1. 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

2. 2 Goal: Virginia Medicaid Preferred Drug List Provision of: n Safe drug therapy n Effective drug therapy n 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

3. 3 How Does This Affect You n Prescribers should proactively change their Medicaid enrollees, as appropriate, to drugs included on the PDL (proactive PA). n For new drug therapy, prescribers should prescribe drugs, as appropriate, that are included on the PDL. n 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. n Pharmacy providers should notify prescribers when prescriptions for non-preferred drugs are received and request changes to preferred drugs. n Pharmacy providers should instruct prescribers to request PA from FHSC Call Center if they are unwilling to change to preferred drugs.

4. 4 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 Preferred Drugs NO PDL PA Required Non-Preferred Drugs Drug requires PA

5. 5 PDL Program “Phase-In” n The goal of this “phased-in” transition process is to minimize the impact of the program on enrollees and providers. n New classes of drugs with approved preferred drugs are to be implemented quarterly: January, April, July 2004 n Soft edits (messages that future PA will be required) precede hard edits (PA required). n All affected Medicaid enrollees will be notified by mail of the PDL program. n 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. n Presentations will be offered to Medicaid providers to introduce the program and to explain operational procedure.

6. 6 Initial Drug Classes Included in the PDL Program for January 2004 Therapeutic Class Description n Proton Pump Inhibitors (PPIs) n H2 Antagonists n Nasal Steroids n Second Generation Antihistamines n Selective Cox-2 Inhibitors n HMG CoA Reductase Inhibitors (Statins) n Sedative Hypnotics n Beta Adrenergics n Inhaled Corticosteroids n ACE Inhibitors n AngiotensinII Receptor Blockers(ARBs) n Calcium Channel Blockers (CCBs) n Beta Blockers Used in the Treatment of: n Gastrointestinal Disorders n Allergies, Asthma, Other Respiratory Illness n Allergic Conditions n Inflammatory Conditions n High Cholesterol and Dyslipidemia n Insomnia n Asthma and Other Respiratory Illness n Hypertension/Other Cardiovascular Illness

7. 7 Drug Classes Proposed for Implementation in April 2004 Therapeutic Class Description Used for Treatment of: n Oral Hypoglycemics Diabetes n Leukotriene Modifiers Allergic Conditions/Asthma n Bisphosphonates Osteoporosis n Traditional NSAIDs Inflammatory Conditions n Serotonin Receptor Agonists Migraine Headache n Oral Antifungals Nail Fungal Infections NOTE: Additional classes of drugs to be implemented quarterly at the recommendation of the P&T Committee.

8. 8 Classes of Drugs Excluded from the PDL Program Therapeutic Class Description n Insulins n Cholinesterase Inhibitors n Platelet Aggregation Inhibitors n Antivirals for HIV n Cancer Chemo. Agents n Anti-convulsants n Immunosupressants n Antiemetics n Anti-psychotics, Atypical and Typicals Used in the Treatment of: n Diabetes n Alzheimers n Clotting Disorders n HIV/AIDS n Cancer n Seizure Disorders, Mental Health n Transplant Rejections, Arthritis n Nausea in Cancer Patients, Aging n Serious Mental Illness

9. 9 What is the Prescribers’ Responsibility n Prescribers should prescribe drugs on the preferred drug list. n New therapy should be initiated on a “preferred drug” unless a “non-preferred drug” is medically necessary. n 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.

10. 10 What is the Pharmacists’ Responsibility n During the soft edit phase of the PDL program implementation, messages will alert pharmacy providers when a “non-preferred drug” claim is submitted n 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. n 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.

11. 11 Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program Scenario #1: n Prescriber writes a prescription for a “preferred drug” n Enrollee takes the prescription to the pharmacy and receives the medication, pays the $1 or $3 co-pay, if applicable

12. 12 Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program Scenario #2: n Prescriber writes a prescription for a “non-preferred drug” n Prescriber faxes or calls a PA Request to the FHSC Call Center BEFORE giving the prescription to the enrollee n Prescriber either changes the prescription to a “preferred drug” or gets a PA approval for the “non-preferred drug” n Enrollee takes the prescription to the pharmacy and receives the medication, pays the $1 or $3 co-pay, if applicable

13. 13 Prescribing and Dispensing Drugs in the Virginia Medicaid PDL Program Scenario #3: n Prescriber writes a prescription for a non-preferred drug and enrollee takes the prescription to the pharmacy n Pharmacy provider gets a message and denial that a PA is required for a “non- preferred drug” n 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 n 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

14. 14 FHSC Prior Authorization/ Call Center Information Methods to Request Prior Authorization: –Telephone Call –Faxed PA Request Form –Mailed PA Request Form n Prescriber/Pharmacy Call Center: 800-932-6648 n Fax: 800-932-6651 n Mailing Address: First Health Services Corporation 4300 Cox Rd. Glen Allen, VA 23060 Attn: MAP n Enrollee Call Center: 800-932-3923 n TYY/TDD: 800-855-1155

16. 16 PA Request: Required Information n Enrollee Name, Medicaid ID#, Date of Birth, Diagnosis n Name of Drug and Strength, Quantity per Day n Documentation of Previous Drug Therapy for the Indicated Diagnosis n Clinical Evidence That a “Preferred Drug” Will Not Provide Adequate Benefit n Physician Name, Signature n Physician Phone # and Fax# n Date

17. 17 Turnaround Time: PA Request n 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. n Fax PA Requests and Mailed PA Requests will be processed within 24 hours of receipt. n Once a PA Request is approved, it is entered into the system for immediate claim adjudication. n If a PA Request is denied, there is an appeals process.

18. 18 Denials and Appeals n FHSC mails a denial letter to both the prescriber and the enrollee outlining the Right to Appeal. n 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 n 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.

19. 19 Quality Initiatives n 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. n Clinical edits will be implemented related to the cost-effective use of medications that are frequently overused or misused. n 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.

20. 20 Pharmacy Contact/Information Sites n Provider Call Center: 800-932-6648 n Enrollee Call Center: 800-932-3923 n Fax: 800-932-6651 n E-mail for Comments: pdlinput@dmas.virginia.gov n Web Sites: www.dmas.state.va.us http://virginia.fhsc.com