2015 FALL CONFERENCE & TRAINING SEMINAR The Implications of a California Pharmacy Formulary CAJPA Fall Conference September 17, 2015

Your Panelists Moderator: Lori Kammerer – President, Kammerer & Company Rupali Das, MD, MPH – Executive Medical Director at the Division of Workers' Compensation, California Department of Industrial Relations Bernyce Peplowski, DO, MS, FACOEM Mark Pew – Senior Vice President, PRIUM “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Learning Objectives Define a pharmacy formulary Identify legislative and statutory steps needed to successfully implement a state pharmacy formulary Define the potential impact of a pharmacy formulary on patient safety, prescribing behavior, claims cost, and pharmacy cost, including limitations and challenges Outline how a California workers’ compensation pharmacy formulary would work “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Take Aways A drug formulary is not just a list of drugs Changing / influencing prescribing behavior is complicated and unpredictable Changes in prescribing behavior need to be linked to the full treatment plan / EBM “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

What is a pharmacy formulary? “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Definition A list of drugs that are either included or excluded from coverage / reimbursement Used extensively outside of Work Comp Types include Closed, Open, Cost-Based, Retail, Preferred Drug List “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Benefits Facilitates timely provision of medical treatment – Require a clinical rationale for others Add evidence-based practices to prescription choices – Clarify the difference between a specific drug, alternative drug options, alternatives to drugs – Reduce drug-to-drug interactions “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Benefits (continued) Drives evidence-based prescribing practices – Prompts reflection Improve treatment outcomes for patients – Trends towards more conservative options Reduce costs, increase settlements – More accurate calculations, better treatment “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

What are legislative and statutory steps needed to successfully implement a state pharmacy formulary? “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Laying the Foundation Develop consensus among stakeholders – Employers (payers) – Employees (labor) Develop open lines of frequent communication among all stakeholders “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Laying the Foundation (continued) Identify EBM / strength of evidence guidelines – Formulary integrated with total care plan Establish maintenance plan – Minimum of quarterly, preferably monthly Define dispute resolution process – Include quick process for medical emergencies “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Laying the Foundation (continued) Define enforcement process – Pharmacy Point-of-Sale, third-party billing Define implementation process – New claims – “Legacy” claims Define how to measure success “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Laying the Foundation (continued) Incentives – Rapid approval of treatment/care – More use of EBM practices – Discourage improper incentives – Easier choices due to formulary structure “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

What are the potential impacts on patient safety, prescribing behavior, claims cost, and pharmacy cost? “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Potential Impacts Patient safety – Talk about return to function Focus on life – Promote (and approve) more conservative options NSAID’s, exercise, Yoga, CBT – Biopsychosocial Deal with their attitude about pain “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Potential Impacts Prescribing behavior – Choose the best options Require clinical rationale for exceptions – Educate on options No longer “that’s how it’s always been done” – Inspire prescriber-patient conversations Office visits no longer just about refills – Change one, change all Future patients reap the benefits “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Potential Impacts Claims / pharmacy cost – Reduce number of drugs / classifications – Reduce utilization, dosage, quantity – Reduce use of compounds – Reduce disability, co-morbidities, indemnity – Reduce friction costs “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Limitations & Challenges Crosswalk to ICD’s / treatment guidelines – Otherwise just a list of drugs Risk of auto approval for drugs which could be inappropriate for the diagnosis – e.g. Vicodin for ankle sprain “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

How would a California workers’ compensation pharmacy formulary work? “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew

Take Aways A drug formulary is not just a list of drugs Changing / influencing prescribing behavior is complicated and unpredictable Changes in prescribing behavior need to be linked to the full treatment plan / EBM “The Implications of a California Pharmacy Formulary” Dr. Rupali Das, Dr. Bernyce Peplowski, Mark Pew