1. Arkansas Children’s Behavioral Health Care Commission AR DHS Division of Medical Services Pharmacy Program Laurence H. Miller, M.D., Senior Psychiatrist Pamela Ford, P.D., MBA Suzette Bridges, P.D., Pharmacy Director Stacy Simpson, M.D., Child Psychiatrist January 16, 2014

3. Oct 1, 2003:  Implemented manual review Prior Authorization (PA) process for C-II stimulants requested for children < 5 yrs of age; Nov 15, 2006:  Implemented quantity and dose-optimization edits in all C-II stimulants; most limited to 2x the maximum FDA recommended dose.  Implemented Therapeutic Duplication (TD) edits that limited C-II stimulants to one short-acting agent and one long-acting agent with overlapping days’ supply for all Medicaid beneficiaries.

4. History of Education  Beginning in the latter part of 2003, DMS and DBHS worked together on a behavioral health (BH) educational project with prescribing providers;  Letters were mailed regarding poly-pharmacy of BH meds, TD of BH medications, multiple prescribers, etc.;  Project terminated after 2 years with little appreciable changes in prescribing habits;  The “multiple prescriber” edit facilitated increased communication among providers raising awareness of “doctor shopping”;

5. Beginning in January 2008….  DMS began working with 2 psychiatrists at the Division of Behavioral Health Services (DBHS) to develop edits which focused on the utilization of antipsychotic agents in AR Medicaid children. These included: ◦ High Doses; ◦ Multiple Agents Used; ◦ Use In Children <5 Yrs of Age;

6. July 2009 Implemented Prior Authorization (PA) criteria:  Manual Review PA required for all children <5 yoa;  Point of Sale (POS) TD edits –these edits allowed one oral antipsychotic agent; a second agent required Manual Review PA;  Dose edits implemented for all oral 2 nd generation antipsychotic agents* for 3 age groups: <5 yoa; 5‐12 yoa, and 13‐17 yoa; *(aripiprazole (Abilify), olanzapine (Zyprexa), risperidone (Risperdal), ziprasidone (Geodon), quentiapine (Seroquel). As newer antipsychotic agents were introduced to market they were placed under manual review PA.)  4 DBHS/ASH Child Psychiatrists volunteered their time & shared the responsibility for reviewing PA requests.

7.  Effects of July 2009 Edits: ◦ Decreased utilization in the < 5 age group by 70%; ◦ Decreased utilization in the 5-12 and 13-17 age groups by 10%; ◦ The number of children receiving more than 1 antipsychotic drug decreased, although the overall number of children receiving antipsychotic medication did not decrease significantly.

8. November 2011  ALL claims for “NEW STARTS” rejected at POS –a PA REQUIRED a Signed INFORMED CONSENT and Metabolic Labs for fasting lipids & glucose;  Increased age to < 6 yoa for PA through Manual Review by a DBHS/ASH child psychiatrists;

9. June 2012  ALL Children < 18 yoa on antipsychotic agent (“established” patients) now required to have metabolic lab tests for fasting lipids and glucose required every 6 months;  A change in chemical entity (from one medication to another) rejected at POS and required a new signed informed consent for the PA approval;

10. July 9, 2013 Implemented additional edits approved at the April 2013 DUR Board meeting:  Added manual review PA to all long-acting or depot injectable antipsychotic agents for children < 18 yrs of age;  Added therapeutic duplication edits for long- acting or depot injectable antipsychotic agents to edit against oral antipsychotic agents;

11. Oct. 15, 2013  Added age-related dose edits and dose- optimization quantity limit for oral 1st generation antipsychotic agent;  Added age-related dose edits and dose- optimization quantity limit for iloperidone (Fanapt), lurasidone (Latuda), and asenapine (Saphris);

12.  Lowered the previously approved dose edits for each age group for oral 2 nd generation antipsychotic agents;  Divided the middle age group of 6-12 yrs. to 6-9 yrs. and 10-12 yrs.;  Manual review all requests for children for doses greater than 1 per day of naltrexone (off label use);  Manual review any requests for any Alzheimer disease agents (off label use);

13. January 2013 Medicaid Pharmacy Program hired 1 ½ FTE psychiatrists:  Now questioning the diagnoses on manual review requests;  Currently reviewing antipsychotic utilization patterns in children;  Reviewing Medicaid drug profiles of children who are receiving >5 mental health drugs & consulting with the prescribers regarding the therapy;  Reviewing PA exception from prescribers who request to waive the required metabolic labs for the child;

14. January 2013, Medicaid Pharmacy Program hired 1½ FTE psychiatrists continued:  Regularly consulting with the Division of Children and Family Services (DCFS) staff regarding use of psychotropic medications in foster children;  Collaborating with the System of Care (SOC) clinical staff requesting that they work with providers and families of children with outlier medication profiles to determine if their treatment plans are adequate to address their psychosocial issues (which could also decrease medication utilization);  Consulting with the Value Options Care Coordination Team reviewing complex cases with multiple hospitalizations and excessive use of medications;

15. Oct 2013  AR developed an educational intervention letter with the RDUR contractor to mail to prescribing providers regarding children who are receiving an antipsychotic agent and have a trauma diagnosis in medical history with no other MH diagnosis to support its use.

16. Dec 2013  Developed an educational intervention letter with RDUR contractor to notify the prescribing provider that although the patient is receiving a C-II stimulant medication there is no supporting diagnosis of ADHD/ADD or narcolepsy in medical history. The informational letter explains that off label uses, diversion, and abuse are concerns with C-II stimulant medications and that these agents have serious adverse effects and should only be used for FDA approved indications.

17.  Adding dose ranges (min. and max) for children receiving antidepressant agents;  Lowering the daily dose allowed for C-II stimulants;

19. % Foster Care Children are on Antipsychotic Agent out of Total Foster Care Population % NON-Foster Care Children are on Antipsychotic Agent out of Total NON-Foster Care Population

25. Provider letter mailed 1/23/13 RE use of C-II stim + antipsychotic combo

26. COMPARING ANTIPSYCHOTIC UTILIZATION FROM 4Q8 (NO EDITS IN EFFECT) TO MOST CURRENT 3 MONTHS (SEPT., OCT., NOV. OF 2013) : FOSTER CARE CHILDREN <6 YRS FOSTER CARE CHILDREN 6-12 YRS FOSTER CARE CHILDREN 13-17 YRS -86.02%-38.80%-17.54% NON-FOSTER CARE CHILDREN <6 YRS NON-FOSTER CARE CHILDREN 6-12 YRS NON-FOSTER CARE CHILDREN 13-17 YRS -92.69%-49.35%-31.23%

28.  SIGNIFICANT DECREASES IN INAPPROPRIATE UTILIZATION OF ANTIPSYCHOTIC AGENTS IN ALL AGE GROUPS OF CHILDREN;  NOW BEGINNING TO QUESTION DIAGNOSIS TO TREATMENT DURING THE MANUAL REVIEW PROCESS & CONSULT WITH PRESCRIBER;  IMPROVING OVERALL CARE BY REQUIRING LAB WORK AND SIGNED INFORMED CONSENTS;

29.  INCREASED COLLABORATIONS WITH OTHER ORGANIZATIONS, SUCH AS DCFS, SOC, VALUE OPTIONS FOR IMPROVED CARE;  RAISING AWARENESS ABOUT ADDRESSING PSYCHOSOCIAL ISSUES RATHER THAN JUST USING MEDICATIONS.