agenda - arkansas · 2017. 11. 7. · recalculated catastrophic reserve is $40.5 million. net...

AGENDA

State and Public School Life and Health Insurance Board

April 18, 2017

1:00 p.m.

EBD Board Room – 501 Building, Suite 500

I. Call to Order ......................................................................... Carla Haugen, Chairman

II. Approval of March 21, 2017 Minutes ................................... Carla Haugen, Chairman

III. ASE-PSE Financials March, 2017 ...................... Marla Wallace, EBD Fiscal Officer

IV. DUEC Report ...................................... Dr. Hank Simmons, Dr. Geri Bemberg, UAMS

V. Benefits Sub-Committee Report ................. Chris Howlett, EBD Executive Director

VI. Quality of Care Committee Report. ......... Mike Motley, Elizabeth Whittington, ACHI

VII. Wellness Committee Report .......................... Dr. Joseph Thompson, Director ACHI

VIII. Preliminary Rate Projections ..................................................John Colberg, Cheiron

IX. Director’s Report .......................................... Chris Howlett, EBD Executive Director

Upcoming Meetings

May 16, 2017, June 20, 2017, July 18, 2017, August 22, 2017

NOTE: All material for this meeting will be available by electronic means only

[email protected].

Notice: Silence your cell phones. Keep your personal conversations to a minimum.

mailto:[email protected]

STATE AND PUBLIC SCHOOL LIFE AND HEALTH INSURANCE BOARD MEETING MINUTES

171st meeting of the State and Public School Life and Health Insurance Board (hereinafter called the Board), met on April 18, 2017 at 1:00 p.m. in the EBD Board Room, 501 Woodlane, Suite 500, Little Rock AR 72201.

Date | time 4/18/2017 1:00 PM | Meeting called to order by Carla Haugen, Chair

Attendance

Members Present Members Absent

Carla Haugen -Chair Dr. John Kirtley

Dr. Joseph Thompson

Shelby McCook

Katrina Burnett - teleconference

Renee Mallory - teleconference

Lori Freno-Engman

Janis Harrison

Dan Honey – Vice Chair

Dr. Andrew Kumpuris

Dr. Tony Thurman

Robert Boyd

Chris Howlett, EBD Executive Director, Employee Benefits Division

OTHERS PRESENT:

Dwight Davis, Sherry Bryant, Kristen Johnson, Daniel Gate, UAMS; Ethel Whittaker, Marla Wallace, Eric Gallo, Terri Freeman, Matt Turner, Gretchen Baggett, Cecilia Walker, Ellen Justus, Shalada Toles; EBD; Kristi Jackson, Jennifer Vaughn, ComPsych; Vicki Slay, Arkansas Secretary of State; Sylvia Landers, Eileen Wider, Securian; Ronda Walthall, Mike Boyd, Wayne Whitley, AR Highway & Transportation Department; Karyn Langley, Qual Choice; Andy Davis, Arkansas Democrat-Gazette; Marc Watts, ASEA; Nina Reed, Sandra Wilson, ActiveHealth; Will Cottrell, Linda B., DHS; David Kizzia, AEA; Marc Parker, Sunovion; Takisha Sanders, Jessica Akins, Health Advantage; Stephen Carroll, AllCare Specialty; Rob B., Drew Crawford & Associates; Randy Loggins, Mike Motley, Elizabeth Whittington, ACHI; Suzanne Woodall, MedImpact; Lydia S., Marc Bagby, LILLY; Sean Seago, Merck; Robyn Keene, AAEA; Martha Hill; Jim Chapman, Abbvie; Phillip White, Scott Yielding, DPAS; Treg Long, ACS

Approval of Minutes by: Carla Haugen, Chair

Haugen asked for a motion to approve the March 28, 2017, minutes.

Honey motioned for adoption of the minutes. Boyd seconded; all were in favor.

Minutes approved.

Financials by: Marla Wallace, EBD Fiscal Officer

Wallace reported financials for March 2017. For March PSE, five (5) weeks of medical and pharmacy claims were paid. The fifth week of claims totaled almost $3.5 million. The FICA Savings received for the month was $516,641. Even with the fifth week of claims there was a net gain of $2.1 million for the month There was a net gain of $2.1 million for the month and $15.26 million year-to-date. The recalculated catastrophic reserve is $40.5 million. Net assets available are $48.8 million.

For ASE for the month of March, five (5) weeks of medical and pharmacy claims were paid. The fifth week of claims totaled $4.14 million. The net gain was $495,488 for the month and $11.28 million year-to-date. Net assets available are $21.3 million.

At the request of the Board, an additional report was provided, which outlines the projected amount of medical claims, pharmacy claims, and expenses. Also, the report provides expected and actual amounts for each month and year-to-date.

DUEC Committee Report by: Dr. Hank Simmons, Dr. Geri Bemberg, UAMS

Dr. Bemberg gave an update and recommendation of medications reviewed by the DCWG Group.

The committee recommended approval of the above recommendations.

Current Coverage Proposed Coverage

Multiple Myeloma

Revlimid (lenalidomide) Tier 4 PA No change, tier 4 PA

Velcade (bortezomib) Covered medical No change, cover medical

Empliciti (elotuzumib) Covered, medical PA No change, cover medical PA

Darzalex (daratumumab) Excluded Cover, medical PA

Kyprolis (carfilzomib) Excluded Cover, medical PA

Ninlaro (ixazomib) Excluded Continue to exclude

Pomalyst (pomalidomide) Excluded Continue to exclude

Farydak (panobinostat) Excluded Continue to exclude

I. 2nd review of Drugs: by Dr. Jill Johnson, Dr. Geri Bemberg, UAMS

Dr. Bemberg and Dr. Johnson reviewed and made recommendations for the following medications.

A. Ocaliva (obeticholic acid): Dr. Johnson reviewed Ocaliva.

Recommendation: Continue to exclude. B. Linezolid (Zyvox): Dr. Bemberg asked the committee to consider removing the PA requirement from

linezolid 600mg tablets. Within the last 6 months, 19 PAs have been requested, 79% of which have

been approved. There has also been a drop in price for the generic formulation.

Recommendation: Remove PA requirement. Leave at Tier 3 with a quantity limit of 28 tablets/30 days. C. Coreg CR (extended release carvedilol): Dr. Bemberg reviewed Coreg CR.

Recommendation: Due to a lack of superiority data over immediate-release carvedilol, exclude Coreg CR. Other generic beta blockers, immediate-release and extended-release, are available tier 1.

D. Myrbetriq (mirabegron): Dr. Bemberg reviewed Myrbetriq.

Recommendation: Due to lack of superiority over available agents and questionable benefit in terms of adverse events, add to Reference Pricing with other Overactive Bladder medications.


McCook motioned to accept the report. Dr. Thompson seconded; all were in favor.

Motion approved.

III. New Drugs: by Dr. Jill Johnson, UAMS

The committee recommended the proposed coverage for non-specialty additions, specialty additions, non-specialty exclusions, and specialty exclusions.

McCook motioned to approve the non-specialty, specialty additions and exclusions. Dr. Thompson seconded; all were in favor.

Motion approved.

IV. Opioid Discussion: by Committee

Opioid Prescription Recommendations:

New Users of Opioids

1. Acute Pain a. Max MME/day: 50 mmE/day b. Day Supply limit: 7 days for the 1st fill c. “Refill limit” for IR products: 2 more fills of 7 days each d. Further restrictions: PA use >30 days

2. Chronic Pain a. Initial start: PA all new long acting opioid prescriptions b. Max MME/day: 50 mmE/day

Edits will not apply to pain management of malignant disease. Current utilizers will be addressed at a later date.

McCook recommended Dr. Ramon, Pain Specialist, work with the division to offer guidance regarding setting appropriate policy limits on opioids when looking at people already using them.

Dr. Thompson remarked he would not support the requirements for current users until either the Quality of Care or Benefits Committee review the Employee Assistance Program for State and School Employees for quality, coverage, and effectiveness before decreasing limits for those who are chronically addicted.

Dr. Thompson inquired what is chronic pain? Dr. Bemberg commented, of 120 days anyone using immediate release opioids for 90-days would be considered chronic.

Dr. Kumpuris reported the real concern is not individuals becoming addicted. The problem is when someone who is not authorized and allowed access to the medicine. Dr. Kumpuris recommended rewarding those who turn in unused meds.

Dr. Simmons explained dependency are those who will have withdrawals upon discontinuing the medicine, but an addict will continue to use drugs without regard to anything else.

McCook motioned that the Board request the pharmacy team to begin implementing a program no later than September 2017, to control the use of opioids by the members. Dr. Thompson seconded; and amended the motion to add the last two lines of page 4 DUEC report:

o Edits will not apply to pain management of malignant disease. o Current utilizers will be addressed at a later date.

all were in favor.

Motion approved.

Dr. Thompson motioned for the Board to request a formal comment from the Arkansas Medical Society, Arkansas Academy of Family Physicians, Arkansas Academy of Pediatricians, and the Arkansas Pharmacy Association. Harrison seconded; all were in favor.

Motion approved.

Benefits Sub-Committee Report by: Chris Howlett, EBD Executive Director

The following report resulted from a meeting of the Benefits Sub-Committee on April 7, 2017, with Jeff Altemus presiding.

Topics Discussed:

February Financials

ACHI Updates

Trend Experience

Wellness Program

February PSE-ASE Financials: Marla Wallace, EBD Fiscal Officer

Wallace reported the financials for February, 2017 and a brief update for March. Please see the attached report.

ACHI UPDATES: Mike Motley, Elizabeth Whittington, ACHI

Motley reported from 2012 through 2013, there were 487 bariatric procedures for which EBD paid $5.6 million for the surgical procedure (average of approximately $11,600/surgery. At 2 or more Years post-surgery, the average annual cost savings is about $178,000 per year for all beneficiaries ($365/per person per year). Initial eligibility criteria include; BMI of 40 and BMI of 35 or greater with an existing co-morbidity condition.

Whittington reported Bariatric Surgery coverage was mandated via legislation in 2011 as a pilot program (routinely, the EBD Board makes benefit coverage decisions); however, coverage was not included as an essential health benefit under the Affordable Care Act.

Trend Experience: John Colberg, Cheiron

Colberg reported the review of trends shows higher increase in utilization between 2015 and 2016. Allowed trends are the change in medical costs after reflecting PPO discounts, but prior to reflecting amounts paid by participants.

PSE had a sharp decrease in unit cost (cost per service) between 2014 and 2015. In part because of fewer large claims. Trends are based on claims paid through January 31, 2017, plus estimated runout. As actual runout claims become known, the percentages will likely change. Allowed trends are not adjusted for geographic and demographic factors.

Wellness Program Comparison: Chris Howlett, EBD Executive Director

Howlett reported the wellness committee had made positive steps to defining the benefit structure and how it will be developed for the members.

Jayme Mayo, Nabholz Wellness Director, addressed the committee and answered questions and concerns and provided recommendations for the wellness committee.

Senate Bill 522 passed with an effective date of 1/1/2018. It extends the bariatric pilot program to December 31, 2021.

There are several new laws signed at the recent session. Howlett will provide additional detail at a later date.

Howlett reported Dr. Thompson made a recommendation to develop a strong cost structure committee similar to the DUEC committee. The committee will provide recommendations to the Board.

Quality of Care Committee Report by: Elizabeth Whittington, Mike Motley, ACHI

The following report resulted from a meeting of the Quality of Care Sub-Committee on April 11, 2017, with Margo Bushmiaer presiding.

Topics Discussed:

ACHI UPDATES – Mike Motley, Izzy Whittington, ACHI

Bariatric Program

Blue and You-School Challenge

Whittington reported Legislation was filed during 91st General Assembly to continue coverage for the bariatric surgery (Act 927). The Act was amended during legislative process to continue bariatric surgery pilot program

through December 31, 2021. The program requires that costs not exceed $3 million for Arkansas State Employees (ASE) or $3 million for Public School Employees (PSE).

Dr. Thompson recommended to the Board regarding legislative direction to consider up to $3 million for both ASE and PSE plans; that has a direct $6 million impact that the actuarial will need to incorporate in the rates. Also, adopt the Medicare approach eligibility of a BMI over 35 with a co-morbidity, or a BMI of over 40 with unsuccessful medical management for obesity; require prior authorization with the Centers for Excellence, and incorporate a 25% withhold for the hospitals and surgeons.

Dr. Thompson motioned to be consistent with Act 927, recommended:

1. The Board conditionally cover up to $3 million each for both ASE and PSE plans.

2. Utilize Medicare requirements for surgery eligibility (BMI of 35 or higher with co-morbidity or a BMI of 40 or higher with no co-morbidity, as well as unsuccessfully attempted medical weight loss treatment).

3. Require prior authorization for surgery and that the surgery be performed at Center of Excellence.

4. Withhold 25% of provider and hospital pay with payment reconciliation contingent upon completion of all pre-surgery and all post-surgery follow-up requirements.

5. Program components to be specified by EBD prior to implementation.

Harrison motioned to approve Dr. Thompson’s recommendation from the Quality of Care Committee. Boyd seconded; all were in favor.

Motion approved.

Whittington reported there are 59 schools participating in the Blue and You-School challenge.

Wellness Report by: Dr. Joseph Thompson, CEO ACHI

Dr. Thompson reported there is a small but effective group discussing the issue of wellness

benefit and its modification. The committee may solicit feedback from the Board as they

develop the structure of the plan. The discussion included relying on the Health Risk

Assessment and increasing the requirements in some categories. Additional information will

follow as the committee continue to research and build a strategic platform.

Preliminary Rate Projections: by John Colberg, Cherion

Colberg reported based on the actual 2017 enrollment through March and calendar year 2016 claims paid through March 2017. For 2018, likely no increase in participant contributions will be needed for ASE or PSE.

Annual trends of:

6% medical

10% pharmacy

2% expenses

There will probably be no changes to State Contribution amounts, and minimum District contributions will increase consistent with past increases. The wellness participation is 90% for PSE and 88% for ASE. Pharmacy rebates will be 5% of pharmacy claims higher than historical levels. No change to desired contingency reserves. The reserve allocations to reduce contributions remain at 50% for the first year, 30% for the second, and 20% the third year. 1,200 employees migrated from premium for PSE, and 300 for ASE. Medicare eligibility retirees increased 400 per year for PSE and 200 per year for ASE.

Projected Assets 12/31/2017

(In millions $)

PSE 12/31/2016 03/31/2017 Projected12/31/17

Net Assets before IBNR

$136.3 $160.0 $125.0

IBNR Reserve (31.1) (31.1) (31.1)

Reserve for Current and Future Premiums

(29.6) (38.0) (3.8)

Catastrophic Reserve (10.9) (40.5) (40.5)

Net Asset Available $64.7 $50.4 $49.5

ASE 12/31/2016 03/31/2017 Projected 12/31/17

Net Assets before IBNR

$101.0 $107.0 $97.5

IBNR Reserve (29.7) (29.7) (29.7)

Reserve for Current and Future Premiums

(40.1) (34.8) (18.8)

Catastrophic Reserve (10.7) (20.6) (20.6)

Net Asset Available $20.5 $21.9 $28.4

Director’s Report: by Chris Howlett, EBD Executive Director

Dr. Kumpuris commented on the issue: of whether is it legal for the Board to work with Blue Cross or Qualchoice that distributes state funds in a non-uniform transparent way?

Dr. Kumpuris would like to amend his original motion from March 28th Board meeting to state “legal opinion” or “review” from the Attorney General’s Office. Harrison seconded; all were in favor.

Motion approved.

Harrison motioned to amend the request for information that had been previously adopted. Boyd seconded; all were in favor.

Motion approved.

The HHS non-discrimination Mandate 1557 remains in the Texas court.

Howlett reported the division is in the final stages of updating the new legislative bills. Additional information will be provided upon completion.

Howlett reported at the recommendation of Dr. Bemberg, Dr. Brad Martin from UAMS will speak at the May Benefits and Quality of Care meetings.

Harrison motioned to adjourn. Boyd seconded. All were in favor.

Meeting Adjourn.

BASIC

CLASSIC

PREMIUM

PRIMARY

TOTAL

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

238,458$

-$ Receivable from Provider

Due to Federal Government ($44 fee) -$

Accounts Payable 654$

Deferred Revenues -$

Liabilities

Catastrophic Reserve (2016 $10,700,000) (10,700,000)$

Net Assets Available 35,437,190$

Fifth Week of Claims $4,879,419.53

Less Reserves Allocated

Premiums for Plan Year 1/1/17 - 12/31/17 ($7,560,000)


Total Liabilities 26,858,466$

Net Assets 70,887,190$

Premiums for Plan Year 1/1/16 - 12/31/16 ($3,600,000 + $12,600,000) (12,150,000)$

Health IBNR 24,700,000$

RX IBNR 1,800,000$

Due to Cafeteria 2,063$

Due to PSE 355,749$

Accounts Receivable 398,711$

Total Assets 97,745,656$

Due from Cafeteria Plan 5,195,886$

Due from PSE -$

Bank Account 5,786,779$

State Treasury 86,364,280$

BALANCE SHEET

Assets

Net Income/(Loss) (803,892)$ 7,537,717$

Total Expenses 25,698,735$ 66,627,414$

RX Administration 214,855$ 639,034$

Plan Administration 289,418$ 975,530$

RX Claims 7,568,151$ 19,650,121$

RX IBNR -$ -$

Employee Assistance Program (EAP) 55,379$ 166,139$

Pharmacy Expenses

Life Insurance 79,490$

Medical Administration Fees 1,114,779$ 3,298,963$

Refunds -$ -$

Claims Expense 16,376,663$ 41,659,170$

Claims IBNR -$ -$

Expenses

Medical Expenses

Total Funding 24,894,843$ 74,165,131$

Allocation of Reserves 1,350,000$ 4,050,000$

Employee Contribution 7,976,701$ 23,986,330$

Other 874,050$ 2,047,953$

REVENUES & EXPENDITURES

Funding

Current

Month

Year to Date

(3 Months)

State Contribution 14,694,092$ 44,080,848$

11928 12366

26464 2473 9110 38047 45941 3351 11928 61220

215 9110 9325 438

2926

23523 2167 25690 41025 2785 43810

1694 64 1758 2839 87

(7,560,000)$

(5,040,000)$

Arkansas State Employees (ASE) Financials - January 1, 2016 through March 31, 2016

EMPLOYEE ONLY EMPLOYEE + DEPENDENTS

ACTIVES RETIREES MEDICARE TOTAL ACTIVES RETIREES MEDICARE TOTAL

1247 27 1274 2077 41 2118

BASIC

CLASSIC

PREMIUM

PRIMARY

TOTAL

1

2

3

4

5

6

7

8

9

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

-$ Receivable from Provider



Deferred Revenues 3,780$

Due from Cafeteria Plan 5,018,599$

BALANCE SHEET


Premiums for Plan Year 1/1/17 - 12/31/17 ($7,560,000 +13,770,000)

Premiums for Plan Year 1/1/18 - 12/31/18 ($5,040,000 + 8,262,000)


Premiums for Plan Year 1/1/19 - 12/31/19 ($5,508,000) (5,508,000)$

236,093$

Net Assets 77,262,072$


RX IBNR 1,700,000$





Due to Cafeteria 2,390$

Due to PSE 183$

Accounts Receivable 660,927$


Liabilities

Due from PSE -$



Assets

Net Income/(Loss) 495,488$ 11,287,290$

Total Expenses 24,427,869$ 64,013,909$


RX Claims 7,465,105$ 18,582,653$

RX IBNR -$ -$


Pharmacy Expenses

Life Insurance 79,045$


Refunds 52$ 1,070$

Claims Expense 15,476,137$ 40,582,156$

Claims IBNR -$ -$

Expenses

Medical Expenses

Total Funding 24,923,357$ 75,301,199$



Other 373,683$ 1,625,861$


Funding

Current

Month

Year to Date

(3 Months)

State Contribution 14,655,732$ 43,965,768$

12422 12838

26254 2487 9519 38260 44968 3323 12422 60713

200 9519 9719 416

3289

22803 2174 24977 39337 2752 42089

1920 71 1991 3192 97

(15,997,500)$

(13,302,000)$

Arkansas State Employees (ASE) Financials - January 1, 2017 through March 31, 2017


ACTIVES RETIREES MEDICARE TOTAL ACTIVES RETIREES MEDICARE TOTAL

1531 42 1573 2439 58 2497

BASIC

CLASSIC

PREMIUM

PRIMARY

TOTAL

1

2

3

4

5

6

7

8

9

10

11

12

13

14

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

33

32

34

35

Premiums for Plan Year 1/1/16 - 12/31/16 ($9,600,000 + $20,000,000 DOE + 18,100,000 DOE)



(35,775,000)$

(5,760,000)$

(3,840,000)$




1,937,231$

Medical Expenses

Public School Employees (PSE) Financials - January 1, 2016 through March 31, 2016

Per Participating Employee Funding (PPE Funding) 8,195,088$ 24,572,576$



Funding

Current

Month

Year to Date

(3 Months)


Total Funding 25,582,376$ 79,727,882$

Department of Education $35,000,000 & $15,000,000 & Other Funding 3,181,818$

Claims IBNR -$ -$


13,295,455$

Other 925,809$

Claims Expense 17,306,177$ 47,122,413$

Expenses

Pharmacy Expenses

RX Claims 4,716,812$ 11,774,313$

Refunds -$ -$


Plan Administration 448,980$ 1,441,963$

Total Expenses 24,539,852$ 66,461,164$

RX IBNR -$ -$


BALANCE SHEET

Net Income/(Loss) 1,042,524$ 13,266,718$

Receivable from Provider -$

Accounts Receivable 4,276,530$

Due from ASE 355,749$

Assets



1,400,000$


Due to ASE -$



Liabilities

3196 231 3427 4798 291 5089

ACTIVES RETIREES MEDICARE TOTAL ACTIVES RETIREES MEDICARE

20642 25336 1087 26423

21990 1850 23840 40840 2245


11649 11821

44819 3176 10675 58670 70974 3795 11649 86418

86 10675 10761 172

43085

19633 1009

Premium Assistance (FICA Savings) (1,471,149)$



Net Assets 104,048,343$



RX IBNR

TOTAL

BASIC

CLASSIC

PREMIUM

PRIMARY

TOTAL

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15 Less DOE Allocation

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

(18,100,000)$

183$

1,100,000$


Due to ASE -$



Liabilities

Premiums for Plan Year 1/1/17 - 12/31/17 ($5,760,000+$20,000,000 + $18,100,000 DOE)


(34,129,091)$

(3,840,000)$




Premium Assistance (FICA Savings) (1,549,731)$

9,730,909$

Total Funding 25,470,031$ 96,741,198$

Department of Education $35,000,000 & $15,000,000 & Other Funding 3,181,818$

Public School Employees (PSE) Financials - January 1, 2017 through March 31, 2017

Per Participating Employee Funding (PPE Funding) 8,234,324$ 24,688,765$



Funding

Current

Month

Year to Date

(3 Months)

3873 336 4209 5808 415 6223

ACTIVES RETIREES MEDICARE TOTAL

Claims IBNR -$ -$


31,395,455$

Other 600,593$

Claims Expense 16,955,464$ 45,476,819$

Expenses

1,871,525$

Medical Expenses

Allocation of Reserves 3,792,121$

Pharmacy Expenses

RX Claims 4,456,229$ 11,202,832$

Refunds -$ -$



Total Expenses 23,334,199$ 63,379,218$

RX IBNR -$ -$


2,135,832$ 15,261,980$

Receivable from Provider -$

Accounts Receivable 3,023,626$

Assets





22942 1947 24889 43062 2341

45399 3137 11479 60015 73133 3741 12512 89386

Due from ASE

BALANCE SHEET

Net Income/(Loss)


45403

18584 779

ACTIVES RETIREES MEDICARE

19363 24263 835 25098

12512 1266275 11479 11554 150



Net Assets 128,858,176$

TOTAL

RX IBNR

1 | P a g e D U E C R E P O R T - 0 4 / 0 3 / 1 7

State and Public School Life and Health Insurance Board Drug Utilization and Evaluation Committee Report

The following report pertains to a meeting of the DUEC on April 3, 2017 with Dr. Hank Simmons presiding.

I. Delivery Coordination Workgroup Report: by Dr. Geri Bemberg, UAMS

Dr. Bemberg gave an update and recommendation of medications reviewed by the DCWG Group.

Current Coverage Proposed Coverage

Multiple Myeloma

Revlimid (lenalidomide) Tier 4 PA No change, tier 4 PA

Velcade (bortezomib) Covered medical No change, cover medical

Empliciti (elotuzumib) Covered, medical PA No change, cover medical PA

Darzalex (daratumumab) Excluded Cover, medical PA

Kyprolis (carfilzomib) Excluded Cover, medical PA

Ninlaro (ixazomib) Excluded Continue to exclude

Pomalyst (pomalidomide) Excluded Continue to exclude

Farydak (panobinostat) Excluded Continue to exclude


II. 2nd review of Drugs: by Dr. Jill Johnson, Dr. Geri Bemberg, UAMS Dr. Bemberg and Dr. Johnson reviewed and made recommendations for the following medications. A. Ocaliva (obeticholic acid): Dr. Johnson reviewed Ocaliva.

Recommendation: Continue to exclude. B. Linezolid (Zyvox): Dr. Bemberg asked the committee to consider removing the PA requirement

from linezolid 600mg tablets. Within the last 6 months, 19 PAs have been requested, 79% of which have been approved. There has also been a drop in price for the generic formulation. Recommendation: Remove PA requirement. Leave at Tier 3 with a quantity limit of 28 tablets/30 days.

C. Coreg CR (extended release carvedilol): Dr. Bemberg reviewed Coreg CR. Recommendation: Due to a lack of superiority data over immediate-release carvedilol, exclude Coreg CR. Other generic beta blockers, immediate-release and extended-release, are available tier 1.

D. Myrbetriq (mirabegron): Dr. Bemberg reviewed Myrbetriq. Recommendation: Due to lack of superiority over available agents and questionable benefit in terms of adverse events, add to Reference Pricing with other Overactive Bladder medications.


2 | P a g e D U E C R E P O R T - 0 4 / 0 3 / 1 7

III. New Drugs: by Dr. Jill Johnson, UAMS Dr. Jill Johnson reported on new drugs. The review covered products released December 5, 2016 – February 27, 2017. A. Recommended Additions

1. Nonspecialty Medications

BRAND NAME

GENERIC NAME PRICING (AWP) INDICATION SIMILAR THERAPIES ON FORMULARY

DUEC VOTE

Trulance Plecanatide 3mg $14.14/tab

Chronic idiopathic constipation

Some laxative available OTC. Rx enemas and laxatives available on formulary (generic Tier 1)

T3PA, QL 1/1. Also add QL to Linzess & Amitiza

B. Recommended Exclusions 1. Nonspecialty Medications

BRAND NAME


DUEC VOTE

Adlyxin Lixisenatide 20mcg/0.2ml; 10 & 20 mcg/0.2ml (Starter pack)

$334.32

Type 2 DM Victoza & Byetta Tier 3PA (Category in process of rebate)

Exclude, code 1

Soliqua Insulin glargine/lixisenatide 100-33/ml

$152.40 Type 2 DM Insulin and GLP-1 covered separately

Exclude, code 1. Revisit in 6 months

Photrexa Viscous

Riboflavin 5-Phos/20% Dextran

Corneal extasia following refractive surgery

Exclude pharmacy & medical until pricing info available.

Alevicyn Plus E101-Namg FI-NaPh-NaCI-Ha-NAH

$282/pkg Exclude, code 3

Eucrisa Crisaborole 2% $696/pkg Atopic dermatitis Several topical agents available at Tier 1 for generic and Tiers 2 and 3 for brands

Exclude, code 13

Ticalast Azalastine-Fluticasone-Sodium Chloride 137-50-0.9

$4,113.31/pkg Seasonal allergic rhinitis

Azelastine, flunisolide, fluticasone available Tier 1

Exclude, code 13

Phlag Spray Palm Oil/Eucalyptus Oil

$96.35/bottle Exclude, code 3

Daxbia Cephalexin 333mg $11.40/tab Multiple types of infection

Generic cephalexin caps, tabs, & oral suspension all available Tier 1 (Price $0.22 - $4.01 each); 750mg caps $7.25 each

Exclude code 13

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BRAND NAME


DUEC VOTE

Ryvent Carbinoxamine maleate 6mg

$4.74/tab Allergies Carbinoxamine 4mg tabs – tier 1 ($0.78 each)

Exclude, code 13

2. Specialty Medications BRAND NAME

GENERIC NAME PRICING (AWP)

INDICATION SIMILAR THERAPIES ON FORMULARY

DUEC VOTE

Zinplava Bezlotoxumab 1000mg/40ml

$4,560/vial

Adjunctive therapy for C. dif

Exclude, code 1

Rubraca Rucaparib camsylate 200mg, 300mg

$137.40/tab Advanced ovarian cancer

Covered antineoplastic meds-Tier 4

Exclude, code 1, code 8

Spinraza Nusinersen 12mg/5ml $150,000/vial Spinal muscular atrophy

Table. Reconsider in 6 months, waiting for additional data

Auvi-Q Epinephrine 0.15mg/0.15ml;0.3mg/0.3ml

$5400/pkg of 2

Anaphylaxis Epinephrine generic – tier 2QL Adrenaclick -Tier 3QL

Exclude, code 13

Emflaza Deflazacort 6mg, 18mg, 30mg, 36mg tabs; $22.75mg/ml oral suspension

$294/tab; $298/ml

Duchenne muscular dystrophy

Exclude, code 13

Triferic Ferric Pyrophosphate Citrate 272mg powder packs

$230.40/pack Iron replacement in hemodialysis-dependent patients

Multiple iron replacement options available

Exclude from pharmacies and infusion centers, code 13. Allow through medical.

The committee recommended the proposed coverage for non-specialty additions, specialty additions, non-specialty exclusions, and specialty exclusions.

III. Opioid Discussion: by Committee Opioid Prescription Recommendations: New Users of Opioids

1. Acute Pain a. Max MME/day: 50 mmE/day b. Day Supply limit: 7 days for the 1st fill c. “Refill limit” for IR products: 2 more fills of 7 days each d. Further restrictions: PA use >30 days

2. Chronic Pain

a. Initial start: PA all new long acting opioid prescriptions b. Max MME/day: 50 mmE/day

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Edits will not apply to pain management of malignant disease. Current utilizers will be addressed at a later date.

IV. EBD Report: by Dr. Geri Bemberg, UAMS Dr. Bemberg reported Dr. Golden requested a list complaints received by the Employee Benefits Division (EBD). The following drugs have received complaints in February and March:

- Bydureon - Orkambi

- Daliresp - Praluent

- Kyprolis - Repatha

- Lonsurf - Tecentriq

- Ninlaro - Trintellix

- Novolin - Voltaren

Respectfully submitted,

Dr. Hank Simmons, Chair, DUEC *New Drug Code Key:

1 Lacks meaningful clinical endpoint data; has shown efficacy for surrogate endpoints only.

2 Drug’s best support is from single arm trial data

3 No information in recognized information sources (PubMed or Drug Facts & Comparisons or Lexicomp)

4

Convenience Kit Policy - As new drugs are released to the market through Medispan, those drugs described as “kits will not be considered for inclusion in the plan and will therefore be excluded products unless the product is available solely as a kit. Kits typically contain, in addition to a pre-packaged quantity of the featured drug(s), items that may be associated with the administration of the drug (rubber gloves, sponges, etc.) and/or additional convenience items (lotion, skin cleanser, etc.). In most cases, the cost of the “kit” is greater than the individual items purchased separately.

Medical Food Policy - Medical foods will be excluded from the plan unless two sources of peer-reviewed, published medical literature supports the use in reducing a medically necessary clinical endpoint.

A medical food is defined below:

5

A medical food, as defined in section 5(b)(3) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)), is “a food which is formulated to be consumed or administered eternally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” FDA considers the statutory definition of medical foods to narrowly constrain the types of products that fit within this category of food. Medical foods are distinguished from the broader category of foods for special dietary use and from foods that make health claims by the requirement that medical foods be intended to meet distinctive nutritional requirements of a disease or condition, used under medical supervision, and

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intended for the specific dietary management of a disease or condition. Medical foods are not those simply recommended by a physician as part of an overall diet to manage the symptoms or reduce the risk of a disease or condition, and all foods fed to sick patients are not medical foods. Instead, medical foods are foods that are specially formulated and processed (as opposed to a naturally occurring foodstuff used in a natural state) for a patient who is seriously ill or who requires use of the product as a major component of a disease or condition’s specific dietary management.

6

Cough & Cold Policy - As new cough and cold products enter the market, they are often simply re-formulations or new combinations of existing products already in the marketplace. Many of these existing products are available in generic form and are relatively inexpensive. The new cough and cold products are branded products and are generally considerably more expensive than existing products. The policy of the ASE/PSE prescription drug program will be to default all new cough and cold products to “excluded” unless the DUEC determines the product offers a distinct advantage over existing products. If so determined, the product will be reviewed at the next regularly scheduled DUEC meeting.

7

Multivitamin Policy - As new vitamin products enter the market, they are often simply re-formulations or new combinations of vitamins/multivitamins in similar amounts already in the marketplace. Many of these existing products are available in generic form and are relatively inexpensive. The new vitamins are branded products and are generally considerably more expensive than existing products. The policy of the ASE/PSE prescription drug program will be to default all new vitamin/multivitamin products to “excluded” unless the DUEC determines the product offers a distinct advantage over existing products. If so determined, the product will be reviewed at the next regularly scheduled DUEC meeting.

8 Drug has limited medical benefit &/or lack of overall survival data or has overall survival data showing

minimal benefit

9 Not medically necessary

10 Peer -reviewed, published cost effectiveness studies support the drug lacks value to the plan.

11

Oral Contraceptives Policy - OCs which are new to the market may be covered by the plan with a zero dollar, tier 1, 2, or 3 copay, or may be excluded. If a new-to-market OC provides an alternative product not similarly achieved by other OCs currently covered by the plan, the DUEC will consider it as a new drug. IF the drug does not offer a novel alternative or offers only the advantage of convenience, it may not be considered for inclusion in the plan.

12 Other 13 Insufficient clinical benefit OR alternative agent(s) available

EBD Quality of Care Subcommittee (QoC) Report April 11, 2017 Meeting

Mike Motley and Izzy Whittington, Arkansas Center for Health Improvement

Bariatric Surgery Program Analysis/Presentation Recap:

During this month’s QoC meeting, ACHI provided the second phase of an analyses on the EBD bariatric program

As a reminder, bariatric surgery coverage was mandated via legislation in 2011 as a pilot

program (routinely, the EBD Board makes benefit coverage decisions); however, coverage

was not included as an essential health benefit under the Affordable Care Act

o SB 522 was filed during this session to continue coverage for morbid obesity/bariatric

surgical procedures as an extension of the pilot program through 2021

Reviewed previous analyses discussed during March meeting:

o Patient demographics of the 775 participants (gender, member type (primary vs.

non-primary), plan type (ASE vs. PSE), age)

o Bariatric surgery volume and cost for each year of program (2012—2016)

o Changes in BMI post-surgery for 2012-2013 cohort with available 2015 HRA data

(Above BMI 35 = 30%, between 30 and 35 = 33%, below 30 = 37%)

o Pre and post-surgery cost impact; Approximately $365 in savings 12-24 months after

surgery date for 2012-2013 cohort

Phase two analysis from April meeting:

o Page 11: Reviewed bariatric surgery procedure types from 2012-2016 with EBD

patient population; Gastric banding becoming less prevalent (11% in 2012 vs. 0% in

2016), Sleeve gastrectomy becoming more prevalent (23% in 2012 vs. 37% in 2016),

Gastric bypass holding steady across program years (65% in 2012 vs. 61% in 2016)

o Page 12-13: Using Arkansas All-Payer Claims Database information from 2013-

2015, EBD members comprise 15% of privately insured population

However, EBD has paid for 57% of bariatric surgeries within the APCD

privately insured population

o Page 14: Inpatient readmissions after bariatric surgery (30 day all-cause

readmissions):

EBD: 2%

National: 4.9%

Tennessee episode program: 5.1%

o Page 15: Emergency room visits after bariatric surgery (30 day all-cause):

EBD: 9%

National: 11.3%


o Page 16: Mortality rates for bariatric surgery patients (30 day):

EBD: 0.12%

National: 0.13%


o Page 17: Reviewed impact of surgery on diabetes medication usage after surgery;

Looked at cohort of 194 patients approximately 4 years before and after surgery

date:

85/194 on medication prior to surgery (43%)

41/194 on medication after surgery (21%)

o Page 18-21: Discussed bariatric Centers of Excellence model and accreditation

process; Reviewed studies comparing the outcomes of surgeries taking place at

these centers vs. non-accredited

Discussed Medicare’s decision to not require surgeries to be performed at

Centers of Excellence

o Page 22: Using available hospital discharge data, reviewed information for 591

surgeries taking place within the EBD population

Found that a majority of surgeries are already being performed at Centers of

Excellence (580), with 11 being performed at non-accredited centers

o Group discussed recommendation from Dr. Thompson:

Conditionally cover up to $3 million each for ASE and PSE plans

Utilize Medicare requirements for surgery eligibility (BMI of 35 or higher with

comorbidity or a BMI of 40 or higher with no comorbidity, as well as having

unsuccessfully attempted medical weight loss treatment)

Require prior authorization for surgery and that the surgery be performed at

Center of Excellence

Withhold 25% of provider and hospital pay with payment reconciliation

contingent upon completion of all pre-surgery and all post-surgery follow-up

requirements

Program components to be specified by EBD

o Additional requests:

Board member requested a map of bariatric surgery recipients with state’s

Centers of Excellence included (to determine potential access issues)

Also discussed opportunities for utilizing intensive behavioral therapies as

another option for obesity treatment/concurrent piece of bariatric surgery

program; Will provide another map of where registered dieticians with

additional certifications in adult weight counseling are available in the state

Blue and You-School Challenge Update:

54 schools and school districts are still participating in challenge (3 dropouts after end of March)

Blue and You posts Leaderboard on their website—https://secure.blueandyoufitnesschallenge-ark.com/index.aspx

Completing 30 Checkpoints:

Small – Central Elementary (100%)

Medium— Lamar Middle School in Lamar, AR (95.65%)

Large—Drew Central School District in Monticello, AR (85.42%)

Percentage Participating:

Small—Rena Rockets, Rena Elementary School in Van Buren, AR (86.67%)

Medium—Lamar Middle School in Lamar, AR (90%)

Large—Northside Elementary in Cabot, AR (78.69%)

https://secure.blueandyoufitnesschallenge-ark.com/index.aspx

EBD Bariatric Surgery

Program Assessment:

Phase Two

Mike Motley, MPH

Assistant Health Policy Director

Elizabeth Whittington, MPA

Policy Analyst

April 2017

Objectives for Presentation:

•Review prior analyses from March 2017

meeting

•Assess readmissions and ER visits

following bariatric surgery

•Evaluate impact of bariatric surgery on

diabetic medication use

•Review background and requirements

for bariatric Centers of Excellence

1

2017 Bariatric Surgery Legislation

•Legislation filed during 91st General

Assembly to continue coverage for

bariatric surgery (Act 927)

•Amended during legislative process to

continue bariatric surgery pilot

program through December 31, 2021

•Requires that costs for program not

exceed $3,000,000 for ASE or

$3,000,000 for PSE

2

Bariatric Surgery Legislation

• Provision of legislation allows for EBD

Board to discontinue program:

• “The State and Public School Life and

Health Insurance Board may discontinue

or suspend a plan option offered under

subsection (a) of this section if the board

determines adjustments are necessary to

ensure the financial soundness and

overall well-being of the State and Public

School Life and Health Insurance

Program.”

3

Bariatric Surgery: Background

• Demonstrated to be effective at achieving

weight loss and improving coexisting

conditions

• Essential components of program:

–Intensive behavioral management before

referral for surgery

–Multidisciplinary team approach (bariatric

specialist, psychologist/psychiatrist,

nutritionist, etc.)

–Post-surgery care including ongoing weight

monitoring, review of dietary changes, and

assessment of coexisting conditions

4

Prior Analyses on EBD

Bariatric Surgery Program

5

EBD Bariatric Surgery Patient Demographics

Gender

Female 638

Male 137

Total 775

Age Group

<=35 108

36-45 237

46-55 259

56-65 146

>65 25

Total 775

Plan

ASE 362

PSE 413

Total 775

Member

Primary 691

Non-

Primary

84

Total 775

6

EBD Bariatric Surgery Volume and Cost

Year Number of

Procedures

Total Amount Paid By Plan for Surgery

Admission

2012 189 $2,144,633

2013 298 $3,516,403

2014 181 $2,301,193

2015 48 $481,850

2016 59 $622,782

Total 775 $9,057,960

*Surgery window includes triggering hospital stay and one day prior to that hospital admission.

7

Changes in BMI Post Surgery

•2015 BMI Data for 2012-2013 cohort of 282

patients with available 2015 HRA data

•Distribution:

•Above 35 BMI = 86 (30%)

•Between 30 and 35 BMI = 92 (33%)

•Below 30 BMI = 104 (37%)

8

Pre/Post-Surgery Costs

• 2012-2013 cohort: 487 patients

• Average surgery cost: $11,624

$5,363

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

12-24 Months Before 1-12 Months Before 1-12 Months After 12-24 Months After

$3,964

$4,763

$3,599

Surgery

Date

9

Phase Two Analyses on EBD

Bariatric Surgery Program

10

Bariatric Surgery Procedures from 2012-2016

*BDPB procedure excluded for low percentage of surgeries across all years.

11% 9% 2% 4%

23% 27%35%

40%

37%

65% 63% 61%56%

61%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2012 2013 2014 2015 2016

Adjustable Gastric Banding Sleeve Gastrectomy Gastric Bypass

11

Total Enrollment for Private Carriers in AR

(2013-2015)

• EBD members comprise 15% of Arkansas

privately insured (All-Payer Claims Database

data)

1,480,229

228,079

Other Private Carriers EBD

85%

15%

12

Bariatric Surgeries Paid by Private Payers (2013-

2015)

483

642

Other Private Carriers EBD

57%

43%

13

Inpatient Readmissions after Bariatric Surgery

• 30 Day all-cause readmission rates:

–EBD bariatric surgery patients: 2%

–National: 4.9%*

–Tennessee episode program: 5.1%

(Some readmissions could be associated with

events not related to bariatric surgery)

*Chen, et. al. “Assessment of post-discharge complications after bariatric surgery: A

National Surgical Quality Improvement Analysis”, Bariatrics, 2015 Sep;158(3):777-86. doi:

10.1016.

14

https://www.ncbi.nlm.nih.gov/pubmed/26096563

Emergency Department Visits After Bariatric

Surgery

• 30 Day all-cause ER visit rates:

–EBD bariatric surgery patients: 9%

–National: 11.3%*

–Tennessee episode program: 11.9%

(Some visits could be associated with events

not related to bariatric surgery)

*Telem, D.A. et. al. “Rates and risk factors for unplanned emergency department utilization and

hospital readmission following bariatric surgery”, Annals of Surgery, 2016 May;263(5):956-60. doi:

10.1097

15

https://www.ncbi.nlm.nih.gov/pubmed/26727087

30-day Mortality Rates for Bariatric Surgery

Patients

• EBD: 0.12%

• ASMBS Bariatric Centers of Excellence

Database: 0.13%*

• Tennessee episode program: 0.0%

(Of all EBD bariatric surgery patients through

2016, only 1 individual died within 30 days of

surgery)

*American Society for Metabolic and Bariatric Surgery (ASMBS), “Bariatric Surgery

Misconceptions”. Accessed April 10, 2017. Retrieved from https://asmbs.org/patients/bariatric-

surgery-misconceptions

16

https://asmbs.org/patients/bariatric-surgery-misconceptions

Impact of Bariatric Surgery on Diabetes

Medication Usage

• 194 EBD bariatric surgery recipients 4 years

before and after surgery

• On medication prior to surgery = 85/194

(43%)

• On medication after surgery = 41/194 (21%)

• 51% decrease in number of patients who are

taking diabetes medication, suggesting

improved control of condition

17

Centers of Excellence

• Metabolic and Bariatric Surgery

Accreditation and Quality Improvement

Program (MBSAQIP)

–Joint accreditation from the American College

of Surgeons and American Society for

Metabolic and Bariatric Surgery

• Accreditation based on surgery volume,

surgeon experience, data collection, and

other key quality indicators

–MBSAQIP Standards Manual

18

https://www.facs.org/~/media/files/quality programs/bariatric/mbsaqip standardsmanual.ashx

In-Hospital Mortality: Centers of Excellence vs

Other

2012 study*

Accredited: 0.06%

Non accredited: 0.21%

2013 study**

Accredited: 0.08%

Non-accredited: 0.19%*

*Nguyen, N.T. et al. “Outcomes of Bariatric Surgery Performed at Accredited vs

Nonaccredited Centers”, Journal of the American College of Surgeons, October 2012;

Volume 215, Issue 4, 467-474

**Gebhart, A. et. al. “Impact of accreditation in bariatric surgery’, Surgery for Obesity and

Related Diseases, 10 (2014), 767-773

19

http://www.journalacs.org/article/S1072-7515(12)00440-1/fulltext

http://asmbs.org/wp/uploads/2014/05/Oct-Nov-article.pdf

Medicare Coverage of Bariatric Surgery

• 2006

–BMI ≥ 35, at least one co-morbidity, and had

unsuccessful medical treatment for obesity

–When performed at Bariatric Center of

Excellence (ASBCOE)

• 2010 providers argued access may be

hindered; appealed to CMS to drop COE

requirement

• 2013 CMS no longer requires that bariatric

surgeries be performed in certified facilities

20

Michigan Bariatric Study (2010)

•No significant difference in COE vs. non-

COE facilities rates of serious

complications

•Other CMS-reviewed studies had similar

conclusions

*Birkmeyer N.J., et al. “Hospital Complication rates with Bariatric Surgery”, JAMA. 2010;

304(4):435-442.

21

http://jamanetwork.com/journals/jama/fullarticle/186297

EBD Bariatric Procedure Breakdown by Facility

• Asterisk denotes facilities which have been

accredited as Centers of Excellence

Facility Name Location Number of

Procedures

Baptist Health Medical Center* Little Rock, AR 357

Northwest Medical Center

Springdale*

Springdale, AR 218

Northwest Health Physicians’

Specialty Hospital*

Fayetteville, AR 4

NEA Baptist Memorial Hospital* Jonesboro, AR 1

Other N/A 11

Total N/A 591

*Includes only Health Data Initiative available hospital discharge data.

22

Next Steps

•Further consideration of EBD bariatric

program by Quality of Care

Subcommittee

•Develop recommendations to track

program efficacy and patient outcomes

moving forward

•Revisit Centers of Excellence

requirement

•Additional items?

23

agenda - arkansas · 2017. 11. 7. · recalculated catastrophic reserve is $40.5 million. net...

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