceptions to the PDL A process to evaluate the long-term implications that our decisions have made.

3. Arkansas’ Solution Creation of an Arkansas Medicaid Preferred Drug List (PDL) PDL created using combination of: Evidence-based literature Expertise of Committee Members Important to note that the committee’s decisions are driven by the evidence, not anecdotes Arkansas is not alone in this process…approx. 15 other states are using the same compilation of data to create a PDL Important to note that the committee’s decisions are driven by the evidence, not anecdotes Arkansas is not alone in this process…approx. 15 other states are using the same compilation of data to create a PDL

4. What is Unique About this Process (Why it’s different from a PBM formulary) Public Comment is available at every Drug Review Committee (DRC) Meeting Physicians and Pharmacists selected to participate in the DRC are done so in consultation with: Arkansas Medical Society Arkansas Pharmacists Association

5. Recommendation Process The Drug Review Committee (DRC) will make their recommendation as to which drug(s) in a therapeutic class should be considered for placement of the PDL. The recommendations will be sent to DHS, to keep them informed on the process, and to the DCC. Once the DCC receives the DRC recommendation, they will have 5 business days to review the recommendation and meet to unseal any supplemental rebate information that may be necessary to arrive at a decision.The Drug Review Committee (DRC) will make their recommendation as to which drug(s) in a therapeutic class should be considered for placement of the PDL. The recommendations will be sent to DHS, to keep them informed on the process, and to the DCC. Once the DCC receives the DRC recommendation, they will have 5 business days to review the recommendation and meet to unseal any supplemental rebate information that may be necessary to arrive at a decision.

6. Manufacturer Rebates Two types of rebates come into play with this program CMS Rebates Supplemental Rebates Supplemental Rebates are not required for products to be placed on PDL CMS rebates are required by the FEDS if the manufacturer wants their product covered by the states Medicaid programs. As I said earlier, the Rx benefit under Medicaid is a voluntary benefit and the states are not required to offer this benefit. However, if the state elects to have an Rx benefit, then they are required to cover every drug that provides the FEDS with a rebate. Supplemental rebates are solicited forCMS rebates are required by the FEDS if the manufacturer wants their product covered by the states Medicaid programs. As I said earlier, the Rx benefit under Medicaid is a voluntary benefit and the states are not required to offer this benefit. However, if the state elects to have an Rx benefit, then they are required to cover every drug that provides the FEDS with a rebate. Supplemental rebates are solicited for

7. Rebate Example $4.28 - price per unit -1.75 - less CMS Rebate $2.53 - net cost with CMS Rebate -0.94 - less Supplemental Rebate $1.59 - Final Net-Net Cost Point out that these numbers are fictitious!!! If questions…. Omeprazole 10mg MAC 2.5016 Omeprazole 20mg MAC 2.6469 Point out that these numbers are fictitious!!! If questions…. Omeprazole 10mg MAC 2.5016 Omeprazole 20mg MAC 2.6469

8. Preferred Drug List Summary

9. Prior Authorization Process Drugs not included on the PDL are subject to prior authorization There are two types of prior authorization Electronic P.A. (seamless at the POS) Manual P.A. via Call Center

10. Electronic Prior Authorizations Through “SmartPA” system Can read past pharmacy claim history, diagnosis history, and procedure history Eliminates the need of the prescriber or pharmacist to complete paperwork or pick up a phone for some PAs

11. SmartPA Example EXAMPLE: (not an actual PDL example) Avandia (rosiglitazone) Check ICD-9 codes for 250.XX in last 12 months (to confirm diabetes mellitus diagnosis and recent treatment), AND; Check Rx history to determine if preferred product has been tried in last 12 months If all conditions are met – approve at POS If all conditions are not met – denied at POS

12. P.A. Call Center Example Prescriber chooses to write Rx for drug not on the Medicaid PDL Prescriber phones the P.A. Call Center P.A. Calls handled by Pharmacists Two MD Medical Directors on staff P.A. requests are always approved or rejected within 24 hours The Manual PA’s are handled in our new Prior Authorization Call Center, which was constructed for this program. The Center was completed in early March of this year, in time for the implementation of our first class of drug on March 25th. The Center is located next to the Arkansas Poison Control Center on the sixth floor of the college of pharmacy. Dr. Howell Foster serves as the PA Call Center Director and also as the Director of the Arkansas Poison Control Center Drs. Hank Simmons & Mark Helm serve as the Medical Directors for the program. When prescriber/nurse calls the center, there is a clinical encounter and a discussion about if the patient needs a non-preferred product. Give example about helping MDs monitor patient compliance -- use Stacie Jones exampleThe Manual PA’s are handled in our new Prior Authorization Call Center, which was constructed for this program. The Center was completed in early March of this year, in time for the implementation of our first class of drug on March 25th. The Center is located next to the Arkansas Poison Control Center on the sixth floor of the college of pharmacy. Dr. Howell Foster serves as the PA Call Center Director and also as the Director of the Arkansas Poison Control Center Drs. Hank Simmons & Mark Helm serve as the Medical Directors for the program. When prescriber/nurse calls the center, there is a clinical encounter and a discussion about if the patient needs a non-preferred product. Give example about helping MDs monitor patient compliance -- use Stacie Jones example

13. Data Trends

16. The average cost went from approximatetly $95/Rx to $20/RxThe average cost went from approximatetly $95/Rx to $20/Rx

19. Cost Savings to Date

20. Website www.ebrx.org

21. Recent Changes

22. Partnership with DF&A Faculty member on Drug Utilization Executive Committee Faculty consultation at DUEC meetings Assistance with RFP solicitation and review (audit process) Prior authorization process and appeals Assist with PA criteria Assist with formulary structuring

23. Partnership with UA System 2 faculty members serving on Drug Review Committee Assist with PBM selection and RFP review Recommendations for formulary structuring Provide expertise with regard to impact on community pharmacy Assist with PA criteria

24. The Goals of EBRx Improve Outcomes By recommending for placement on the Preferred Drug List (PDL) drugs that have documented benefit Control Costs By encouraging use of less expensive medications, when appropriate, and soliciting supplemental rebates from manufacturers to ensure the lowest cost of drugs to the State We will discuss the evidence review process in a few minutesWe will discuss the evidence review process in a few minutes

25. Questions? Where is the program headed? Talk about continuing the Medicaid Contract through PDL development and Call Center operations… But also, looking forward, we will be trying to take advantage of our existing infrastructure to bring in house PA operations for other state agencies or private companiesWhere is the program headed? Talk about continuing the Medicaid Contract through PDL development and Call Center operations… But also, looking forward, we will be trying to take advantage of our existing infrastructure to bring in house PA operations for other state agencies or private companies