Governor’s Office of Health Policy and Finance

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Governor’s Office of Health Policy and Finance

MaineCarePharmacy Initiatives

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PDL Preferred Drugs:

By definition are usually Cost-Effective

Provide the best clinical outcome for the least amount of money

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PDL What it’s not A PDL is not a Formulary Formulary is a limited list of drugs that are

covered In a PDL all Drugs continue to be covered Members have access to Non-Preferred Drugs

in a variety of ways:

By Prior Authorization By Step Therapy By Grandfathering in certain Drug Classes By Special Medical Conditions (Cancer)

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Antipsychotics Nearly $20 million (state + federal) spent

annually 11% of drug budget Over 12,000 users Presently, PDL only addresses high doses

and duplicate therapy Can save over $1 million (state) by

selecting first-line drugs that won’t need PA

15 States currently PA in this Category

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PA for Some Atypicals Follow National Association of State

Mental Health Directors Guidelines (see next 2 slides) Many choices in first line medications Established users not affected (about

50% over course of the year) Only affects new starters

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Antipsychotic PDL: Ensuring Appropriate Access and Efficient Utilization (NASMHD) All medications should be available. Not all medications need be available on a first-line basis. PA should be simple and flexible. Choices of first-line medications at a minimum must

include: Clozapine (any approved formulation) [Treatment-

resistance] Risperidone or paliperidone [Atypical with long-acting

formulation] Ziprasidone or aripiprazole [Weight-neutral atypical] Olanzapine or quetiapine [Sedating atypical] Haloperidol or fluphenazine [high potency typical and long-

acting formulation] Perphenazine or thiothixene or other medium-potency

typical Chlorpromazine or other low-potency typical.

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Antipsychotic PDL: Ensuring Appropriate

Access and Efficient Utilization (NASMHD) Helps ensure that medications are prescribed

according to manufacturer indications A prescription drug may be selected for prior

authorization if one of the following characteristics apply: Clinically appropriate High ingredient cost Use is within a narrow member population Drugs with a high potential for inappropriate use or

abuse Agents that are best reserved for second or third

line therapies

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What happens when a PA is needed? But the doctor has not completed the PA request

There was a one time override the pharmacist could use to dispense a one month supply during the PDL implementation phase.

The member always has access to a 96 hour emergency supply.

Nearly 80% of PA’s submitted are approved Completed PA receive a decision on average

within 3 hours of submission

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Draft PA Criteria Grandfather existing users Start of NP in Hospital setting will be grandfathered 3 week trial of an effective dose of a Preferred

Drug will meet approval criteria for a NP Drug Documentation of good response to samples of NP

Drug Documentation of significant side effects will meet

approval criteria for NP Drug Doctor can always request a prior authorization

without having to use Preferred Drug if medical necessity is documented

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What happens when a PA is not approved?

Additional information documenting medical necessity for a re-determination may be submitted.

A member can appeal the decision by requesting a Fair Hearing.

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Safety Net Protections Completed PA’s acted on within 24

hours of submission Average time to review a

completed PA is 3 hours 96 hour supply of drug is available

on an emergency basis

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4 Brand Name Per Month Limit

$1 Million savings (State) Only for MaineCare members who are:

Not a dual eligible Over 18 years of age

Will not apply to: Cancer medications HIV medications Antipsychotics

Currently have 5 Brand limit for MaineCare members living in certain settings

17 States currently have limits in place