Roles of DMAS, Pharmacy & Therapeutics Committee, and Preferred Drug List Contractor Presentation to: The Medicaid Pharmacy & Therapeutics Committee Patrick W. Finnerty Department of Medical Assistance Services June 18, 2003 Richmond, Virginia

2 Key DMAS Staff Contacts n Pat Finnerty, DMAS Director ( ) n Cindi Jones, Chief Deputy Director, ( ) n Cheryl Roberts,Deputy Director, Programs and Operations ( ) n Bryan Tomlinson, Director, Division of Health Care Programs ( ) n Adrienne Fegans, Program Administration Specialist ( )

3 DMAS’ Role n Ensure PDL program conforms to all statutory/regulatory requirements n Support P&T Committee Members and activities n Procure services of a PDL Contractor –monitor Contractor and ensure performance meets required quality and service standards n Review and approve all Contractor-written communications to clients, providers, and others prior to release n Provide Contractor with all necessary and current client eligibility and utilization data

4 DMAS’ Role (cont’d) n Coordinate Contractor’s support of P&T Committee –ensure Contractor is responsive to P&T Committee n Interpret policies and make final decisions regarding all aspects of program –Appropriations Act requires that DMAS establish a process for acting on the recommendations of the P&T Committee and documenting any decisions that deviate from recommendations of the Committee n Review and approve all supplemental rebate agreements n Handle all media inquiries

5 Members of P&T Committee Member Background n Randy Axelrod (MD) (Chairman)Anthem Chief Medical Officer n Roy Beveridge (MD)Oncologist n Avtar Dhillon (MD)Psychiatrist (CSB) n James Reinhard (MD)Psychiatrist (DMHMRSAS) n Arthur Garson, Jr (MD)Dean, UVA Med. School n Mariann Johnson (MD)Family Practice n Eleanor (Sue) Cantrell (MD)Local Health District Director n Christine Tully (MD)Geriatrician, VCU/MCV n Mark Szalwinski (Pharmacist)Sentara Health Care (Vice Chairman) n Gill Abernathy (Pharmacist) INOVA Health System n Mark Oley (Pharmacist) Westwood Pharmacy n Renita Warren (Pharmacist) Edloe’s Pharmacies

Appropriations Act: P&T Committee Responsibilities n The P&T Committee shall recommend to the Department: –therapeutic classes of drugs to be subject to the PDL and prior authorization requirements –specific drugs within each class to be included on the PDL –appropriate exclusions for medications, including atypical anti-psychotics, used for the treatment of serious mental illnesses such as bi-polar disorders, schizophrenia, and depression –appropriate exclusions for medications used for the treatment of brain disorders, cancer, and HIV-related conditions –other appropriate exclusions and “grandfather” clauses

7 Role of P&T Committee (cont’d) n Conduct clinical reviews of preferred and non-preferred drugs as needed to maintain the PDL n Conduct clinical reviews of new drugs n Provide advice to DMAS and Contractor on clinical issues regarding all aspects of the PDL program, including the prior authorization process for non-preferred drugs n Provide clinical advice/input to DMAS and Contractor on prior authorization of “more than 9 unique prescriptions”

8 Role of PDL Contractor n Provide information and staff support to the P&T Committee n Establish and maintain the PDL based on clinical recommendations of the P&T Committee –cost effectiveness is to be considered only after drug is determined to be safe and clinically effective –exclude from the PDL and prior authorization program for non-preferred drugs those classes of drugs previously excluded by DMAS n Manage the reference pricing process n Ensure all program components required by the Appropriations Act are implemented

9 Role of PDL Contractor (cont’d) n Negotiate and administer state supplemental rebates n Administer the PDL prior authorization program for non- preferred drugs and the prior authorization program for “more than nine unique prescriptions” –administer a reconsideration and appeals process n Provide and maintain Call Center 24 hours/day; 7 days/week n Provide PDL and prior authorization program education services for clients and providers n Ensure confidentiality of client/provider information

10 PDL Development Process All Therapeutic Classes of Drugs P&T Committee Recommends Drug Classes To Be Subject to PDL & P.A. P&T Committee Recommends Drugs Within Each Class That Are Clinically Effective and Safe Preferred Drugs Drugs at or below cost of most cost-effective drug Non-Preferred Drugs Drugs above cost of most cost-effective drug require P.A.

11 Overview of PDL With Reference Pricing and Supplemental Rebates Source: DMAS Staff Illustration $27 $22 $11 $29 $70 $38 $56 Non-Participating Manuf. Drug Available through P.A. Original Price Most Cost Effective Drug