1 / 31

The PA Process

Mohanish Shrestha PharmD candidate Campbell University. The PA Process. ___________________________________________________________________. Raison d'etre : During state fiscal year 2012, the NC Medicaid program spent $563

annick
Download Presentation

The PA Process

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. MohanishShrestha PharmD candidate Campbell University The PA Process ___________________________________________________________________ • Raison d'etre: • During state fiscal year 2012, the NC Medicaid program spent $563 • million on outpatient prescription drugs for 1.58 million recipients.1 • The PA program exists to control spiraling healthcare costs and ensure • that public funds are spent responsibly. • Most drugs included in the PA program are high dollar items or drugs • that have the potential for abuse and over-utilization. NC Medicaid and Health Choice Enhanced pharmacy program. http://ncmedicaidpbm.com. Accessed July 06, 2013.

  2. Brand Name Drugs ___________________________________________________________________ • For any brand name multisource drug that has an FDA (A-rated) • generic equivalent. Prescriber must state DAW1. • Criteria: • Prescriber must go to www.documentforsafety.org and complete the • FDA Medwatch form detailing the adverse event that the beneficiary has • experienced with the generic. • Non-preferred agents require PA and in most cases trial and failure of 2 • preferred agents are REQUIRED. • Brand name drugs Exempt from PA: • Medications used for the treatment of seizures • Medications designated as NTI drugs by the NC Board of Pharmacy (e.g., Coumadin, Synthroid) • Brand medications that are designated as Preferred on the NC Medicaid Preferred Drug List while • the equivalent generic medication is Non-Preferred (e.g., Kadian ER, Lovenox, Accolate, Aricept) • Brand name over the counter/non-prescription medications (e.g., Prilosec OTC, Nicorette)

  3. Anticonvulsants ___________________________________________________________________ • PA is not required for seizure medications for documented diagnosis • Of seizure disorder. • Procedure – Pharmacist may override at POS with PA code “1” if • prescriber writes “meets PA criteria” on the face of the prescription.

  4. Anticonvulsants contd… ___________________________________________________________________ • Special Criteria: • Lamictal– documented diagnosis of Bipolar Disorder I or II, Depressive • Or Maintenance phase. • Lyrica– documented diagnosis of: • Neuropathic pain1/Fibromyalgia2/Anxiety disorderSSRIANDdocumented • failure with a 60 day trial of # agents in the past 12 months • ORdocumented AE/CI. • Topamax – documented diagnosis of Migraine headacheAND • Documented failure with a 60 day trial of 2 agents in the past • 12 months ORdocumented AE/CI.

  5. Aranesp/Procrit/Epogen ___________________________________________________________________ • Criteria:6 months • Anemia associated with renal failure OR • Anemia associated with HIV Infection OR • Anemia associated with chemotherapy OR • Anemia associated with myelodysplastic syndromes OR • Drug induced anemia such as with ribavarin or zidovudine Initial Therapy - Beneficiary shall meet all requirements: 1. Hemoglobin less than or equal to 11 for initial therapy AND 2. Lab data within 3 months of PA

  6. Botox ___________________________________________________________________ • Botox or onabotulinum toxin A • Criteria: • Blepharospasm • Disorders of eye movement (strabismus) • Spasmodic Torticollis, secondary to cervical dystonia • Upper limb spasticity in adults • Severe axillaryhyperhidrosis • Urinary Incontinence • Chronic Migraine (age 18 and older)6 months • 15 or more days each month with HA lasting 4 or more hours • AND Trial and failure of Px medications from 3 drug classes • OR documented CI/intolerated side effect/allergy

  7. Narcotic Analgesics ___________________________________________________________________ • PA requests for Narcotic Analgesics should not be taken over the phone • Criteria: • Short Acting Non-Preferred Narcotic Analgesics:12 months • Document failure in the past year of 30 day trial of a preferred narcotic • analgesic at a dose equivalent to the brand being prescribed OR • Documented CI/Allergy to Preferred product AND • Prescriber has agreed to NCMB statement on the use of controlled • Substances in the treatment of pain and is adhering to treatment • guidelines • Long Acting Narcotic Analgesics:12 months • Documented diagnosis of chronic pain syndrome of at least 4 weeks • duration AND • Prescriber has agreed to NCMB statement… Dose Limit: equivalent dose of 750 mg of morphine/day; 4 g of APAP/ASA per day

  8. Celebrex ___________________________________________________________________ • Criteria6 months: • Management of Acute/Chronic pain for one of following: • Hx of GI bleed/Gastric ulcer/Duodenal ulcer • Previous intolerance to at least 2 non-COX2 NSAids • Concurrent use of corticosteriods • Concurrent use of warfarin or heparin • Hx of platelet dysfunction or coagulopathy • Use in reducing adenomatus colorectal polyps in FAP • Age > 60 are exempt from PA

  9. Cialis ___________________________________________________________________ • Criteria: • Beneficiary is 18 or older male AND • Confirmed Dx of BPH AND • No concurrent therapy with alpha blockers or nitrates AND • Tried and failed all preferred products AND • May not be prescribed to treat ED

  10. Emend ___________________________________________________________________ • Criteria: • Must be undergoing surgery and requires prevention post-operative N/V • OR • Receiving highly/moderately emetogenic chemotherapy agent • AND • Concurrent use of Dexamethasone • Must have tried and failed or intolerant to ondansetron/Zofran/Kytril • /Anzemet • Dosage limits apply to each cycle: • 125 mg for 1 day • 80 mg daily for 2 days

  11. Growth Hormones ___________________________________________________________________ • Children with growth hormone deficiency • Criteria: (separate criteria for Adults) • Coverage is provided in the presence of ALL the following: • GH dysfunction or lack of adequate endogenous GH documented by • any of two provocative tests of less than 10mg/ml • Beneficiary’s height must be below the third percentile for their age and • gender related height • Epiphysis confirmed as open in beneficiaries greater than 9 years of age P&T recommends that a pharmacist handle all prior authorization requests for this therapeutic class

  12. Kalydeco ___________________________________________________________________ • Criteria: • Recipient has been diagnosed with Cystic Fibrosis • AND • Recipient is age 6 or greater • AND • Recipient has a documented G551D mutation in the CFTR gene • AND • Dosing is 150mg taken every 12 hours (300mg/day total) or less • AND • A baseline ALT and AST assessed prior to beginning therapy $30,723 for a month supply

  13. Leukotrienes ___________________________________________________________________ • Criteria: • Covered with diagnosis of Asthma if: • Beneficiary has documented CI/AE to inhaled corticosteroids • OR • Beneficiary has growth suppression due to inhaled corticosteroids • OR • Beneficiary is on medium dose inhaled corticosteroid and needs addition • of Leukotriene Receptor Antagonist or 5-Lipooxygenase Inhibitor to • achieve control (Stepwise Approach for Managing Asthma Long Term) • Exercise Induced Broncho-constriction (singulair): • Documented 30 day T&F of SA bronchodilator OR documented AE/CI • Allergic Rhinitis (singulair): • Documented 30 day T&F of steriod nasal spray/NS antihistamine • OR documented AE/CI

  14. Lidoderm ___________________________________________________________________ • Criteria: • Patient diagnosed with Post-Herpetic Neuralgia. • OR • Neuropathic pain with a previous documented T&F of at least • two of the following drug categories: TCAs, SSRI’s, SNRI’s, • anticonvulsants, NSAID’s or COXII’s • OR • Chronic musculo-skeletal pain (greater than 6 month in duration) with • a previous documented T&F of at least two of the following drug • categories: TCAs, SSRI’s, SNRI’s, anticonvulsants, NSAID’s or COXII’s • AND • Prescribed dose within the FDA recommended maximum amount • of 3 patches per day and no more than 90 patches per month. New prescriptions will be limited to coverage of 1 box (30 patches) upon the first fill. Subsequent refills will be for up to a 34 day supply.

  15. Incivek ___________________________________________________________________ • Criteria:12 weeks • Beneficiary is 18 or older • AND • Beneficiary has confirmed diagnosis of HCV with genotype 1 • AND • Beneficiary has concurrent therapy with ribavirin and peginterferon • AND • Beneficiary has no previous HCV NS3/4A protease inhibitor treatment • for Hepatitis • Approved for up to 12 weeks • One course of treatment per lifetime $22,110 for a bottle of 168

  16. Oral Inhaled steroids ___________________________________________________________________ • Criteria: • QVAR (beclomethasonedipropionate) does not require PA. • Patients must have a documented 30-day T&F of QVAR to receive • other brand name oral inhaled steroids. • OR • Patients must have a documented 30-day T&F of any oral inhaled steroid • product to receive long acting inhaled beta-agonist/steroid combination • products. • Exemptions: • AE/CI to QVAR • COPD patients • Children up to 5 years old may use Flovent without PA

  17. Provigil/Nuvigil ___________________________________________________________________ • Criteria: • Approval will be considered as treatment to improve wakefulness if • Have a diagnosis of narcolepsy • OR • Have excessive sleepiness associated with shift work sleep disorder • OR • Require adjunct treatment for a diagnosis of obstructive • sleep apnea/hypopnea syndrome (OSAHS) with concurrent use of CPAP • OR • Have excessive fatigue associated with multiple sclerosis • or myotonic dystrophy The maximum daily dose for modafinil is 400 mg The maximum daily dose for armodafinil is 250 mg

  18. Qualaquin ___________________________________________________________________ • Criteria: • Treatment for uncomplicated Malaria • May be approved for 1 month

  19. Sedative hypnotics ___________________________________________________________________ • PA requests for Sedative hypnotics should not be taken over the phone • Criteria:6 months • Must have a diagnosis of chronic primary insomnia lasting • one month or longer • OR • Being discontinued from a sedative hypnotic and tapering • is required to prevent symptoms of withdrawal3 months • OR • Being actively assessed for a diagnosis of chronic primary • or secondary/co-morbid insomnia.

  20. Subutex/Suboxone ___________________________________________________________________ • Criteria (suboxone): • Prescription must be written by a physician who has an “X”DEA number • AND • Beneficiary must have a diagnosis of opioid dependence. • AND • Physician must have reviewed the Controlled Substances Reporting • System Database • For Subutex/Buprenorphine: • Must be unable to take suboxone due to pregnancy/CI/AE • Maximum daily dose of 24 mg/day • Length of therapy may be approved for up to 12 months • Request for renewal will require a treatment plan

  21. Synagis ___________________________________________________________________ • Each Synagis dose is individually authorized • After the initial approval, providers must submit a “next dose request” • Maximum of five doses during the RSV season can be authorized for • Chronic lung disease (CLD) and hemodynamically significant congenital • heart disease (HSCHD) for infants and children less than 24 months of • age $2807 for 1 ml IM injection

  22. Topical anti-inflammatories ___________________________________________________________________ • Criteria (for Elidel and Protopic 0.03%): • For areas other than groin or face, failed 2 generic topical • corticosteroids in highest potency class and patient is greater • than 2 years of age. • For groin and face failed 2 topical generic corticosteroids from • preferred list in any potency class and patient is greater than • 2 years of age. • OR • Patient has a documented AE/CI that precludes trial of 2 generic • topical corticosteroids from preferred list.

  23. Triptans ___________________________________________________________________ • Criteria (> 12 units/doses): • Documentation of Dx of migraine headache/cluster headache with • > 6 mod/sev headaches per month • AND • Beneficiary must have T&F NSAIDS within the last year or currently • being using NSAIDS, unless CIed • AND • Beneficiary must concurrently be using migraine preventative medication(s) • (i.e. Beta-Blockers, TCAs, Anticonvulsants) unless CIed • AND • Beneficiary must not have history, symptoms, or signs of • CVD, angina, MI, strokes, uncontrolled hypertension etc. • AND • Prescribing clinician has reviewed evidence based recommendations

  24. Victrelis ___________________________________________________________________ • Criteria:36 weeks • Beneficiary is 18 or older • AND • Beneficiary has confirmed diagnosis of HCV with genotype 1 • AND • Beneficiary has at least 4 weeks of prior therapy with ribavirin and • peginterferon • AND • Beneficiary has concurrent therapy with ribavirin and peginterferon • AND • Beneficiary has no previous HCV NS3/4A protease inhibitor treatment • for Hepatitis C

  25. Vusion ___________________________________________________________________ • Criteria:60days • Requires a trial of at least two different prescription products from • the following list within the previous 60 days: • nystatin cream, nystatin ointment, nystatin/triamcinolone cream, • nystatin/triamcinolone ointment, or clotrimazole cream. • AND • Beneficiary must be at least 4 weeks of age • AND • A quantity limit of 50 gm per 60 days prescription is in place.

  26. Xolair ___________________________________________________________________ • Criteria for initial therapy: • Must be 6 years of age and older • AND • Must have a diagnosis of asthma • AND • Must have inadequately controlled asthma • AND • A percutaneous skin test or RAST allergy test in the past twelve months • indicating reactivity to at least one perennial aeroallergen • AND • IgE level above 30 IU/mL • For continuation of therapy reductions in asthma exacerbation should be • Evidenced by current asthma status/response to Xolair/smoking status $862 for a SC injection

  27. Diabetic Supplies ___________________________________________________________________ • Roche is NC Medicaid’s preferred Diabetic supplier • Meters: Accu-Chek Aviva/Compact/Nano • Test Strips: Accu-Chek Aviva/Smart/Compact • Lancets: Accu-ChekMulticlix/Softclix/Fastclix • Lancing Devices: Accu-ChekMulticlix/Softclix/Fastclix • Diabetic supplies are covered under the Outpatient pharmacy program and can be submitted under the pharmacy POS system • With a valid Rx. They can also be submitted under DME • using the NDC and HCPCS code.

  28. Quantity limitations ___________________________________________________________________ Cetirizine-D/Loratadine-D OTC limited to 102 days supply for 12 months Solodyn ER is limited to 12 weeks supply Chantix - 6 month supply per 12 months Triptansare limited to 12 units (doses). This includes oral tablets, Nasal sprays and injections. Additional quantity requires PA.

  29. Exemptions from PA ___________________________________________________________________ PPIs for patients < 12 years old are exempt Renvela powder pack for patients < 12 years old are exempt QVAR does not require PA Children up to 5 years old may use Flovent without PA TCN antibiotics – Non-preferred TCNs required failure of Doxy and Mino. Solodyn ER is limited to 12 weeks supply. Oral Doxy liquid is exempt for patients < 12 Accuneb/generic Accunebfor patients < 2 years old are exempt Patients < 4 years old are exempt from PA for steroids (nasal sprays) Serostim used for AIDS wasting syndrome is exempt Clarinex syrup in patients < 2 years old are exempt

  30. Exemptions from PA contd… ___________________________________________________________________ Lovaza is exempt if triglycerides are > 500 mg/dL (must be Documented) All Anticonvulsants(1st and 2nd gen. anticonvulsants) are exempt if documented diagnosis of seizures Pantoprazole is exempt if used concomitantly with Plavix Celebrex is exempt for recipient age > 60 Oral Doxy liquid is exempt for patients < 12 Narcotic Analgesics for patients with diagnosis of pain secondary to cancer is exempt

  31. Useful facts contd… ___________________________________________________________________ Pro-Air HFA is now the preferred SABA inhaler (previously was Ventolin HFA) ARB/combn requires trial and failure of ACEiOR CI/AE when using preferred product DRI/combnrequires trial and failure of ACEiOR CI/AE when using preferred product Amylin analogs, GLP-1 receptor agonists, DPP-IV inhibitors require trial and failure of metformin containing products OR CI/AE when using preferred product Daliresp – requires failure of only one preferred agent ICD-9 diagnosis codes are not required by Medicaid. They should either be removed entirely or put in without decimals. 25000 NOT250.00

More Related