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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
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