1 / 12

Governor’s Office of Health Policy and Finance

Governor’s Office of Health Policy and Finance. MaineCare Pharmacy Initiatives. PDL. Preferred Drugs: By definition are usually Cost-Effective Provide the best clinical outcome for the least amount of money. PDL What it’s not. A PDL is not a Formulary

bunme
Download Presentation

Governor’s Office of Health Policy and Finance

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. Governor’s Office of Health Policy and Finance MaineCare Pharmacy Initiatives

  2. PDL • Preferred Drugs: • By definition are usually Cost-Effective • Provide the best clinical outcome for the least amount of money

  3. PDL What it’s not • A PDL is not a Formulary • Formulary is a limited list of drugs that are covered • In a PDL all Drugs continue to be covered • Members have access to Non-Preferred Drugs in a variety of ways: • By Prior Authorization • By Step Therapy • By Grandfathering in certain Drug Classes • By Special Medical Conditions (Cancer)

  4. Antipsychotics • Nearly $20 million (state + federal) spent annually • 11% of drug budget • Over 12,000 users • Presently, PDL only addresses high doses and duplicate therapy • Can save over $1 million (state) by selecting first-line drugs that won’t need PA • 15 States currently PA in this Category

  5. PA for Some Atypicals • Follow National Association of State Mental Health Directors Guidelines (see next 2 slides) • Many choices in first line medications • Established users not affected (about 50% over course of the year) • Only affects new starters

  6. Antipsychotic PDL: Ensuring Appropriate Access and Efficient Utilization(NASMHD) • All medications should be available. • Not all medications need be available on a first-line basis. • PA should be simple and flexible. • Choices of first-line medications at a minimum must include: • Clozapine (any approved formulation) [Treatment-resistance] • Risperidone or paliperidone [Atypical with long-acting formulation] • Ziprasidone or aripiprazole [Weight-neutral atypical] • Olanzapine or quetiapine [Sedating atypical] • Haloperidol or fluphenazine [high potency typical and long-acting formulation] • Perphenazine or thiothixene or other medium-potency typical • Chlorpromazine or other low-potency typical.

  7. Antipsychotic PDL: Ensuring Appropriate Access and Efficient Utilization(NASMHD) • Helps ensure that medications are prescribed according to manufacturer indications • A prescription drug may be selected for prior authorization if one of the following characteristics apply: • Clinically appropriate • High ingredient cost • Use is within a narrow member population • Drugs with a high potential for inappropriate use or abuse • Agents that are best reserved for second or third line therapies

  8. What happens when a PA is needed? • But the doctor has not completed the PA request • There was a one time override the pharmacist could use to dispense a one month supply during the PDL implementation phase. • The member always has access to a 96 hour emergency supply. • Nearly 80% of PA’s submitted are approved • Completed PA receive a decision on average within 3 hours of submission

  9. Draft PA Criteria • Grandfather existing users • Start of NP in Hospital setting will be grandfathered • 3 week trial of an effective dose of a Preferred Drug will meet approval criteria for a NP Drug • Documentation of good response to samples of NP Drug • Documentation of significant side effects will meet approval criteria for NP Drug • Doctor can always request a prior authorization without having to use Preferred Drug if medical necessity is documented

  10. What happens when a PA is not approved? • Additional information documenting medical necessity for a re-determination may be submitted. • A member can appeal the decision by requesting a Fair Hearing.

  11. Safety Net Protections • Completed PA’s acted on within 24 hours of submission • Average time to review a completed PA is 3 hours • 96 hour supply of drug is available on an emergency basis

  12. 4 Brand Name Per Month Limit • $1 Million savings (State) • Only for MaineCare members who are: • Not a dual eligible • Over 18 years of age • Will not apply to: • Cancer medications • HIV medications • Antipsychotics • Currently have 5 Brand limit for MaineCare members living in certain settings • 17 States currently have limits in place

More Related