slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Goal: Virginia Medicaid Preferred Drug List PowerPoint Presentation
Download Presentation
Goal: Virginia Medicaid Preferred Drug List

Loading in 2 Seconds...

play fullscreen
1 / 20

Goal: Virginia Medicaid Preferred Drug List - PowerPoint PPT Presentation


  • 186 Views
  • Uploaded on

Virginia Medicaid Preferred Drug List and Other Pharmacy Programs: What You Need To Know Presented by: Department of Medical Assistance Services and First Health Services Corporation. Goal: Virginia Medicaid Preferred Drug List. Provision of: Safe drug therapy Effective drug therapy

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Goal: Virginia Medicaid Preferred Drug List' - gavrila


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.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Virginia Medicaid Preferred Drug List and Other Pharmacy Programs:What You Need To KnowPresented by:Department of Medical Assistance Servicesand First Health Services Corporation

goal virginia medicaid preferred drug list
Goal: Virginia Medicaid Preferred Drug List

Provision of:

  • Safe drug therapy
  • Effective drug therapy
  • Appropriate drug therapy

To: Fee for Service/MEDALLION Enrollees

At: A reasonable cost to the Medicaid program

The assistance from prescribers and pharmacists is key to the success of the program

how does this affect you
How Does This Affect You
  • Prescribers should proactively change their Medicaid enrollees, as appropriate, to drugs included on the PDL (proactive PA).
  • For new drug therapy, prescribers should prescribe drugs, as appropriate, that are included on the PDL.
  • In the event that a non-preferred drug is medically necessary, the prescriber must contact the FHSC Call Center to request PA before giving a prescription to an enrollee.
  • Pharmacy providers should notify prescribers when prescriptions for non-preferred drugs are received and request changes to preferred drugs.
  • Pharmacy providers should instruct prescribers to request PA from FHSC Call Center if they are unwilling to change to preferred drugs.
summary of pdl development process

All Therapeutic Classes of Drugs

Pharmacy & Therapeutics Committee Recommends Drug Classes To Be Subject to PDL & PA

P&T Committee Recommends Drugs Within Each Class That Are Clinically Effective and Safe

Non-Preferred Drugs

Drug requires PA

Summary of PDL Development Process

Preferred Drugs

NO PDL PA Required

pdl program phase in
PDL Program “Phase-In”
  • The goal of this “phased-in” transition process is to minimize the impact of the program on enrollees and providers.
  • New classes of drugs with approved preferred drugs are to be implemented quarterly: January, April, July 2004
  • Soft edits (messages that future PA will be required) precede hard edits (PA required).
  • All affected Medicaid enrollees will be notified by mail of the PDL program.
  • All Medicaid providers will receive a Medicaid Memo announcing the PDL program including a copy of the PDL and instructions for requesting PA for non-preferred drugs.
  • Presentations will be offered to Medicaid providers to introduce the program and to explain operational procedure.
initial drug classes included in the pdl program for january 2004
Therapeutic Class Description

Proton Pump Inhibitors (PPIs)

H2 Antagonists

Nasal Steroids

Second Generation Antihistamines

Selective Cox-2 Inhibitors

HMG CoA Reductase Inhibitors (Statins)

Sedative Hypnotics

Beta Adrenergics

Inhaled Corticosteroids

ACE Inhibitors

AngiotensinII Receptor Blockers(ARBs)

Calcium Channel Blockers (CCBs)

Beta Blockers

Used in the Treatment of:

Gastrointestinal Disorders

Gastrointestinal Disorders

Allergies, Asthma, Other Respiratory Illness

Allergic Conditions

Inflammatory Conditions

High Cholesterol and Dyslipidemia

Insomnia

Asthma and Other Respiratory Illness

Asthma and Other Respiratory Illness

Hypertension/Other Cardiovascular Illness

Hypertension/Other Cardiovascular Illness

Hypertension/Other Cardiovascular Illness

Hypertension/Other Cardiovascular Illness

Initial Drug Classes Included in the PDL Program for January 2004
drug classes proposed for implementation in april 2004
Drug Classes Proposed for Implementation in April 2004

Therapeutic Class Description Used for Treatment of:

  • Oral Hypoglycemics Diabetes
  • Leukotriene Modifiers Allergic Conditions/Asthma
  • Bisphosphonates Osteoporosis
  • Traditional NSAIDs Inflammatory Conditions
  • Serotonin Receptor Agonists Migraine Headache
  • Oral Antifungals Nail Fungal Infections

NOTE: Additional classes of drugs to be implemented quarterly at the recommendation of the P&T Committee.

classes of drugs excluded from the pdl program
Therapeutic Class Description

Insulins

Cholinesterase Inhibitors

Platelet Aggregation Inhibitors

Antivirals for HIV

Cancer Chemo. Agents

Anti-convulsants

Immunosupressants

Antiemetics

Anti-psychotics, Atypical and Typicals

Used in the Treatment of:

Diabetes

Alzheimers

Clotting Disorders

HIV/AIDS

Cancer

Seizure Disorders, Mental Health

Transplant Rejections, Arthritis

Nausea in Cancer Patients, Aging

Serious Mental Illness

Classes of Drugs Excludedfrom the PDL Program
what is the prescribers responsibility
What is the Prescribers’ Responsibility
  • Prescribers should prescribe drugs on the preferred drug list.
  • New therapy should be initiated on a “preferred drug” unless a “non-preferred drug” is medically necessary.
  • Prescribers should review the therapy of their Medicaid enrollees for utilization of “non-preferred drugs”and wherever medically appropriate, change patients to “preferred drugs”.
    • Therapy review and modification should begin immediately, during December and January.
    • In situations where “non-preferred drugs” are medically necessary, prescribers should initiate PA requests by phone, fax or mail to the FHSC Call Center.
what is the pharmacists responsibility
What is the Pharmacists’ Responsibility
  • During the soft edit phase of the PDL program implementation, messages will alert pharmacy providers when a “non-preferred drug” claim is submitted
  • Pharmacy providers should call the prescriber with a request to change the drug to a “preferred drug” within the same therapeutic class
    • If the prescriber does not feel it is medically appropriate to change to a “preferred drug”, the pharmacy provider should instruct the prescriber to call or fax FHSC with a PA request for the non-preferred drug.
  • When hard edits begin, if the pharmacy provider deems that the patient’s medical condition warrants it, he/she can call FHSC for a 72hr supply of medication.
prescribing and dispensing drugs in the virginia medicaid pdl program
Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program

Scenario #1:

  • Prescriber writes a prescription for a “preferred drug”
  • Enrollee takes the prescription to the pharmacy and receives the medication, pays the $1 or $3 co-pay, if applicable
prescribing and dispensing drugs in the virginia medicaid pdl program1
Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program

Scenario #2:

  • Prescriber writes a prescription for a “non-preferred drug”
  • Prescriber faxes or calls a PA Request to the FHSC Call Center BEFORE giving the prescription to the enrollee
  • Prescriber either changes the prescription to a “preferred drug” or gets a PA approval for the “non-preferred drug”
  • Enrollee takes the prescription to the pharmacy and receives the medication, pays the $1 or $3 co-pay, if applicable
prescribing and dispensing drugs in the virginia medicaid pdl program2
Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program

Scenario #3:

  • Prescriber writes a prescription for a non-preferred drug and enrollee takes the prescription to the pharmacy
  • Pharmacy provider gets a message and denial that a PA is required for a “non-preferred drug”
  • Pharmacy provider calls the prescriber by phone
    • Prescriber changes the prescription to a “preferred drug” and medication is dispensed, or
    • Prescriber told to call FHSC to request a PA for a “non-preferred drug”
    • If pharmacy provider deems the patient’s medical condition warrants it, he/she calls FHSC for a 72-hour supply of medication
  • Prescriber calls FHSC to request a PA for a “non-preferred drug”
    • Prescriber changes prescription to a “preferred drug” and medication is dispensed, or
    • Prescriber receives PA approval for “non-preferred drug” and medication is dispensed, or
    • PA request is denied and appeals options are offered
fhsc prior authorization call center information
FHSC Prior Authorization/Call Center Information

Methods to Request Prior Authorization:

    • Telephone Call
    • Faxed PA Request Form
    • Mailed PA Request Form
  • Prescriber/Pharmacy Call Center: 800-932-6648
  • Fax: 800-932-6651
  • Mailing Address: First Health Services Corporation 4300 Cox Rd. Glen Allen, VA 23060 Attn: MAP
  • Enrollee Call Center: 800-932-3923
  • TYY/TDD: 800-855-1155
pa request required information
PA Request: Required Information
  • Enrollee Name, Medicaid ID#, Date of Birth, Diagnosis
  • Name of Drug and Strength, Quantity per Day
  • Documentation of Previous Drug Therapy for the Indicated Diagnosis
  • Clinical Evidence That a “Preferred Drug” Will Not Provide Adequate Benefit
  • Physician Name, Signature
  • Physician Phone # and Fax#
  • Date
turnaround time pa request
Turnaround Time: PA Request
  • Phone PA Requests will be processed on the initial call.
    • Certified pharmacy technicians will respond initially. If prior authorization cannot be determined, the call will be transferred to a clinical pharmacist for further review.
    • If necessary, further review can be requested from a lead clinical pharmacist and finally, a physician.
  • Fax PA Requests and Mailed PA Requests will be processed within 24 hours of receipt.
  • Once a PA Request is approved, it is entered into the system for immediate claim adjudication.
  • If a PA Request is denied, there is an appeals process.
denials and appeals
Denials and Appeals
  • FHSC mails a denial letter to both the prescriber and the enrollee outlining the Right to Appeal.
  • The prescriber and/or the enrollee decides to complete the appeals paperwork and submits to DMAS Appeals Division.

Department of Medical Assistance Services

Appeals Division

600 E. Broad Street

Richmond, Virginia 23219

  • Appeals Hearing is conducted with the support of FHSC to provide background information related to the PA request denial and to be available to attend the hearing.
quality initiatives
Quality Initiatives
  • Prospective Drug Utilization Review (ProDUR) related to possible serious drug/drug interactions, pregnancy contraindications and therapeutic duplication and early refill requests that may compromise quality of care will require PA.
  • Clinical edits will be implemented related to the cost-effective use of medications that are frequently overused or misused.
  • Retrospective Drug Utilization Review (RetroDUR) related to polypharmacy through established threshold limits for number of utilized medications will occur.
    • Prescribers will receive letters, requiring response, as indicated by clinical review of enrollee medication profiles.
    • Medications determined to be inappropriate will be prevented from further adjudication until PA is requested by the prescriber and approved.
pharmacy contact information sites
Pharmacy Contact/Information Sites
  • Provider Call Center: 800-932-6648
  • Enrollee Call Center: 800-932-3923
  • Fax: 800-932-6651
  • E-mail for Comments: pdlinput@dmas.virginia.gov
  • Web Sites: www.dmas.state.va.us

http://virginia.fhsc.com