Formulary Management: Prior Authorization Process

C. Bernie Good Pharmacy Benefits Management ServicesJeanne Tuttle VA Central Office

March 2014, Informatics Call

VETERANS HEALTH ADMINISTRATION

Background• At the recommendation of the Health Delivery

Committee (HDC), an interdisciplinary Pharmaceutical Cost Proposal(s) Taskforce was formed to examine options to prospectively address how VA can continue to provide access to costly drugs while ensuring the pharmacy benefit is sustainable well into the future.

• HDC, NLC approval, signed EDM.• Evolve the National Formulary to include “Prior

Authorization”

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VETERANS HEALTH ADMINISTRATION

Formulary Evolution

• Formulary decisions will still be made by the MAP/VPEs

• Prior Authorization is new formulary designation – formalizes process for criteria for use

• Prior authorization reviews may take place at National, VISN or Facility Level

• Designations on the posted formulary will be PA-N, PA-V and PA-F

• Implementation will be staged3

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New drug – MAP/VPE Discuss Evidence and Vote

Formulary

Formulary With Criteria

Non-Formulary

Non-Formulary with Criteria

Field Implementation

Current Process

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New drug – MAP/VPE Discuss Evidence and Vote

Formulary Non-Formulary

Non-Formulary with Criteria

Formulary – National Prior

AuthFormulary –

VISN Prior Auth

Future Process

Formulary With Criteria

Field Implementation

VETERANS HEALTH ADMINISTRATION

Prior Authorization Considerations

• Cost• Volume• Marginal clinical benefit• Narrow spectrum of safety • Special significance to the mission of the VA (to

ensure access to all veterans)• Subject matter experts

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VETERANS HEALTH ADMINISTRATION

Benefits of Centralized Approach

• Supported by field clinicians– These can be very difficult and sometimes emotional

decisions and there is support to have them made centrally• Decisions will be made objectively and will be evidence-

based• Less chance for inappropriate denials due to cost • Promotes positive relationships between local prescribers

and formulary managers (reduced policing/gate keeping tensions)

• Decreases the administrative burdens that would be necessary to replicate these processes across all 21 VISNs

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VETERANS HEALTH ADMINISTRATION

Benefits of Centralized Approach

• Leverages the practices a small number of VISNs have been able to implement and extends them to the entire enterprise

• Improves ability to gather cost and patient outcome data at a national level which will can be used to determine value based decisions going forward– Specifically, can better accommodate a “coverage with

evidence-development” scheme for particular drugs of interest

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VETERANS HEALTH ADMINISTRATION

**DRAFT** National Prior Authorization Process

• Inter-facility consults– Existing technology, provider and informatics staff

familiarity– Located under a CPRS screen that ensures high visibility for

providers – e.g. IFC section of CPRS and/or drug consults menus.

– Keeps documentation within the EMR

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VETERANS HEALTH ADMINISTRATION

Inter-facility Consults

• Consult template developed nationally based on MAP/VPE criteria determinations and sent out as TXML file

• Facility level consult set-up and drug file management• Hines VA is the receiving facility• Expectation for turn around is 96 hours in alignment

with requirements for non-formulary reviews (VHA Handbook 1108.08)

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VETERANS HEALTH ADMINISTRATION

Inter-facility Consult Set-up

Pharmacy ADPAC and CAC will need to work together on local set-up• Simultaneous notification to local pharmacy, Chief of

staff and National Reviewers when consult placed• Creation of any associated drug quick orders or

“hiding” drug in CPRS alpha list• Placement on menus (e.g. IFC menu, drug consult

menu, etc.)– Menu structure different across facilities

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VETERANS HEALTH ADMINISTRATION

Menu Placement

• In deciding consider… Menu intuitive to providers – engage providers in

decision Facility Culture Teaching vs Non-Teaching Facility Additional provider training/education needed

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VETERANS HEALTH ADMINISTRATION

Example Consult Menus

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All drug consults on same menu separated by inpatient and outpatient

Example 2:

Placement choices: Use existing drug classification scheme ORCreate a new menu “Prior Authorization Medications”

Prior Authorization Requests:

Example 3: Using the “Alpha list”

Prior Authorization Requests:

Placement choices: 1. Existing Meds Outpatient – provider receives an alert with quick order 2. Add new category “Meds Prior Authorization Request “ to house new and future requests

Meds Prior Authorization

This is a “Prior Authorization medication!Please complete the Prior Authorization request before ordering or contact pharmacy.

311 < LMNOP> PA

LMNOP

VETERANS HEALTH ADMINISTRATION

Drug File Management

• Drug File Management for Non-Formulary and Criteria For Use medications varies widely across facilities, therefore a standardized process for handling PA medications will not be mandated

• Chief should ensure strong processes are in place that ensures prescriptions will not be processed until the prior authorization request is approved

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VETERANS HEALTH ADMINISTRATION

Drug File Management Considerations

• Populate the message field of national prior authorization medications with “National Prior Auth Consult required”

• Create a place holder entry (in addition to the actual drug) in the drug file that is not matched to the NDF of an orderable item and contains information to direct the provider to the consult location. See additional presentations– Thank-you to George Knight, VISN 2 VPE and Jennifer Yahnian,

Pharmacy Information Manager/ADPAC VA Central California HCS (Fresno)

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VETERANS HEALTH ADMINISTRATION

Drug File Management Considerations

• Mark the actual drug entry so that it does not appear in the alpha list for providers to order and use a quick order associated with the consult or have the pharmacist enter the prescription through the appropriate Pharmacy VistA package once the consult is approved

• Develop a standardized process and educate staff on how to manage prescription orders in the pending file for national prior authorization medications prior to approval

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VETERANS HEALTH ADMINISTRATION

Communication• Mailgroup established to facilitate communication:

VHAPBH Prior Authorization National• POC in PBM phone directory - Recommend populate

with Outlook Mailgroup– Heads up on drugs requiring special ordering– Help with requests for additional information if provider not

responding– Notification of adjudication results– Request for facilities to populate sent to VPEs 2/13

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VETERANS HEALTH ADMINISTRATION

Assessment of Outcomes

• Timeliness of response. These reports will include IFC entry and response dates, appeals, consult type and outcome of request.

• Prescription Processing. Prescriptions dispensed to the facility prior to consult review and adjudication. Will monitor fills without a consult.

• Patient Outcomes. In collaboration with local facility, will track patient response and adverse events to drug therapy and report quarterly to MAP and VPEs.

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YOUR INSIGHTS AND THOUGHTS?