state of california department of health care services · 9/17/2019 · global medi-cal drug use...

GLOBAL MEDI-CAL DRUG USE REVIEW (DUR) BOARD MEETING AGENDA

State of California DEPARTMENT OF HEALTH CARE SERVICES

Notice is hereby given that the Global Medi-Cal DUR Board will conduct a public meeting on Tuesday, September 17, 2019, at the following location:

Department of Health Care Services 1700 K Street

1st Floor Conference Room Sacramento, CA 95814

9:30 AM-3:00 PM All times shown are approximate and are subject to change

Registration link to attend meeting via webinar

Report Type* Agenda Item Presenter Time

C 1. Welcome/Announcements/Introductions/Roll Call Pauline Chan, RPh, MBA 930-940

I/D 2. Call to Order/Guidelines/Robert’s Rules Randall Stafford, MD, PhD 940-945

R/A/D 3. Review and Approval of Previous Minutes from May 21, 2019

Randall Stafford, MD, PhD 945-950

4. Old BusinessI/D a. Review of Board Action Items from May 21, 2019

b. Recommended Action Items for MCPs from May 21,2019

Pauline Chan, RPh, MBA 950-1000

5. New BusinessR/A/D a. Presentation: Aligning Quality Measurement Across

ProgramsLinette Scott, MD, MPH 1000-

1030 R/A/D b. Health Plan Presentations by CalOptima:

i. Promoting Pharmacist-Furnished Naloxone: ATool Kit for Community Pharmacy

ii. Pharmacist-Driven Deprescribing of ProtonPump Inhibitors (PPIs) in the Elderly

Nicki Ghazanfarpour, PharmD

Anita Lee, PharmD

1030-1055

Morning Break 1055-1100

R/A/D c. DUR Board Activitiesi. DUR Board Vice Chair Electionsii. Summary of MCO Best Practicesiii. Review OIG Report: ADHDiv. Retrospective DUR Review: Antihyperglycemic

Medications

Randall Stafford, MD, PhD

Robert Mowers, PharmD

1100-1140

1140-1200

Lunch Break 1200-100

https://dhcs.webex.com/dhcs/onstage/g.php?MTID=ee0783546eb2167b26cb26789827014ba

R/D d. Recap of morning action items Hannah Orozco, PharmD

100- 105

R/A/D e. Health Plan Presentation by Central California Alliance for Health: i. Academic Detailing ii. PAD and Retail Pharmacy Benefit Alignment

Project

Navnett Sachdeva, PharmD Michelle Williams

105-130

R/A/D f. UCSF Update i. Prospective DUR: Fee-for-Service ii. DUR Educational Outreach to Providers iii. Retrospective DUR iv. Review of DUR Publications

Amanda Fingado, MPH Shalini Lynch, PharmD

130-155 155-200

Afternoon Break 200-210

R/I//D g. Pharmacy Update i. H.R. 6 – SUPPORT for Patients and

Communities Act ii. Medi-Cal Rx

Ivana Thompson, PharmD and Harry Hendrix

210-245

R/D h. Recap of afternoon action items i. Looking ahead: Call for future meeting agenda topics

i. Partnership Health Plan – Insulin Best Practice ii. LA Care – Opioids

Hannah Orozco, PharmD

245- 250

C 6. Public Comments ** 250-

300

I 7. Consent Agenda a. Meeting feedback

b. Next meeting: Tuesday, November 19, 2019 1700 K Street 1st Floor Conference Room Sacramento, CA 95814

c. Proposed DUR Board Meeting Dates for 2020: Tuesday, February 25, 2020 Tuesday, May 19, 2020 Tuesday, September 15, 2020 Tuesday, November 17, 2020

8. Adjournment 300

* REPORT TYPE LEGEND: A: Action; C: Comment; D: Discussion; I: Information; R: Report ** Comments from the public are always appreciated. However, comments will be limited to five minutes per individual.

Picture identification is required to gain access into the California Department of Health Services building. However, your security information will not be provided to the Global DUR Board.

You can obtain the Global DUR Board agenda from the Medi-Cal DUR Main Menu Web site (http://files.medi-cal.ca.gov/pubsdoco/dur/dur_home.asp).

GLOBAL MEDI-CAL DUR BOARD MEETING PACKET SUMMARY September 17, 2019

• Suggested Sections to Review Prior to Meeting:o Best Practices Summary (Pages 43 – 51)

! DHCS has been working with Medi-Cal managed care plans (MCPs) to develop a summary of MCP best practices. Please review in advance of the meeting and be prepared with questions and comments.

o Office of Inspector General Report (Page 52)! Please take a moment to click the link provided and review the

August 2019 report from the Office of Inspector General entitled, “Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care.”

o Global Annual Report: 2018 (Pages 68 – 84)! Quarterly pharmacy utilization data from claims processed through

both the Medi-Cal fee-for-service (FFS) program and the Medi-Cal managed care plan (MCP) program are summarized for 2019 Q1. Based on Board feedback, additions to this report include mean days’ supply per utilizing beneficiary and stratification by population aid code group. Please review in advance of the meeting for potential opportunities for further evaluation and/or educational outreach to providers.

• Important Reminders:o The following tentative dates for the 2019/2020 DUR Board meetings have

posted:! Tuesday, November 19, 2019 ! Tuesday, February 25, 2020 ! Tuesday, May 19, 2020 ! Tuesday, September 15, 2020 ! Tuesday, November 17, 2020

Announcements

1. CDC, ACIP Release Flu Vaccine Recommendations for

Upcoming Flu Season. August 23, 2019

2. CDC, ACIP Release Human Papillomavirus Vaccination

for Adults: Updated Recommendations. August 16, 2019

3. CDC Releases Interim Infection Prevention and Control

Recommendations for Measles. July 2019

4. California Drug Take Back Program

5. Resource: Accelerating Opioid Safety: Ambulatory Care

Toolkit

https://www.cdc.gov/mmwr/volumes/68/rr/pdfs/rr6803-H.pdf

https://www.cdc.gov/mmwr/volumes/68/wr/pdfs/mm6832a3-H.pdf

https://www.cdc.gov/infectioncontrol/guidelines/measles/index.html

https://www.takebackdrugs.org/

http://www.calquality.org/storage/documents/Toolkits/AcceleratingOpioidSafety_Ambulatory_Care_Toolkit.pdf

Global Medi-Cal DUR Board General Meeting Guidelines

• Be familiar with the Bagley-Keene Open Meeting Act

• Be familiar with Robert’s Rules of Order

• Be courteous, respectful, and open minded ofother’s comments

• Be prepared by reviewing materials anddownloading documents on PC/tablet in advance

Robert’s Rules of Order

Purpose:• Supports an orderly and democratic decision process

• Facilitates group decisions

Motion:• A member presents a formal proposal requesting the

group to take a certain action or position

• A main motion is required to begin the decision makingprocess

• A motion occurs prior to discussion

http://www.dca.ca.gov/publications/bagleykeene_meetingact.pdf

https://robertsrules.org/robertsrules.pdf

The Main Motion Process1

• Member makes a clearly worded motion to take action on a position.

• “I moved…..”. Motion recorded in minutes

2

• Motion must be seconded. A motion without a second does not move forward.

• “Second!” A second allows discussion to occur; it does not signify approval.

3

• Chairperson restates the motion. This provides clarity.

• “It is moved and seconded that…..”

4

• Discussion/debate occurs.

• Maker of motion starts discussion.

• If amendments offered – return to step 1 to amend motion: “I move to amend the motion by…..”

5

• Chairperson closes discussion and states the question/asks for a vote.

• “The question is on the adoption of the motion that….”(Repeat the motion word for word)

6

• Chairperson provides voting directions: “Those in favor of the motion, say aye”, “those oppose, say no”.

7

• Chairperson announces the result of the vote: The “ayes have it, and the motion is adopted” or “the nos have it, and the motion is lost”. Recorded in minutes.

What to Say….

Purpose Motion SayDebate

allowed

Vote

Required

Introduce business Main “I move that…” Yes Majority

Second a Motion Second “Second” No No

Change the

wording/clarify a

motion

Amend “I move to amend the motion by….” Yes Majority

Postpone action until a

specific timePostpone “I move the motion be postponed until…” Yes Purpose

Take break Recess I move to recess for (x) minutes No Majority

Close meeting Adjourn I move to adjourn No Majority

GLOBAL MEDI-CAL DRUG USE REVIEW (DUR) BOARD MEETING MINUTES

Tuesday, May 21, 2019 9:30 a.m. – 3:00 p.m.

Location: Department of Health Care Services (DHCS)

1700 K Street, 1st Floor Conference Room Sacramento, CA 95814

Topic Discussion

1) WELCOME/ INTRODUCTIONS

The Global Medi-Cal Drug Use Review Board (the “Board”) members and meeting attendees introduced themselves.

Board members present: Drs. Michael Blatt, Lakshmi Dhanvanthari, Jose Dryjanski, Stan Leung, Johanna Liu, Janeen McBride, Robert Mowers, Yana Paulson, Randall Stafford, Marilyn Stebbins, Andrew Wong, and Ramiro Zuniga.

Board members absent: Drs. Timothy Albertson, Chis Chan (attended via webinar), and Vic Walker (attended via webinar).

DHCS staff present included Pauline Chan, RPh, David Do, PharmD, Robert Garlick, RPh, Paul Nguyen, PharmD, Emily Schulz, PharmD, Jose Villalobos, MPA, and Dorothy Uzoh, PharmD.

Representatives present from other Medi-Cal managed care plans (MCPs) attending in-person included Matthew Garrett, PharmD (Health Plan of San Joaquin), Michael T. Gee, PharmD (Kaiser), Lisa Ghotbi, PharmD (San Francisco Health Plan), Adam Horn, PharmD (CenCal Health), Amit Khurana, PharmD (Aetna Better Health of California), Susan Nakahiro, PharmD (Care 1st Partner Plan), Flora Siao, PharmD (California Health & Wellness), and Bruce Wearda, RPh (Kern Family Heath Care).

Representatives present from other Medi-Cal managed care plans (MCPs) attending via webinar included Barrie Cheung, PharmD (Health Plan of San Mateo), Anthony Dao (AIDS Healthcare Foundation), Riona Fujinaga (Inland Empire Health Plan), Kris Gericke, PharmD (CalOptima), Jeff Januska, PharmD (CenCal Health), Helen Lee, PharmD, MBA (Alameda Alliance for Health), Stephanie Lem, PharmD (CenCal Health), Luke Lim, PharmD (Anthem Blue Cross), Charles Lino, PharmD (Community Health Group), Andrea Ocampo (Partnership Health Plan of California, Inc.), Ankit Shah, PharmD (UnitedHealthcare Community Plan of California, Inc.), Jessica Shost, PharmD (San Francisco Health Plan), Kristen Tokunaga, PharmD (Health Plan of San Joaquin), and Mimosa Tran, PharmD (Molina Healthcare of California Partner Plan, Inc.).

2) CALL TO ORDER/

GUIDELINES The Chair of the Board, Dr. Randall Stafford, called the meeting to order. Dr. Stafford reviewed the general meeting guidelines and stated that everyone should have the mindset to be courteous, respectful, and open-minded. Dr. Stafford stated that he is viewing an electronic copy of the agenda and packet in order to follow the agenda and attachments being presented. He explained that any Board members using personal computing devices during the meeting are viewing the same materials provided to the public. This statement is required by Open Meeting rules. Finally, Dr. Stafford asked Dr. Orozco to share questions from webinar participants as they arise. Ms. Chan provided a brief overview of Robert’s Rules of Order and introduced Emily Schulz, PharmD, a new pharmacist with the Pharmacy Operations Branch.

3) REVIEW AND

APPROVAL OF PREVIOUS MINUTES FROM FEBRUARY 26, 2019

The Board reviewed the minutes from the Board meeting held on February 26, 2019. Dr. Wong and Dr. Mowers stated they had minor edits to the minutes. Dr. Stebbins motioned that the minutes be approved with these edits. The motion was seconded. There was no discussion. The Board voted to approve the minutes with the edits suggested by Dr. Wong and Dr. Mowers included. AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker ACTION ITEM: Incorporate edits from Dr. Wong and Dr. Mowers into the February 26, 2019, minutes and post to the DUR website.

4) OLD BUSINESS

a. Review of Board Action Items from February 26, 2019: i. Complete an additional review of the Treatment Authorization Request (TAR) data to

determine the percentage of TARs for each drug that are due to the statutory prescription limit and the top three reasons for denials among antipsychotic medications – Ms. Chan stated that due to system limitations it is not possible to retrieve a report listed the top three reasons for denials among antipsychotic medications. Ms. Chan provided a list of the top 30 TAR drugs for Q12019, which included the percentage of TARs for each drug due to the statutory prescription limit. Ms. Chan then introduced Robert Garlick, RPh, who is a supervisor from the Northern Pharmacy Section TAR field office. Mr. Garlick acknowledged that the Pharmacy Benefits Division prepared the Q12019 report and he was here to talk more about the report and would try to answer any questions. He provided historical context about the TAR system and said that the column on the report regarding the percentage of TAR submissions due to the statutory prescription limit are not related to the actual prescription count by the claims processing system and are instead based on provider self-report. Dr. Stebbins asked if provider in this context meant a prescriber or a pharmacist. Mr. Garlick confirmed it is the pharmacist. Mr. Garlick also noted that any drug not on the Medi-Cal fee-for-service List of Contract Drugs (CDL) requires a TAR, regardless. Dr. McBride asked what percentage of all TARs is due to the statutory limit. Mr. Garlick stated approximately 20% of TARs are due to the six prescription limit. Mr. Garlick took additional questions from the board on the average turnaround time (24 hours, if during business hours), why the statutory limit was imposed (thought to be due to state budgetary reasons, but was implemented before he started working at the TAR office), and whether vitamins are included in the limit (depends on whether it is on the CDL, with some exceptions). Dr. Leung asked if the pharmacist knows at the point-of-sale if a drug is not on the CDL and does not count toward the statutory limit. Mr. Garlick stated that reject codes might not be accurate. Dr. Leung stated in his experience, pharmacists might pick out the most important six medications and put those through first to ensure there are no access issues, but that beyond those six there could be issues. Mr. Garlick reminded everyone of the emergency access provisions available to pharmacists. Dr. Stafford asked if any of the MCPs have similar TAR requirements based on the total number of prescriptions and the consensus at the meeting was that no MCPs have similar restrictions. Mr. Walker stated he would support efforts to remove this restriction in the fee-for-service population. Dr. Wong asked what could be done to update the law, especially since many times pairs of medications are needed and should be considered as one medication instead of two. He gave the example of methotrexate and folic acid and said there are similar cases for other medications and diseases such as diabetes.

Mr. Garlick noted that sometimes because of the prescription limit, the TAR office has been able to identify other issues, including potential drug interactions, incorrect dosage, and duplicate therapies. Dr. Stebbins commented she was surprised that if none of the managed care plans have a similar limitation, that this isn’t considered discrimination or a barrier to access for fee-for-service beneficiaries. Dr. Stafford then noted the time and asked the Board if they felt there should be a motion for a policy change or whether there should be a more thorough review of the statute and options for how the Board could move forward. Dr. Ghotbi suggested changing a law might be difficult, but perhaps there could be action taken at a policy level. Dr. Mowers confirmed the TAR is approved at the National Drug Code (NDC) level, so if a dose change occurred, a new TAR would be needed based on the specific NDC on the CDL. Dr. Stafford stated that the number of steps a patient needs to go through to get access is a large source of dissatisfaction for Medi-Cal providers and noted that in the absence of evidence that there is a direct benefit to limiting the number of prescriptions, the Board should go beyond asking DHCS staff to investigate this issue. Dr. Garrett reported that South Carolina had a similar policy, and a subsequent investigation convinced the legislature that the negative outcomes and barriers to care as a result of the prescription limit outweighed any financial benefit to the state. Dr. Zuniga motioned that staff to collect more information regarding the details of the statute, look at the intended consequences, and prepare a list of possible options available. The motion was seconded. The motion passed.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker ACTION ITEM: The DUR Board recommendation to investigate options to remove the TAR requirement for > 6 prescriptions, including policy workarounds will be submitted to DHCS.

Dr. Blatt stated it would be interesting to look at denied claims due to the statute and see if there was a paid claim at a later time. Dr. Blatt suggested this might vary by pharmacy and the level of training and experience that pharmacy staff has navigating the TAR process. Dr. Stebbins clarified that the reasons for denied claims are not as important as whether or not there is an eventual paid claim within the same therapeutic class. Dr. Blatt motioned for the analysis of claims denied because of the > 6 prescriptions TAR requirement to include a review for cases without a subsequent paid claim within the same therapeutic class. The motion was seconded. There was no further discussion. The motion passed.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker ACTION ITEM: The DUR Board recommendation to analyze claims denied because of the > 6 prescriptions TAR requirement and review for cases without a subsequent paid claim within the same therapeutic class will be submitted to DHCS.

ii. Review best practices for prior authorization process improvement and strategies to prevent filling prescriptions that are already cancelled – Ms. Chan stated that best practices collated from Annual Reports would be presented later today.

iii. Review the use and prescribing of opioids in the emergency department and surgical setting and review naloxone prescribing after the implementation of the new legislative requirements in California – Ms. Chan stated that this topic was approved and will be presented at the Board meeting on November 19, 2019.

iv. Review diabetes management, hypertension management, asthma management, and immunizations within populations with chronic disease, including a review of best practices among managed health care plans – Ms. Chan again stated that best practices collated from Annual Reports would be presented later today.

v. Approve the FFY2018 DUR Annual Report to CMS for the Medi-Cal Fee-for-Service (FFS) program – Ms. Chan stated this report has been submitted electronically to CMS and all that is needed is Dr. Stafford’s signature on the cover letter to present the report to Director Kent of DHCS.

vi. Present generic utilization and expenditure data exclusive of carved-out drugs for all FFS beneficiaries and MCPs (by plan) and also for all carved-out drugs – Ms. Chan noted that generic utilization in the FFS program exclusive of carved-out drugs for FFY 2018 was 82.5% (vs. 74.1% overall) and, similarly, generic expenditures was 15.7% of the total (vs. 7.3% overall). In addition, Ms. Chan shared MCP generic utilization for FFY 2018 ranged from 83.5% to 96.2% and the carved-out generic utilization for FFY 2018 was 56.2%, with a generic expenditure of 3.1%.

vii. Archive the varenicline alert – Ms. Chan stated this was completed. viii. Conduct a retrospective DUR review of gabapentinoids – Ms. Chan stated this review

would be presented later today. ix. Use the DUR Vital Directions Framework to guide priority area topic clusters – Ms.

Chan noted the framework has been incorporated into the discussion of priority areas that will take place later in the day.

b. Recommended Action Items for MCPs from February 26, 2019: Ms. Chan presented the

recommended action items for MCPs from the Board meeting held on February 26, 2019. Recommendations are separated into two categories: required action items and suggested action items.

5) NEW BUSINESS

a. Global DUR Board Activities

i. Summary of Best Practices – Dr. Stafford presented a summary of health plan best practices in the following four areas:

Prior authorization process improvement

Strategies to prevent fill of cancelled prescriptions

Diabetes, hypertension, and asthma management

Immunization

Ms. Chan explained that these best practices were identified through the managed care health plan DUR annual reports for Federal fiscal year (FFY) 2018. Dr. Stafford asked the group to consider whether having policies that direct plans to enact these best practices might be feasible. Dr. McBride suggested we could also look at what the health plans are doing and recommend these strategies for FFS. Dr. Stafford wondered to what extent these best practices are being implemented in FFS. Ms. Chan stated that FFS would review what is reported in the annual reports to see what can be done. Dr. Dhanvanthari proposed that rather than direct plans to adopt everything, the Board should endorse adopting only what is possible, considering that each plan has a different set of priorities and schedule of implementation. Dr. Stebbins recommended that at the very least the Board could be accountable to give a status update or an explanation for why they do not choose to implement a particular best practice. Dr. Stafford asked for comments from those attending via webinar and suggested there was room for additions to the list of best practices. Dr. Zuniga suggested the Board promote use of guidelines to manage chronic diseases and asked to include congestive heart failure along with diabetes, hypertension, and asthma management. Ms. Chan reminded the group of the process used to compile the summary of best

practices and noted the differences between plans. Dr. Stafford stated that the existence of potential systemic barriers should not dissuade us from trying to implement these practices. Dr. Ghotbi shared a concern with the slides seeming to endorse specific products and suggested changing the slide text for future discussions of best practices to more neutral wording. Dr. Mowers stated that best practices might be developed and modified to meet the needs of a specific site and agreed it would be helpful to be aware of what other groups are doing and consider if they might be a good fit. He suggested the Board review the best practices and encourage FFS and MCPs to see if any of these will work in their specific environment. Dr. Stafford recommended being more proactive in implementing best practices within the FFS population. Dr. Dhanvanthari motioned that the Board recommend that the plans – including FFS – review the best practices and adopt those that have the easiest fit for their plan, with each plan to report back in six months what they have implemented or not implemented (and why not). Plans could also make a determination whether adoption is possible within a year. Dr. Dhanvanthari also recommended assigning a limited number of best practices to review. Dr. Paulson agreed there are too many best practices and proposed grouping them into smaller numbers that would be more manageable. Dr. Ghotbi noted that a review of best practices is beyond the obligation of the all-plan letter (APL). She suggested any requirements for reporting be within the scope of the APL. Dr. Leung suggested it would be helpful to have clarification of the intent of this review of best practices. He asked if it was to report back to DHCS or to learn from each other. Dr. Leung recommended identifying three to five of the best practices that each plan doesn’t do and explain why they don’t. Dr. Zuniga stated that plans already submit an annual report, so there is already a mechanism to report what is being done and he hesitates to recommend any duplicative activity. Dr. Stebbins asked if the summary presented on the slides include any best practices from the FFS program. Ms. Chan stated that the immunization practice is from FFS and is an award-winning program. Dr. Stebbins suggested that perhaps MCPs have already fulfilled their contractual obligations to report and that it could now be incumbent upon FFS to review these best practices and respond about the feasibility of implementation. Dr. Dhanvanthari amended her original motion to recommend that all plans, including FFS, review best practices and assess if already implemented, could be implemented, or why could not be implemented. The motion was seconded. There was no further discussion. The motion passed.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: McBride ABSENT: Albertson, Chan, Walker ACTION ITEM: The DUR Board recommendation for all plans, including FFS, to review best practices and assess if already implemented, could be implemented, or why could not be implemented will be submitted to DHCS.

b. Health Plan Presentation: The Safe Choice Program: A Response to the Opiate Crisis –

Heidi Solz, MD [Anthem Blue Cross] gave a brief overview of the Safe Choice Program and then introduced co-presenters Beth Stewart, MD [Medical Director, Anthem Blue Cross] and Nick Osterman, MA, LMFT [Director of Behavioral Health Services, West Region, Anthem Blue Cross]. Dr. Stewart stated that Safe Choice is a case management (CM) program that

utilizes pharmacy and/or provider lock-in as a tool for members. Dr. Stewart explained that Safe Choice was started in 2015 due to concerns with duplicate drug therapies, high-dose opioid prescriptions, multiple prescribers and pharmacies, drug-disease and drug-drug interactions, and medication misuse and abuse. Dr. Stewart stated the goals of Safe Choice were to design a member-centric program that was not punitive in order to enhance patient safety, improve provider awareness/education, improve coordination of care, including counseling, treatment for substance use disorder, and pain management. Dr. Stewart then covered the structure and process of the Safe Choice committee, which includes physical and behavioral health medical directors, physical and behavioral health case managers, a pharmacy director, a data analyst, and a project manager. Dr. Stewart reviewed the program workflow steps, the inclusion/exclusion criteria for members, the launch strategy, identification of metrics, and program interventions. Dr. Stafford asked if prescribers are informed when members are locked-in. Dr. Stewart confirmed that prescribers are informed and that providers are asked before being designated as the lock-in provider. Mr. Osterman then reviewed the outcomes from the Safe Choice pilot that started in July 2015 in both Tulare and Sacramento counties. He stated that in August 2015, there were eight members locked-in and that during the first year of the program a total of 155 referrals were reviewed, 25 members were locked-in and referred to CM, 85 members were referred to CM only, and three members were left in the program. After the first year, there was a decrease in both emergency room (ER) visits and opiate use among the first eight members locked-in, as well as a decrease in ER use among those who were only referred to CM. He then summarized the outcomes of the Safe Choice program from 2017 and 2018, noting that the program had been expanded to include members in Butte, Fresno, Alameda, and San Francisco counties. Mr. Osterman explained that the Choice Plus program was developed as an alternative to the Safe Choice program for those members who were at high-risk, but did not qualify for the lock-in program. He stated that Choice Plus had the same algorithm as Safe Choice, has a referral requirement for CM and care coordination, involves two-way communication with members and providers, and that the program has demonstrated a reduction in ER visits, inpatient admissions, and overall opiate prescriptions. Mr. Osterman shared lessons learned, including recognizing the value of physical health and behavioral health team integration and the importance of communication among case managers, members, pharmacies, and providers. Mr. Osterman concluded by summarizing next steps, which include statewide expansion, provider intervention for top opiate prescribers, and provider communication upon controlled substance-related ER visit or admission. Dr. Stafford asked if sensitivity was established when determining initial eligibility criteria. Dr. Stewart and Mr. Osterman replied that all cases are identified via the algorithm and then are thoroughly reviewed to determine whether the case is appropriate for referral. They also stated that they would advise other plans implementing a similar program to begin with specific eligibility criteria, allowing for expansion and adjustments as needed. Dr. Stebbins questioned if a control group was examined that compared those members who met lock-in requirements that were locked-in to those who met the requirements that were not locked-in, in order to compare the effectiveness of CM alone, the lock-in program alone, or a combination of the two. Mr. Osterman stated that not everyone who was locked-in was willing to have CM. Dr. Wong asked why diseases such as AIDS, multiple sclerosis, and lupus were on the exclusion criteria. Dr. Stewart explained that the exclusion criteria were established based on what the various plans within Anthem recommended.

c. DUR Annual Report to CMS: FFY 2018 MCO Summary – Ms. Chan provided a question-by-question summary of the MCO answers on the FFY 2018 DUR annual report to CMS. Ms. Chan thanked all of the plans for their help in working through this process and stated she appreciated all plans meeting the deadline for submission to DHCS, with many plans even turning in their reports early. Ms. Chan noted that of the 26 Medi-Cal managed care plans, there were a total of 72 innovative practices described within the annual reports. She stated that the innovative practices focused on several different areas, including the following:

Improving the DUR Program

Improving appropriate drug prescribing and use

Increasing access to care

Improving coordination of care

Aligning of benefits

Collaborating across agencies

Promoting cost-effective prescribing

Implementing value-based purchasing

Ms. Chan proposed next steps for highlighting and disseminating these innovative practices across plans. She suggested inviting health plans to present at future Board meetings, either through a live presentation with time for questions and answers or as part of a lunchtime poster session. Ms. Chan also suggested presentations outside the Board meetings might be scheduled and could include webinars arranged by topics, panel discussions, or case studies. She asked the Board to brainstorm other opportunities for shared learning across plans. Ms. Chan then asked Bruce Wearda, RPh from Kern Family Heath Care to present a brief overview of some of the innovative practices from Kern Family Health Care, including their approach to complex case rounds. Their interdisciplinary team has weekly meetings with a focus on mental health, transportation, and adherence. Kern Family Health Care uses a 2D profile that includes a provider scorecard and actionable measures.

d. Recap of morning action items – Dr. Orozco and Ms. Fingado read the Board action items from the morning session. There was no discussion and no edits were made to the listed action items. Dr. Orozco then reviewed the following two items: 1) the election for the Global Medi-Cal DUR Board Vice Chair will be held at the September 17, 2019, Board meeting and all candidates must submit a brief (no more than one page) statement to [email protected] by August 1, 2019 and 2) the proposed Board meeting dates for 2020 were provided. Dr. Wong suggested moving the March 3, 2020, Board meeting date to a date in February. Ms. Fingado stated that the timing of the data reports and completing the packet was easier if the meeting was pushed to the first Tuesday in March. Dr. Wong stated that he preferred a date in February. Dr. Stafford proposed that as long as the data reports were completed by the day of the meeting, it was not critical that they be included with the posted packet. Dr. Wong suggested a date of February 25, 2020. There were no objections to this date and there was no further discussion about proposed Board meeting dates.

e. Retrospective DUR i. Global Annual Report FFY 2018 – Ms. Fingado presented the Global Medi-Cal DUR

report for FFY 2018. This annual report was presented for the first time and contains all pharmacy utilization data for the Medi-Cal program. Utilization data are presented in aggregate, and then stratified by Medi-Cal FFS enrollees only and by Medi-Cal managed care plan (MCP) enrollees only. Ms. Fingado reported that she repeated the data pull for the previous global quarterly report three months after the initial data pull and found that 99.2% of the data were present at the time of the initial pull. As a result, Ms. Fingado reported that subsequent global quarterly reports will be presented at each Board meeting and will only be one quarter behind the FFS quarterly report (instead of two quarters behind). Dr. Leung asked about the difference between the percentages when comparing total utilizing beneficiaries to total paid claims. Ms. Fingado stated that she could add mean days supply per beneficiary to Table 4 and Table 6, in order to provide more useful information about the utilization patterns of the top 20 drug therapeutic categories and drugs. Dr. Stafford noted that among the drugs that are taken as needed, the ratio of claims per person is higher for FFS than for MCP. Dr. Zuniga requested more information about the demographics and complexity of the patients within each group. He stated that the reports the plans get are stratified by aid codes collapsed into categories. Ms. Fingado stated that she will provide more

mailto:[email protected]

information about the beneficiaries in future reports, including a summary of aid codes and age groups stratified by FFS and MCP enrollees. Dr. Leung motioned to update the global quarterly report to include both the mean days supply per beneficiary for the top 20 drug therapeutic categories and drugs and a description of beneficiaries in each population by age and aid code. The motion was seconded and passed without further discussion.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker ACTION ITEM: The DUR Board recommendations to update the global quarterly report template to include: 1) the mean days supply per beneficiary for the top 20 drug therapeutic categories and drugs and 2) a description of beneficiaries in each population by age and aid code will be submitted to DHCS.

ii. FFS Quarterly Report: 1Q2019 (January – March 2019) – Ms. Fingado presented the

Medi-Cal fee-for-service quarterly DUR report for the 1st quarter of 2019, which includes both prospective and retrospective DUR data. This quarterly report contains fee-for-service pharmacy utilization data presented in aggregate, and then stratified by Medi-Cal FFS enrollees only and by Medi-Cal managed care plan (MCP) enrollees only. This report includes all carved-out drugs processed through the FFS program. Ms. Fingado noted that the total number of eligible beneficiaries decreased from both the prior quarter (decreased by 2%) and prior-year quarter (decreased by 3%). She also reported that naloxone posted a 249% increase in total paid claims from 2018 Q4, coinciding with California legislation effective January 1, 2019, which requires prescribers to offer a prescription for naloxone for patients meeting certain requirements.

iii. Biennial Report 2018: Part II – Ms. Fingado presented Part 2 (of 2) of the biennial report for 2018, which provides detailed evaluations of the following eight DUR educational articles, published between October 2014 and September 2016:

Clinical Review: Morphine Equivalent Daily Dose to Prevent Opioid Overuse – September 2015

Clinical Review: Concomitant Use of Anticholinergics and Antipsychotics – November 2015

Alert: California Upgrades Prescription Drug Monitoring Program to CURES 2.0 – January 2016

Drug Safety Communication: Saxagliptin, Alogliptin and Risk of Heart Failure – April 2016

Clinical Review: Atypical Antipsychotics and Adverse Metabolic Effects – April 2016

Drug Safety Communication: New Safety Warnings Added to Prescription Opioids – April 2016

Clinical Review: The Treatment of Opioid Addiction with Buprenorphine – August 2016

2016 Immunization Updates: Influenza, Meningococcal, Tdap, Hib, Rotavirus – September 2016

Ms. Fingado stated that there were errors identified with the data presented in the biennial review of “Clinical Review: The Treatment of Opioid Addiction with Buprenorphine – August 2016,” and that a corrected review of this article would be presented at a future meeting. The Board agreed with all suggested recommendations in the biennial report. A motion was made to update the anticholinergic and antipsychotic bulletin, including adding extrapyramidal symptom (EPS) propensity for asenapine, iloperidone, and lurasidone. The motion was seconded. There was no further discussion. The motion passed.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins,

Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker

ACTION ITEM: The DUR Board recommendation to update the anticholinergic and antipsychotic bulletin, including extrapyramidal symptom (EPS) propensity for asenapine, iloperidone, and lurasidone will be submitted to DHCS.

Dr. Ghotbi expressed concern with the increased percentage of beneficiaries 65 years of age or older with greater than six paid claims for both anticholinergic and antipsychotic medications, which almost doubled since the original article was published (increased from 1.0% to 1.7%). Dr. Ghotbi recommended taking a look at the use of drugs listed in the American Geriatrics Society (AGS) Beers Criteria® for Potentially Inappropriate Medication Use in Older Adults in the 65 years of age or older Medi-Cal population. There was discussion about how it would be important to know how many FFS and MCP beneficiaries are 65 years of age or older and are not also enrolled in Medicare, and then see how many of them are taking drugs appearing on the 2019 AGS Beers Criteria® lists. A motion was made to identify the total number of Medi-Cal beneficiaries age 65 years of age or older not eligible for Medicare (FFS and MCP), review literature for the typical cutoff age for Beers list interventions, and analyze paid claims for drugs appearing on the 2019 AGS Beers Criteria® lists. The motion was seconded. There was no further discussion. The motion passed.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker

ACTION ITEM: The DUR Board recommendation to identify the total number of Medi-Cal beneficiaries age 65 years of age or older not eligible for Medicare (FFS and MCP), review literature for the typical cutoff age for Beers list interventions, and analyze paid claims for these drugs accordingly will be submitted to DHCS.

iv. Review: Gabapentinoids – Dr. Lynch presented a retrospective DUR review on gabapentinoids (gabapentin and pregabalin), which are frequently prescribed with opioids for their opioid-sparing and adjuvant analgesic effects. Dr. Lynch stated that recent reports suggest concomitant use of gabapentinoids and opioids might be an indicator of high-risk opioid misuse and could increase the risk of serious adverse events and pointed to a 2018 CDC report of overdose deaths in 11 states that found gabapentin detected in 21.6% of prescription opioid–only deaths. She noted that pregabalin is a Schedule V controlled substance, however gabapentin is not scheduled under the Controlled Substances Act of 1970. Many US states have implemented regulatory approaches to mitigate diversion and abuse of gabapentin and during FFY 2018, more than half of state DUR programs completed educational interventions focused on gabapentinoids. Dr. Lynch stated that in the Medi-Cal fee-for-service program, pregabalin is available only with an approved Treatment Authorization Request and gabapentin is on the Medi-Cal List of Contract Drugs without any additional restrictions to use. Dr. Lynch reported that for this review, all paid pharmacy claims for gabapentinoids were included for calendar years 2010 – 2018, and were subsequently stratified by FFS and MCP enrollees. In addition, she reported that for calendar year 2018, an additional evaluation was conducted for all continuously-eligible FFS enrollees, including the following:

Top concomitant medications by utilizing beneficiary

Top primary/secondary diagnosis codes by utilizing beneficiary

% of utilizing beneficiaries with FDA-approved indication Dr. Lynch presented the results of the review, showing that a total of 393,514 Medi-Cal

https://www.cdc.gov/mmwr/volumes/67/wr/mm6734a2.htm

enrollees had a paid claim for a gabapentinoid during calendar year 2018, including a total of 38,532 FFS enrollees (4,102 of these were continuously-eligible in the FFS program for all of calendar year 2018). Utilization trends showing increasing use of gabapentinoids over time. Dr. Lynch showed that only 12% of continuously eligible FFS beneficiaries had an FDA-approved indication for a gabapentinoid within the last five years. Dr. Lynch recommended writing a DUR educational bulletin focused on gabapentinoids, including a summary of use within the Medi-Cal population. The bulletin would include a review of the potential for adverse-events attributed to use within high-risk populations and the potential for abuse and misuse of gabapentinoids. The Board agreed that gabapentinoids, specifically gabapentin, should be the topic of an educational bulletin. Dr. Stafford suggested keeping references to pregabalin as well, but to separate out the data for the two drugs, as he thought the results would likely be different for each drug. Dr. Stebbins motioned to develop an educational bulletin focused on gabapentin, with reference to pregabalin. The motioned was seconded. There was no further discussion. The motion passed.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker

ACTION ITEM: The DUR Board recommendation to develop an educational bulletin focused on gabapentin (with reference to pregabalin) will be submitted to DHCS. f. Review of DUR Publications presented by Dr. Lynch

i. Bulletin (February 2019): MEDD Updates – Dr. Lynch let the Board know that the DUR educational bulletin entitled, “Clinical Review Update: Morphine Equivalent Daily Dose” published in February 2019. This was an update to a previous bulletin on morphine equivalent daily dose, which was published in 2015. Major updates included a summary of the CDC pain guidelines and information about recent legislation in California related to prescription opioids.

ii. Alert (March 2019): Fluoroquinolones – Dr. Lynch let the Board know that the DUR educational alert entitled, “Drug Safety Communication: Updated Adverse Effects from Fluoroquinolones” published in March 2019. This alert was in response to the U.S. Food and Drug Administration (FDA) warning that fluoroquinolones administered orally or intravenously may increase the risk of ruptures of an aortic aneurysm or aortic dissections, which are rare but serious events that can lead to dangerous bleeding or even death.

iii. Alert (April 2019): Sudden Discontinuation of Opioids – Dr. Lynch let the Board know that the DUR educational alert entitled, “Drug Safety Communication: Risks with Sudden Discontinuation of Opioids” published in April 2019. This alert summarized the FDA warning that it has received reports of serious harm in patients who are physically dependent on opioid pain medicines when these medicines are suddenly discontinued or the dose is rapidly decreased.

iv. Discussion/Recommendations for Future Educational Bulletins – Due to time constraints, the calendar for future DUR educational bulletins was not reviewed in detail at this meeting.

g. Prospective DUR: Fee-for-Service

i. Review of DUR Alerts for New GCNs in 1Q2019 (January – March 2019): At each Board meeting, a list of new GCN additions with prospective DUR alerts turned on other than DD, ER, and PG are provided to the Board for review. At this meeting, the Board reviewed the alert profiles of the following GCNs:

GCNs #078222, #079488, and #079489: BENZHYDROCODONE/ACETAMINOPHEN – Additive Toxicity (AT), Ingredient Duplication (ID), High Dose (HD)

GCN #074339: CHLORPHENIRAMINE/CODEINE PHOS – Additive Toxicity (AT), Drug-Age (PA)

http://files.medi-cal.ca.gov/pubsdoco/dur/Articles/dured_27703.pdf





GCN #079435: DESOGESTREL-ETHINYL ESTRADIOL – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCN #079386: DIGOXIN, MICRONIZED – Late Refill (LR), Dose (HD), Low Dose (LD)

GCN #079443: DM/PE/ACETAMINOPH/DIPHENHYDRAM – Ingredient Duplication (ID), High Dose (HD)

GCN #079420: ESTRADIOL – Drug-Disease (MC)

GCN #079208: ESTRADIOL/PROGESTERONE – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCNs #079428 and #079537: ETHYNODIOL D-ETHINYL ESTRADIOL – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCNs #079442 and #079434: LEVONORGESTREL-ETHIN ESTRADIOL – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCN #079449: LEVORPHANOL TARTRATE – Additive Toxicity (AT)

GCNs #076957 - #076959, #076961, #076963, #076964, #076966, #076967, #076969 - #076972, #079369, and #079370: LEVOTHYROXINE SODIUM – Therapeutic Duplication (TD), Late Refill (LR), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCN #079439: NORETHINDRONE – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCNs #079438, #079405, #079411, #079412, and #079426: NORETHINDRONE-ETHINYL ESTRAD – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCN #079436: NORGESTIMATE-ETHINYL ESTRADIOL – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCNs #079413 and #079427: NORGESTREL-ETHINYL ESTRADIOL – Drug-Disease (MC), Therapeutic Duplication (TD), Ingredient Duplication (ID), High Dose (HD), Low Dose (LD)

GCN #079437: SUFENTANIL CITRATE – Additive Toxicity (AT) There were no questions or objections to these alert profile recommendations. There was no further discussion.

ii. Update: AT Alert and Gabapentinoids – Ms. Fingado reported that effective April 15,

2019, both pregabalin and gabapentin have been added to the list of drugs for the AT alert based on side effect profile, literature review, and analysis of pharmacy claims data. Ms. Fingado stated there has been a 12% increase in AT alerts since that time, and alert burden would continue to be monitored over time.

h. DUR Educational Outreach to Providers: Fee-for-Service i. Proposal: Zolpidem – Ms. Fingado presented a proposal to address potential

inappropriate use of zolpidem products based on FDA warnings that female patients have lower clearance rates than males. The top 100 prescribers of zolpidem in the Medi-Cal fee-for-service population will receive a letter that will include reference data including the overall percentage of initial zolpidem prescriptions exceeding the recommended initial dosage limits, stratified by gender. Ms. Fingado stated that the primary outcome would be provider-specific percentages of initial zolpidem prescriptions exceeding the recommended initial dosage limits, stratified by gender within 12 months following the mailing and the secondary outcome would be the total number of initial zolpidem prescriptions within 12 months following the mailing. Dr. Stafford suggested including all Medi-Cal data in the prescriber-specific profiles, in order for providers to have a more comprehensive look at the data. Ms. Fingado stated this recommendation would be incorporated into the mailing. There was a motion to recommend approval of this proposal. The motion was seconded. There was no further discussion.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker ACTION ITEM: The DUR Board recommendation to send an educational letter to prescribers of zolpidem and include all Medi-Cal claims when calculating prescriber-specific data will be submitted to DHCS.

ii. Proposal: Opioids in Children < 18 – Ms. Fingado presented a proposal to inform health care providers and patients of the serious risks attributed to prescribing medications containing codeine and tramadol to patients <18 years. Prescribers with at least one paid claim within a 90-day period for a selected opioid medication in a child or adolescent < 18 years of age in the Medi-Cal fee-for-service population will receive a letter and a copy of the DUR alert on this topic. Ms. Fingado stated that the primary outcome would be the total number of continuously eligible beneficiaries < 18 years of age with a paid claim for selected opioids within the 12 months following the mailing. Dr. Mowers suggested expanding the date range to include data from January 1, 2019, in order to include a timeframe that overlapped with peak use of cough and cold products containing codeine. There was a motion to recommend approval of this proposal with the date range modified to include paid claims with dates of service between January 1, 2019, and June 30, 2019. The motion was seconded. There was no further discussion.

AYE: Blatt, Dhanvanthari, Dryjanski, Leung, Liu, McBride, Mowers, Paulson, Stafford, Stebbins, Wong, Zuniga NAY: None ABSTAIN: None ABSENT: Albertson, Chan, Walker ACTION ITEM: The DUR Board recommendation to send an educational letter to all prescribers of codeine and tramadol in children between January 1, 2019, and June 30, 2019, will be submitted to DHCS.

iii. Outcomes: MEDD 2019 – Ms. Fingado presented details from the most recent mailing

aimed to educate providers about morphine equivalent daily dose thresholds and updated legislation regarding prescribing opioids in California. Ms. Fingado reported that the study population included 87 Medi-Cal fee-for-service beneficiaries with at least 1 paid claim > 120 mg MEDD since January 1, 2019. A total of 85 prescribers were identified for educational outreach letters, which were mailed on April 26, 2019. Each letter included patient profiles, the updated Medi-Cal DUR MEDD article, a naloxone handout, and provider response surveys. Ms. Fingado reminded the Board that the primary outcome is the percentage of the continuously eligible study population with a paid claim exceeding > 120 mg MEDD in the 6-month period following the mailing of the intervention letter. Final outcomes, as well as the response rate and returned mail rate will be presented at a future Board meeting.

i. Pharmacy Update presented by Pauline Chan i. Policy: AB1114 Implementation – Ms. Chan stated that AB1114 implementation would

be on April 1, 2019, for FFS and by December 31, 2019, for MCPs. She added that a FAQ resource will be posted to the Medi-Cal website upon completion.

ii. DUR goals, priority areas, and related measures – Ms. Chan suggested aligning DUR with Medicaid Health Care Quality Measures, including medication-related measures in both the 2019 Child Core Set and the 2019 Adult Core Set.

iii. Opioids Safety Toolkit for Health Plans – Ms. Chan shared the link for the California Health Care Foundation’s Opioid Safety Toolkit, and noted that tools, tactics, best practices, and success stories can be found on that link.

https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-child-core-set.pdf

https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-adult-core-set.pdf

https://www.chcf.org/resource-center/opioid-safety-toolkit/

iv. CURES 2.0 – Ms. Chan reported that CURES 2.0 is available for use and suggested providers refer to the CURES Mandatory Use reference sheet, CURES Advisory Memo, and the Medical Board of California’s FAQs for further guidance, if needed.

v. Academic Detailing – Ms. Chan shared an interview with a clinician who had completed academic detailing training with the National Resource Center for Academic Detailing (NaRCAD). The interview focused on the barriers to and enablers of success when implementing an academic detailing program. Ms. Chan also provided a registration link for the NaRCAD training on Opioid Safety Academic Detailing, which will be held in July 2019.

i. Addressing Complex Drug Regimens – Ms. Chan stated that the Centers for Health Care Strategies provided access to their webinar entitled, “Addressing Medication Complexity Through Innovative Community-Based Strategies and Partnerships.”

ii. SUPPORT Act – Ms. Chan provided information about the SUPPORT Act. Ms. Chan confirmed CMS would be providing additional guidance on the DUR minimum requirements outlined in the SUPPORT Act in the upcoming months.

iii. FFY 2018 DUR Annual Report – Ms. Chan reported that all annual reports for California (FFS and MCO) have been submitted to CMS, well in advance of the July 1 deadline.

j. Recap of today’s action items – Due to time constraints, the action items for the afternoon

session were not discussed.

k. Looking ahead: Call for future meeting agenda – Ms. Chan stated that she welcomes recommendations from the Board for speakers. Two possible presentations for September include one by Linette Scott, MD, MPH on Core Set Measures and one by Sharon Cummins, PhD and Neal Kohatsu, MD, MPH entitled, “Tobacco Quitlines, Incentives and the Medicaid Population.”

6) PUBLIC COMMENTS

There was a public comment from Thomas Jough, MBA, a senior strategic account manager at Walgreens. Mr. Jough updated the Board on several ongoing projects at Walgreens, including mental health initiatives, a collaboration with the U.S. Department of Veterans Affairs’ (VA), take-back kiosks located within pharmacies across California, refill- and adherence-based initiatives, and express pickup.

7) CONSENT AGENDA

The next Board meeting will be held from 9:30 a.m. to 3:00 p.m. on September 17, 2019, in the DHCS 1st Floor Conference Room located at 1700 K Street, Sacramento, CA 95814.

8) ADJOURNMENT The meeting was adjourned at 3:04 p.m.

Action Items Ownership

Incorporate edits from Dr. Wong and Dr. Mowers into the February 26, 2019, minutes and post to the DUR website.

Amanda

The DUR Board recommendation to investigate options to remove the TAR requirement for > 6 prescriptions, including policy workarounds will be submitted to DHCS.

Pauline

The DUR Board recommendation to analyze claims denied because of the > 6 prescriptions TAR requirement and review for cases without a subsequent paid claim within the same therapeutic class will be submitted to DHCS.

Pauline

The DUR Board recommendation for all plans, including FFS, to review best practices and assess if already implemented, could be implemented, or why could not be implemented will be submitted to DHCS.

Pauline

The DUR Board recommendations to update the global quarterly report template to include: 1) the mean days supply per beneficiary for the top 20 drug therapeutic categories and drugs and 2) a description of beneficiaries in each population by age and aid code will be submitted to DHCS.

Amanda

The DUR Board recommendation to update the anticholinergic and antipsychotic bulletin, Amanda/Shal

https://oag.ca.gov/cures

https://oag.ca.gov/sites/all/files/agweb/pdfs/pdmp/cures-mandatory-use.pdf?

https://oag.ca.gov/sites/all/files/agweb/pdfs/pdmp/cures-advisory-memo.pdf?

http://www.mbc.ca.gov/Licensees/Prescribing/CURES/CURES_FAQ.pdf?utm_source=link&utm_medium=website_homepage&utm_campaign=CURES&utm_content=faq

https://www.narcad.org/blog/clinicians-as-champions-understanding-barriers-enablers-to-detailing-success?utm_source=Spring+2019+E-newsletter&utm_campaign=Spring+2019+e-newsletter&utm_medium=email

http://www.narcad.org/training-series.html?utm_source=Spring+2019+E-newsletter&utm_campaign=Spring+2019+e-newsletter&utm_medium=email

https://www.chcs.org/resource/addressing-medication-complexity-through-innovative-community-based-strategies-and-partnerships/

https://www.chcs.org/resource/addressing-medication-complexity-through-innovative-community-based-strategies-and-partnerships/

https://www.congress.gov/bill/115th-congress/house-bill/6

including extrapyramidal symptom (EPS) propensity for asenapine, iloperidone, and lurasidone will be submitted to DHCS.

The DUR Board recommendation to identify the total number of Medi-Cal beneficiaries age 65 years of age or older not eligible for Medicare (FFS and MCP), review literature for the typical cutoff age for Beers list interventions, and analyze paid claims for these drugs accordingly will be submitted to DHCS.

Amanda

The DUR Board recommendation to develop an educational bulletin focused on gabapentin (but with reference to pregabalin) will be submitted to DHCS.

Amanda/Shal

The DUR Board recommendation to send an educational letter to prescribers of zolpidem and include all Medi-Cal claims when calculating prescriber-specific data will be submitted to DHCS.

Hannah/Amanda/Shal

The DUR Board recommendation to send an educational letter to all prescribers of codeine and tramadol in children between January 1, 2019 and June 30, 2019 will be submitted to DHCS.

Hannah/Amanda/Shal

Board Ac)on Items from May 21, 2019

•  Inves&gateop&onstoremovetheTARrequirementfor>6prescrip&ons,includingpolicyworkarounds.o Willbediscussedtoday.

•  Analyzeclaimsdeniedbecauseofthe>6prescrip&onsTARrequirementandreviewcaseswithoutasubsequentpaidclaimwithinthesametherapeu&cclass.o Willbediscussedtoday.

•  Reviewbestprac&cesandassessifalreadyimplemented,couldbeimplemented,orwhycouldnotbeimplemented.o Willbediscussedtoday.

•  Updatetheglobalquarterlyreporttemplatetoinclude:1)themeandayssupplyperbeneficiaryforthetop20drugtherapeu&ccategoriesanddrugsand2)adescrip&onofbeneficiariesineachpopula&onbyageandaidcodeclusters.o  Approved.Includedintheglobalquarterlyreporttobepresentedtoday.

Board Ac)on Items from May 21, 2019 (cont.)

•  Updatethean&cholinergicandan&psycho&cbulle&n,includingextrapyramidalsymptom(EPS)propensityforasenapine,iloperidone,andlurasidone.o  ApprovedandpublishedtotheDUReduca&onalbulle&nwebpage.

•  Iden&fythetotalnumberofMedi-Calbeneficiariesage65yearsofageoroldernoteligibleforMedicare(FFSandMCP),reviewliteratureforthetypicalcutoffageforBeerslistinterven&ons,andanalyzepaidclaimsforthesedrugso  Approved.DatawillbepresentedinNovember2019.

•  Developaneduca&onalbulle&nfocusedongabapen&n(withreferencetopregabalin).o  ApprovedandpublishedtotheDUReduca&onalbulle&nwebpage.

•  Sendaneduca&onalleZertoprescribersofzolpidemandincludeallMedi-Calclaimswhencalcula&ngprescriber-specificdata.o  ApprovedandsentinAugust2019.

•  Sendaneduca&onalleZertoprescribersofcodeineandtramadolinchildrenbetweenJanuary1,2019andJune30,2019.o  ApprovedandsentinAugust2019.

GLOBAL MEDI-CAL DRUG USE REVIEW BOARD May 21, 2019 BOARD MEETING MCP ACTIONS

MCP: ___________________________________________________________________________ Name of DUR representative: ___________________________Attended meeting? Yes ___ No ___

Summary of Required Actions

I. Educational Bulletins: MCP to have a process for distribution of provider education programs and materials developed by Global DUR Board to their providers via established mechanisms.

Required dissemination of DUR educational bulletins and alerts

Description Mechanism of dissemination

Date of Dissemination

February 2019 Bulletin: Clinical Review Update: Morphine Equivalent Daily Dose March 2019 Alert: Drug Safety Communication: Updated Adverse Effects from Fluoroquinolones April 2019 Alert: Drug Safety Communication: Risks with Sudden Discontinuation of Opioids







Summary of Global Medi-Cal DUR Board Activities (not required to document on the Annual Report to CMS)

1. Review Board Goals and Priorities: a. Optimizing Drug Prescribing and Dispensing, including specialty drugs b. Optimizing Pain Management and Opioids c. Optimizing Chronic Disease Management, including prevention

Action:

a. Review board goals and priority areas at MCPs P&T/DUR Committee. b. Submit innovative practices on priority areas MCPs has worked on and share

lessons learned, with focus on asthma, diabetes, and hypertension. c. Consider presenting best practices at future DUR board meetings.

2. Review MCP’s reported best practices as documented in the plan’s CMS DUR annual

report.

Action: a. Assess whether each best practice is scalable and can be reasonably adopted by

other health plans. b. Consider sharing “how we did it” and “lessons learned” with the rest of the MCPs by

volunteer to present at future Global Medi-Cal DUR board meetings.

3. Review Anthem Blue Cross “Safe Choice” Program Action:

a. Review and assess if this practice or similar practice has already been implemented, could be implemented, or why could not be implemented.

4. Review FFS Biennial Report

Action: a. Share FFS Biennial Report at MCP’s P&T Committee/DUR meeting, and consider

developing a similar report to evaluate effectiveness of DUR interventions. b. If MCP already has a similar report, consider to include a summary in the FFY 2019

DUR annual report under the “Retrospective DUR” narrative (report due April 1, 2020).

Reminders

MCPs are required to ensure representation and participation at Global Medi-Cal DUR Board meetings, either in-person or via webinar. Refer to the Global Medi-Cal DUR Board bylaws for the attendance requirements for Global Medi-Cal DUR Board members.

MCPs are required to have a process for distribution of provider education programs and materials developed by Global Medi-Cal DUR Board to their providers.

Aligning Quality Measurement Across

Programs

Global Medi-Cal Drug Utilization Review Board

Linette T Scott, MD, MPH

Chief Medical Information Officer

• Medicaid Core Set Measures

• Alignment Examples

– Value Based Payment Program

– Supplemental data

– Data Quality and the Transformed Medicaid Statistical Information System (TMSIS)

• HITECH Investments & Medicaid Information Technology Architecture (MITA)

Supporting Program Goals

• Driving alignment across programs

• Originating from the Affordable Care Act

• Updated annually through stakeholder process

• Subset of measures are included in the Medicaid Score Card

• Child Core Set Measures

– Will be required for state reporting for fiscal year 2024 (H.R. 1892 - Bipartisan Budget Act 2018)

• Adult Core Set Measures

– Behavioral health measures will be required for state reporting for fiscal year 2024 (H.R. 6: SUPPORT for Patients and Communities Act)

Medicaid Core Set Measures

• Aligning programs to Medicaid Core Set Measures:

– Core Set Reporting

– Managed Care Plans

– Mental Health Plans

– Value-Based Payment Program

• Exploring the use of measures at the county level to

monitor coordination between systems (physical

health and behavioral health)

• Measures that can be calculated with administrative

data can be used to report at more granular levels

(sub-state, specific program populations, etc.)

Alignment Examples

• Will provide incentive payments to providers for meeting specific measures aimed at improving care for certain high-cost or high-need populations

• Will target areas such as:

– behavioral health integration

– chronic disease management

– prenatal/post-partum care

– early childhood prevention

• To address and consider health disparities, will pay an increased incentive amount for events tied to beneficiaries diagnosed as having a substance use disorder or serious mental illness, or who are homeless

Value Based Payment (VBP)

Program

• VBP program will be implemented for at least three years

in the managed care delivery system, subject to funding

approved in the final 2019 Budget

• Implementation date will be July 1, 2019 for all measures

including behavioral health measures

• Implementation date will be January 1, 2020 for the

Behavioral Health Integration Project Plan component

Program Implementation

Providers will be identified based on:

• National Provider Identifier (NPI) in the rendering or ordering provider field that is an NPI for an individual (Type 1)

• If the rendering or ordering is not filled, then look for prescribing provider field that is an NPI for an individual (Type 1)

• If the rendering, ordering, or prescribing is not filled, then look for billing provider that is an NPI for an individual (Type 1)

If the encounter data does not include an individual (Type 1) NPI, then no payment will be made for the encounter

Providers to be paid

• Medi-Cal administrative data reported through the Managed Care Plans encounter data

• Medi-Cal administrative data reported in the Medi-Cal Eligibility Data System

• For measures involving immunizations, the expectation is that immunizations reported through the California Department of Public Health (CDPH) California Immunization Registry (CAIR) 2.0 will be used as a supplementary data source

• For the Blood Lead Screening measure, the expectation is that blood lead test results reported through the CDPH Blood Lead Registry may be used as a supplementary data source

Data to be used to

calculate payments

An enhanced payment factor will be applied to the above services provided to beneficiaries with the following conditions:

• Substance Use Disorder – CMS Core Set Measure Set: AOD Abuse and Dependence Value Set

• Serious Mental Illness – CMS Core Set Measure Sets: Schizophrenia Value Set, Bipolar Disorder Value Set, Other Bipolar Disorder Value Set, and Major Depression Value Set

• Homeless ICD-10 Diagnosis code with the following values:

– Z59.0 Homeless

– Z59.1 Inadequate Housing

Post utilization monitoring will be performed to ensure overuse of services is not occurring

Additional payment factors

https://www.medicaid.gov/license-agreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adult-value-set-directory.zip

https://www.medicaid.gov/license-agreement.html?file=%2Fmedicaid%2Fquality-of-care%2Fdownloads%2F2019-adult-value-set-directory.zip

• California Immunization Registry (CAIR) received federal funding through the Electronic Health Record Incentive Program

• Data sharing with Perinatal Hepatitis B Prevention Program identified gaps in claims and gaps in the CAIR

• Data sharing under the CHHS Data Exchange Agreement to further pilot opportunities for data integration (in process)

– Populate Registry with Medi-Cal administrative data

– Compare results for Core Set Immunization measures calculated based on CAIR to results reported by Managed Care Plans

Immunization Reporting

• Childhood Lead Poisoning Prevention Program (CLPPP), California Department of Public Health

– Blood lead tests drawn in California are reported to CLPPP

– Elevated levels are investigated

• Medi-Cal reports to CMS via the CMS-416

– Reporting on the CMS-416 under-represents actual testing

– Data sharing with CLPPP identified gaps in claims

– Percentage screened is approximately 10% higher when CLPPP data is included

• Joint cohort analysis of 3 year olds assessed blood lead screening using linked data

Blood Lead Screening

• Measurement and reporting is dependent on data quality

• TMSIS is driving data quality and helping the department create a broad data quality program

• 2017 state and federal funding were approved to establish a federated team at DHCS with approximately a dozen staff

• Partnership between CMS and the state has helped us work through the data quality “To Do List”

• Improving T-MSIS data quality has served as a common department wide goal which has increased communication and cooperation among the various programs within DHCS

(See diagram on next slide)

Data Quality and TMSIS

TMSIS Journey

• Health Information Technology for Economic and Clinical Health (HITECH) Act was signed into law on February 17, 2009

• A new name and focus for the Medi-Cal Electronic Health Record (EHR) Incentive Program arrived April, 2018:

Promoting Interoperability Program

– commitment to promoting and prioritizing interoperability of health care data

– move beyond existing requirements of meaningful use

– increased focus on interoperability and improving patient access to health information

HITECH turns 10!

Medicaid Enterprise Systems (MES)

• Previously referred to as the Medicaid Management Information System (MMIS) moving to a modular MES

• Maturing through the Medicaid Information Technology Architecture (MITA) Framework and Initiative

• Incorporating goals and requirements of the Promoting Interoperability Program

• Opportunities for funding related to Core Set reporting of quality measures and associated TMSIS and data quality efforts

Transitioning from

HITECH to Medicaid Systems

• California HIE Onboarding Program (Cal-HOP)

• Health Information Technology for Emergency Medical Services (HITEMS)

• Public Health Registries (California Immunization Registry, California Reportable Disease Information Exchange, California Cancer Registry, etc.)

• Integration with Controlled Substance Utilization Review and Evaluation System (CURES), California’s Prescription Drug Monitoring Program

• Shared rules of the road

– California Data Use and Reciprocal Support Agreement (CalDURSA)

– California Trusted Exchange Network (CTEN)

Focus on Interoperability

• Focus on interoperability while balancing data protection and information blocking rules

• Governance and data sharing agreements to support data integration and linkage

• Integration of diverse data that is not currently standardized to create more robust understanding

• Alignment of measurement and reporting creates synergy to improve data reporting, data quality, and data management

• Focus on patient and client centered care drives use cases for engagement while integrated data informs policy decisions and evaluation of outcomes

Medicaid Data for the Future

• HITECH

• MITA and MITA

• Medicaid Child Core Set Measures

• Medicaid Adult Core Set Measures

• HIV Surveillance Reports

Resources

https://www.healthit.gov/

https://www.medicaid.gov/medicaid/data-and-systems/mita/index.html

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/MedicaidInfoTechArch/downloads/mitaoverview.pdf

https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/child-core-set/index.html

https://www.medicaid.gov/medicaid/quality-of-care/performance-measurement/adult-core-set/index.html

https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OA_case_surveillance_reports.aspx

Randall Stafford, MD., PhD, Board Chair

Pauline Chan, R.Ph. MBA

September 17, 2019

Managed Care Health Plans (MCPs) & Fee For Service

Optimizing Chronic Disease Management

Best Practice Summary

Global Medi-Cal DUR Board Meeting

Global Medi-Cal DUR Board Meeting 09-17-2019

1. Optimizing Drug Prescribing and Dispensing, including

- specialty drugs

2. Optimizing Pain Management and Opioid Use

3. Optimizing Chronic Disease Management, including

- diabetes

- hypertension

- asthma

- prevention (immunization)

Global Medi-Cal DUR Board Priority Areas 2019


• On 5/21/19, the Global DUR Board recommended for all

plans, including Fee-For-Service, to:

a. Review best practices in the priority areas, and

b. Assess if these best practices have:

i. already implemented

ii. could be implemented

iii. why could not be implemented

Global Medi-Cal DUR Board Actions


Chronic Disease Management Best Practices

• Today’s discussion to cover:

– Summarize best practices in priority area #3,

“Optimizing Chronic Disease Management”, including

asthma, diabetes, hypertension and prevention

(immunization)

– Proposed next steps

– Proposed recommendations


Chronic Disease Management Best Practices -2

• Sources of Best Practices include:

– DUR Annual reports, Federal Fiscal Year (FFY) 2018

• FFS

• 24 MCPs and 2 SHPs

– Immunization

– Medi-Cal Managed Care Quality & Monitoring Division (MMCQMD)

• Performance Improvement Projects (PIPs) by MCPs

– Quality Learning Collaboratives participated by FFS & MCPs

• Million Hearts: 10 MCPs

• Right Care Initiative


Overview of Medi-Cal

• Medi-Cal Managed Care (MCMC) provides managed

health care services to more than 10 million beneficiaries

in all 58 counties

– Full scope managed care health plans (MCPs)

– Specialty health plans (SHPs)

• Medi-Cal Fee-For-Service (FFS) provides services to

those not in managed care

– Includes “carved out” services in managed care


DUR Annual Report FFY 2018

Best Practices in Diabetes Management

• Evaluate statin use in persons with diabetes

• Analyze insulin utilization

• Establish specialty clinic for patients with diabetes

• Implement rounds for complex case management

• Develop diabetes polypharmacy program (> 10 medications)

– Includes a comprehensive medication review, evaluation of statin

use, and monitoring of elevated A1C

Source: DUR annual report FFY 2018


DUR Annual Report FFY 2018

Best Practices in Hypertension Management

• Increase access to Home Blood Pressure Monitors (HBPMs)

• Provide academic detailing and training to prescribers and

pharmacists

• Promote dedicated residency projects




DUR Annual Report

Best Practices in Asthma Management

• Establish Clinical Pharmacy Outreach Program (CPOP)

• Develop Asthma Medication Ratio Patient Engagement Project


• Conduct interventions on use of steroid inhalers and anticholinergic

inhalers

• Evaluate asthma medication adherence

• Initiate new start outreach calls

• Implement “Gaps in Asthma Report”



DUR Annual Report

Best Practices in Asthma Management (cont.)

• Implement a Direct Model, including disease management, case

management, and outreach

• Implement a Community Partnership Model, including partner with

county, public health, local agencies and hospitals

• Educate members with COPD on proper use of oral corticosteroids

and long-acting beta agonists



Best Practices in Immunization

• Expanded pharmacists’ scope of practice to include

independently initiating and administering immunizations

to patients ≥3 years old


Medi-Cal Managed Care Quality Monitoring

• The Office of the Medical Director (OMD) develops and implements

the Managed Care Quality Strategy for Managed Care Health Plans.

– Addresses specific chronic conditions, including

• Diabetes care

• Hypertension control

• Medi-Cal Managed Care Quality Monitoring Division (MMCQMD)

monitors quality, timeliness and accessibility of services related to

the above chronic conditions through quality metrics

– Use of rapid cycle performance improvement project approach

– Evaluation


Medi-Cal Managed Care Quality Monitoring -2

• The rapid-cycle PIP approach requires up-front preparation to allow

for a more structured, scientific approach to quality improvement:

– improving both health care outcomes and processes through

the integration of quality improvement science

– pilot small changes rather than implementing one large

transformation

– opportunities to determine the effectiveness of several changes

prior to expanding the successful interventions

– successful interventions can be adopted widely as best practices

Source: Medi-Cal Managed Care External Quality Review Report 2019


Quality Monitoring:

Performance Improvement Projects (PIPs)

Performance Improvement Project by Topics and Timeline

Source: Medi-Cal Managed Care External Quality Review Report 2019

Topics Number of PIPS

In Year 2015-16

Number of PIPS

In Year 2017-19

Diabetes Care 13 8

Hypertension

control

4 2

Asthma 2 2

Immunization 2 3


Quality Learning Collaborative : Million Hearts

• Health plans that shared best practices improved hypertension

control for low-income Californians

- Study conducted by the DHCS and UC Davis Institute of

Population Health Improvement (IPHI)

- Study is part of Million Hearts initiative, led by the Centers for

Disease Control (CDC) and the Centers for Medicare & Medicaid

Services (CMS)

- Ten (10) Medi-Cal MCPs participated. Nine (9) have performed

below Million Hearts target controlled-hypertension rate for 2012-

2017 of 70 percent. The plan performed above the target was

excluded in the analyses.


Quality Learning Collaborative : Million Hearts -2

• How they did it

“ We found that participating in quarterly webinars, and having access to

evidence-based tools and resources, improved the rate of hypertension

control among nine managed care plans with performance below the

Million Hearts goal.”

- Neal D. Kohatsu, former Medical Director, DHCS



• Lessons Learned

“ This improvement is notable because all plans had a multiyear history

of declining hypertension control rates before the intervention. In

addition, among those plans that did not participate, 9 of 10 continued to

show declining rates of hypertension control during the study period.

Our results demonstrate that structured learning collaboratives can

improve health plan performance with a modest investment of

resources.”

IPHI Director Kenneth W. Kizer,



MCPs participated in Million Hearts Initiative

Source: Health Plans that shared best practices improved hypertension control for low-income

Californians - Million Hearts health plan champions

Alameda

Alliance for Health

Anthem Blue

Cross Partnership

Plan

CalOptima

Care 1st Partner

Plan

Health Net

Community

Solutions, Inc.

Health Plan of San

Mateo

LA Care Health

Plan

Molina Healthcare

of California

Partnership Health

Plan of California


Quality Learning Collaborative: Right Care Initiative

• One In Five Fewer Heart Attacks: Impact, Savings, And Sustainability

In San Diego County Collaborative

– The collaborative “Be There San Diego” (BTSD), was initiated by

the California Department of Managed Health Care and the Right

Care Initiative of the University of California (UC)

– BTSD focuses on primary, secondary and tertiary prevention of

cardiovascular disease

• Identification and modification of risk factors

• Improved quality of clinical care

• Implementation of best practices


Quality Learning Collaborative: Right Care Initiative -2

• How they did it

– Sharing of best practices among collaborators and transmitted to other

clinicians and community partners, and key clinical metrics are reviewed

and discussed by participating health care organizations

– Incorporates a model known as the University of Best Practices

• Monthly forum to learn practical ways to implement the latest

research findings and recommendations

• Identify and share best clinical practices

– Expanded to include other strategies, including use of guidelines aimed

at spreading best practices and reducing cardiovascular risks and

adverse events

• Improve use of medications

• Medication adherence


Quality Learning Collaborative: Right Care Initiative -3

• Lessons learned

– Result oriented: Study shows an association between a quality learning

collaborative using performance data, best practices and quality

improvement and reductions in population-based hospitalizations for a

condition targeted by the collaborative

– Responsive to change: Evolve with local and macro-level changes in

health care that drive systems transformation

• Value based purchasing

– Building up: Serves as “backbone” organization for even broader

initiative known as “San Diego Accountable Community for Health”

Source: Health Affairs: One In Five Fewer Heart Attacks: Impact, Savings, And

Sustainability In San Diego County. September 2018


Proposed Next Steps

• Share Best Practices

– Examine each best practice by inviting leaders in high-performing

MCPs and SHPs to present at DUR board meetings

– Share “how they did it” and “lessons learned”

• Align each best practice with MMCQMD quality improvement plan

– 2019 CMS Medicaid Core Measures, both adult and children

• Align and coordinate quality improvement efforts with MMCQMD

– Use of Quality Improvement resources and tools

– Participate in quality collaboratives and awards nominations

• Incorporate DUR in the DHCS quality strategy

Global Medi-Cal DUR Board Meeting 09-17-

2019

Proposed Next Steps -2

• Recommendations to the Board

– Board to develop a plan to assess if these best

practices have:

i. already implemented

ii. could be implemented

iii. why could not be implemented


References

• Quality Measures and Reporting:

– 2019 Core Set of Adult Health Care Quality Measures for Medicaid

(Adult Core Set) Adult Core Set

– 2019 Core Set of Children’s Health Care Quality Measures for Medicaid

and CHIP (Child Core Set) Child Core Set

– Medi-Cal Managed Care External Quality Review Technical Report July

1, 2017 to June 30, 2018 Managed Care Quality Review Report

https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-adult-core-set.pdf

https://www.medicaid.gov/medicaid/quality-of-care/downloads/performance-measurement/2019-child-core-set.pdf

https://www.dhcs.ca.gov/dataandstats/reports/Documents/CA2017-18_EQR_Technical_Report_F1.pdf


References -2

• Best Practices:

– Health Affairs: One In Five Fewer Heart Attacks: Impact, Savings, And

Sustainability In San Diego County. September 2018. Health Affairs

– Be There San Diego. The campaign to make San Diego a heart attack

and stroke-free zone. Simplified Hypertension Treatment Approach

– Right Care Initiative. California Statewide Goals using HEDIS measures.

Right Care Initiative

– Health Plans that shared best practices improved hypertension control

for low-income Californians - Million Hearts health plan champions.

Million Hearts

– Implementing a Quality Improvement Collaborative to Improve

Hypertension Control and Advance Million Hearts Among Low-Income

Californians, 2014–2015 Million Hearts Study

Global Medi-Cal DUR Board Meeting

09-17-2019

Acknowledgement

• Medi-Cal Managed Care Health Plans (MCPs) and

Specialty Health Plans (SHPs) for sharing best practices

as documented in the FFY 2018 DUR annual reports and

presenting highlights at the quarterly DUR board

meetings


Questions ?

Questions?

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2018.0443

https://rightcare.berkeley.edu/wp-content/uploads/2015/01/Be-There-San-Diego_HTN-Treatment-Approach_FINAL.pdf

https://rightcare.berkeley.edu/about/about-project

https://health.ucdavis.edu/publish/news/newsroom/12184

https://www.cdc.gov/pcd/issues/2017/16_0587.htm

For Review

• Office of Inspector General Report, 8/13/19

• Many Medicaid-Enrolled Children Who Were Treated for ADHD Did Not Receive Recommended Followup Care

https://oig.hhs.gov/oei/reports/oei-07-17-00170.asp?utm_source=website&utm_medium=asp&utm_campaign=adhd-followup

Global Medi-Cal DUR Updates: Q2 2019

Amanda R. Fingado, MPH

Senior Epidemiologist/Statistician

Department of Clinical Pharmacy

Shal Lynch, PharmD, CGPHealth Sciences Associate Clinical Professor

Department of Clinical Pharmacy

Fee-for-Service Prospective DUR

- New GCNs Q2 2019

- Website updates

Educational Outreach

- Tramadol, codeine, and zolpidem mailing updates

- Gabapentin proposal

Topics for Discussion

Retrospective DUR

- Global Quarterly Report: 1Q2019 (January – March 2019)

- FFS Quarterly Report: 2Q2019 (April – June 2019)

- FFS PAD Annual Report: 2018 (January – December 2018)

Publications

- June 2019: Sleep Aids Alert

- August 2019: Anticholinergic Bulletin

Topics for Discussion (cont.)

Background

Each week new Generic Code Numbers (GCNs) are added

Overutilization (ER), Drug-Pregnancy (PG) and Drug-Drug

Interactions (DD) alerts are automatically turned on for all

new GCNs

New GCNs are reviewed weekly for additional alerts

New GCNs with alerts turned on other than ER, PG, and DD

are provided at each Board meeting for review

New GCN Alert Profiles

New GCN Alert Profiles (cont.)

Table 1. New GCNs for Existing DUR Target Drugs: Q2 2019

Drug Description Alerts Turned OnDICLOFENAC/LIDO/ME-SAL/CAMPHOR DA, MC, TD, ID, HD, LD

DIPHENHYD/PHENYLEPH/ACETAMINOP ID, HD

DOLUTEGRAVIR SODIUM/LAMIVUDINE ID

LEVOTHYROXINE SODIUM TD, LR, ID, HD, LD

METHYLPHENIDATE HCL HD, LD

STIRIPENTOL AT

DA Drug-Allergy

MC Drug-Disease

TD Therapeutic Duplication

LR Late Refill

AT Additive Toxicity

ID Ingredient Duplication

PA Drug-Age

HD High Dose

LD Low Dose

Board questions/recommendations?

Website Updates

All content from DUR manual has been transferred to DUR

web pages

DUR: Alert Criteria page has description of all DUR alerts and the

Medi-Cal Fee-for-Service Prospective Drug Use Review (DUR)

Target Drugs spreadsheet

- Can search/sort by alert or drug

- Updates to be sent through Medi-Cal Subscription Service (MCSS)

Website Updates (cont.)


http://files.medi-cal.ca.gov/pubsdoco/dur/dur_a_cri.asp

http://files.medi-cal.ca.gov/pubsdoco/dur/AlertActivity/TargetDrugs.xls

Original proposal to Board suggested mailing letters to all

providers who prescribed tramadol and/or codeine to Medi-

Cal FFS beneficiaries < 18 years of age (dates of service

from January 1, 2019, through June 30, 2019)

- Only one provider prescribed both tramadol and codeine to

beneficiaries < 18 years of age

- Decided to split letter into two letters; one for tramadol

prescribers and one for codeine prescribers

Mailing Update: Tramadol/Codeine Letter

A total of 44 letters were mailed on July 29, 2019

- Represented 40 beneficiaries (65% were 17 years of age)

- Letters included DUR article, patient profiles, provider survey

Primary outcome to be presented at November 2020 meeting

- Total beneficiaries < 18 years of age with a paid claim for

tramadol within the 12 months following the mailing

- Response rate and undeliverable rate will also be presented

Mailing Update: Tramadol Letter

A total of 313 letters were mailed on August 1, 2019

- 36% (n=113) prescribers were dentists and 53% (n = 29) of

prescribers with more than one patient profile were dentists

- Represented 450 beneficiaries

- Letters included DUR article, patient profiles, provider survey

Primary outcome to be presented at November 2020 meeting

- Total beneficiaries < 18 years of age with a paid claim for codeine

within the 12 months following the mailing


Mailing Update: Codeine Letter

A total of 100 letters were mailed on August 20, 2019

- Letters included DUR article, provider survey, and the following

provider-specific data:

% of female Medi-Cal beneficiaries with an initial dose of zolpidem exceeding

the recommended initial dosage limits

% of female Medi-Cal beneficiaries with initial dose of IR zolpidem > 5 mg

% of female Medi-Cal beneficiaries with initial dose of ER zolpidem > 6.25 mg.

Mailing Update: Zolpidem Letter

Final outcomes to be presented at November 2020 meeting

- Provider-specific percentages of initial zolpidem prescriptions

exceeding the recommended initial dosage limits, stratified by

female gender within 12 months following the mailing

- Total initial zolpidem prescriptions exceeding the recommended

initial dosage limits, within 12 months following the mailing


Mailing Update: Zolpidem Letter (cont.)

Background

- Concomitant use of gabapentinoids and opioids might be an

indicator of high-risk opioid use and could increase risk of serious

adverse events

- A 2018 CDC report of overdose deaths in 11 states found

gabapentin detected in 21.6% of prescription opioid–only deaths

Objective

- To inform health care providers of the serious risks associated

with gabapentin use

Proposal: Gabapentin Letter

https://www.cdc.gov/mmwr/volumes/67/wr/mm6734a2.htm

Methods

- Top ~100 prescribers of gabapentin (by volume) in the Medi-Cal fee-

for-service population will receive letter

- Mailing will include % of patients with concomitant opioid prescriptions

Outcomes

- Primary: Provider-specific total paid claims for gabapentin within 12

months following the mailing

- Secondary: Total initial paid claims for gabapentin within 12 months

following the mailing

Proposal: Gabapentin Letter (cont.)


DUR Educational Outreach to Pharmacies/Providers

Updated ACOG guidelines for postpartum pain

Updated NAMS guidelines for hormone replacement therapy

Updated ADA opioid guidelines to dentists

Oseltamivir or zanamivir paid claims + influenza vaccine

Statin use with cardiovascular disease

Chronic use of PPIs

Chronic use of temazepam/zolpidem

Future Educational Outreach Topics


Per Board request, the report now includes mean days’

supply per utilizing beneficiary and data are stratified by

population aid code group:

- Affordable Care Act (ACA)

- Optional Targeted Low Income Children (OTLIC)

- Seniors and Persons with Disabilities (SPD)

- All other aid codes not categorized as ACA, OTLIC, or SPD

(OTHER)

Global Quarterly Report: 1Q2019

Across all population aid code groups, the vast majority are

MCP enrollees (range from 96% of OTLIC to 78% of OTHER)

With few exceptions, MCP enrollees have a higher mean

days’ supply per total utilizing beneficiary than FFS enrollees

Board should review this report for areas that merit further

data evaluation and/or potential educational outreach to

providers

Will continue to present these data quarterly at each Board

meeting

Global Quarterly Report: 1Q2019 (cont.)


Stratified tables represent 95.7% of paid claims

15% of eligible Medi-Cal FFS enrollees had a paid claim through

the Medi-Cal fee-for-service program, compared with only 2% of

Medi-Cal MCP enrollees

FFS utilization of proton-pump inhibitors showed a 41% increase

in total paid claims from 2018 Q2, which may be attributed to the

addition of omeprazole to the Medi-Cal fee-for-service List of

Contract Drugs (CDL), effective May 1, 2019

Naloxone had a 518% increase in total paid claims from 2018 Q2

FFS Quarterly Report: 2Q2019


First annual review of PADs (used to be presented quarterly)

VFC administration costs began effective July 1, 2017, so

data is skewed when comparing 2018 utilization to 2017:

- 1% overall increase in total utilizing beneficiaries (28% increase

among vaccines)

- 3% overall increase in total paid claims (48% increase among

vaccines)

- 6%overall increase in total reimbursement dollars paid (37%

increase among vaccines)

FFS PAD Annual Report: 2018


Annual review of drugs added to the Medi-Cal List of Contract

Drugs (ongoing, presented each November)

HCV medications (ongoing, presented each November)

Opioid prescribing by dentists

NSAIDs

Pharmacist furnishing of hormonal contraceptives

Assessment of opioid use and mortality (stratified by gender)

Antipsychotic polypharmacy in adults

Future Topics

Antidepressant Medication Management (AMM-AD)

Concurrent Use of Opioids and Benzodiazepines (COB-AD)

Contraceptive Care – Postpartum Women Ages 21–44 (CCP-AD)

Flu Vaccinations for Adults Ages 18–64 (FVA-AD)

Use of Opioids at High Dosage in Persons Without Cancer (OHD-AD)

Adherence to Antipsychotic Medications for Individuals with

Schizophrenia (SAA-AD)

Diabetes Screening for People With Schizophrenia or Bipolar Disorder

Who Are Using Antipsychotic Medications (SSD-AD)

Future Topics: Adult Core Set Measures

Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity

Disorder (ADHD) Medication (ADD-CH)

Asthma Medication Ratio: Ages 5–18 (AMR-CH)

Contraceptive Care – Postpartum Women Ages 15–20 (CCP-CH)

Childhood Immunization Status (CIS-CH)

Immunizations for Adolescents (IMA-CH)

Future Topics: Child Core Set Measures


June 2019: Alert

Drug Safety Communication: Sleep Behavior Risks with

Select Sleep Aids

August 2019: Bulletins

Clinical Review Update: Concomitant Anticholinergic and

Antipsychotic Use

DUR Publications

Alerts:

- California Upgrades Immunization Registry to CAIR2

Bulletins:

- Annual immunization update (published each September)

- Managing pain in population with comorbid mental health conditions

- Pharmacist furnishing of naloxone

- Pharmacist furnishing of hormonal contraception

- Hypertension medication adherence

- Topic presented today: antihyperglycemic medications

Future Topics: Publications




Global DUR Quarterly Report – Version 1.0: July 30, 2019 2019 Q1 (JANUARY – MARCH 2019)

1

ANNUAL SUMMARY GLOBAL MEDI-CAL DRUG USE REVIEW

REPORT PERIOD: 1ST QUARTER 2019 (JANUARY – MARCH 2019)

Executive Summary

The Global DUR quarterly report provides information on retrospective drug utilization for all paid pharmacy claims for beneficiaries in the Medi-Cal program. For this report, the retrospective data cover the first quarter of 2019 (2019 Q1). In 2019 Q1, approximately 32% of eligible Medi-Cal enrollees had a paid pharmacy claim through the Medi-Cal program, including 15% of eligible Medi-Cal fee-for-service enrollees and 36% of Medi-Cal managed care plan (MCP) enrollees (Table 1.1). Among all Medi-Cal beneficiaries with a paid claim through the Medi-Cal fee-for-service program in 2019 Q2, 57% were FFS enrollees and 36% were MCP enrollees (numbers add up to less than 100% due to the lag in processing time). When data from 2019 Q1 were compared to the prior year (2018 Q1), data from 2019 Q1 showed a 3% decrease in total eligible beneficiaries, a 4% decreased in total utilizing beneficiaries, and a 5% decrease in total paid pharmacy claims. When beneficiaries eligible for Medi-Cal were stratified by population aid code group (Tables 1.2 – 1.5), 30% were Affordable Care Act (ACA), 6% were Optional Targeted Low Income Children (OTLIC), and 16% were Seniors and Persons with Disabilities (SPD). Within the population aid code groups, the vast majority were MCP enrollees, including 80% of the ACA population, 94% of the OTLIC population, 79% of the SPD population, and 78% of the remaining (OTHER) population. Of note, approximately 1% of eligible beneficiaries had more than one population aid code group throughout the duration of 2019 Q1. As shown in Tables 2.1 – 2.3, there was an decrease in total utilizing beneficiaries and total paid claims across all age groups for both FFS and MCP enrollees in comparison to the prior-year quarter. The greatest decrease in total utilizing beneficiaries and total paid claims within the top 20 drug therapeutic categories by total utilizing beneficiaries was seen in the OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS drug therapeutic category, which posted a 20% decrease in total utilizing beneficiaries from the prior-year quarter (Table 3). Similar results are shown on Table 5, where HYDROCODONE/ACETAMINOPHEN also posted a 20% decrease in total utilizing beneficiaries from the prior-year quarter. Of note, Tables 4.1 – 4.4 show the top 20 drug therapeutic categories by total utilizing beneficiaries in 2019 Q1, stratified by population aid code group and Tables 6.1 – 6.4 show the top 20 drugs by total utilizing beneficiaries in 2019 Q1, stratified by population aid code group. Within each of these tables, the mean days’ supply per utilizing beneficiary is shown across all Medi-Cal enrollees, as well as by FFS and MCP programs. The percentage of utilizing beneficiaries with a paid claim is also included by FFS and MCP programs, wih the total number of utilizing beneficiaries shown across the Medi-Cal program. With few exceptions, the mean days’ supply was almost always lower for FFS enrollees in comparison to MCP enrollees across all population aid code groups for both the top 20 drug therapeutic categories and top 20 drugs during 2019 Q1.


2

Tables 1.1-1.5. Summary of Global Medi-Cal Pharmacy Utilization. Table 1.1 shows pharmacy utilization in the Medi-Cal program, including the percent change from the prior-year quarter. Beneficiaries with enrollments in both FFS and MCP during the quarter may be counted twice (represents 2.2% of utilizing beneficiaries). Tables 1.2-1.5 show pharmacy utilization in the Medi-Cal program, stratified by population aid code group Table 1: Global Medi-Cal Pharmacy Utilization Measures for the Entire Medi-Cal Population

Category Current Quarter 2019 Q1

Prior-Year Quarter 2018 Q1

% Change from Prior Year

Total Eligible Beneficiaries 15,372,324 15,802,041 -2.7% Total Utilizing Beneficiaries 4,968,889 5,191,689 -4.3% Total Paid Rx Claims 27,024,296 28,313,422 -4.6% Average Paid Rx Claims per Eligible Beneficiary 1.76 1.79 -1.9% Average Paid Rx Claims per Utilizing Beneficiary 5.44 5.45 -0.3% Fee-for-Service Enrollees Total Eligible Beneficiaries 3,174,181 3,337,584 -4.9% Total Utilizing Beneficiaries 476,260 513,763 -7.3% Total Paid Rx Claims 1,693,716 1,816,014 -6.7% Average Paid Rx Claims per Eligible Beneficiary 0.53 0.54 -1.9% Average Paid Rx Claims per Utilizing Beneficiary 3.56 3.53 0.6% Managed Care Plan Enrollees Total Eligible Beneficiaries 12,598,891 12,917,327 -2.5% Total Utilizing Beneficiaries 4,522,256 4,707,708 -3.9% Total Paid Rx Claims 25,324,785 26,476,893 -4.4% Average Paid Rx Claims per Eligible Beneficiary 2.01 2.05 -1.9% Average Paid Rx Claims per Utilizing Beneficiary 5.60 5.62 -0.4%


3

Table 1.2 shows pharmacy utilization within the Affordable Care Act (ACA) population, which consists of the following Adult Expansion aid codes: M1, M2, L1, and 7U. Table 1.2: Global Medi-Cal Pharmacy Utilization Measures for the ACA Population




Total Eligible Beneficiaries 4,544,032 4,589,091 -1.0% Total Utilizing Beneficiaries 1,591,062 1,598,305 -0.5% Total Paid Rx Claims 10,292,558 10,382,829 -0.9% Average Paid Rx Claims per Eligible Beneficiary 2.27 2.26 0.1% Average Paid Rx Claims per Utilizing Beneficiary 6.47 6.50 -0.4% Fee-for-Service Enrollees Total Eligible Beneficiaries 948,780 988,160 -4.0% Total Utilizing Beneficiaries 122,330 127,034 -3.7% Total Paid Rx Claims 484,076 494,482 -2.1% Average Paid Rx Claims per Eligible Beneficiary 0.51 0.50 2.0% Average Paid Rx Claims per Utilizing Beneficiary 3.96 3.89 1.7% Managed Care Plan Enrollees Total Eligible Beneficiaries 3,738,161 3,764,971 -0.7% Total Utilizing Beneficiaries 1,483,502 1,487,738 -0.3% Total Paid Rx Claims 9,808,482 9,888,166 -0.8% Average Paid Rx Claims per Eligible Beneficiary 2.62 2.63 -0.1% Average Paid Rx Claims per Utilizing Beneficiary 6.61 6.65 -0.5%


4

Table 1.3 shows pharmacy utilization within the Optional Targeted Low Income Children (OTLIC) population consists of the following OTLIC aid codes: 2P, 2R, 2S, 2T, 2U, 5C, 5D, E2, E5, E6, E7, H1, H2, H3, H4, H5, M5, T0, T1, T2, T3, T4, T5, T6, T7, T8, and T9. Table 1.3: Global Medi-Cal Pharmacy Utilization Measures for the OTLIC Population




Total Eligible Beneficiaries 939,987 963,392 -2.4% Total Utilizing Beneficiaries 234,180 243,764 -3.9% Total Paid Rx Claims 658,772 679,968 -3.1% Average Paid Rx Claims per Eligible Beneficiary 0.70 0.71 -0.7% Average Paid Rx Claims per Utilizing Beneficiary 2.81 2.79 0.8% Fee-for-Service Enrollees Total Eligible Beneficiaries 59,926 63,007 -4.9% Total Utilizing Beneficiaries 4,519 4,816 -6.2% Total Paid Rx Claims 10,112 10,737 -5.8% Average Paid Rx Claims per Eligible Beneficiary 0.17 0.17 -1.0% Average Paid Rx Claims per Utilizing Beneficiary 2.24 2.23 0.4% Managed Care Plan Enrollees Total Eligible Beneficiaries 897,878 919,545 -2.4% Total Utilizing Beneficiaries 230,079 239,425 -3.9% Total Paid Rx Claims 648,660 669,230 -3.1% Average Paid Rx Claims per Eligible Beneficiary 0.72 0.73 -0.7% Average Paid Rx Claims per Utilizing Beneficiary 2.82 2.80 0.9%


5

Table 1.4 shows pharmacy utilization within the Seniors and Persons with Disabilities (SPD) population, which consists of the following SPD aid codes: 10, 13, 14, 16, 17, 1E, 1H, 20, 23, 24, 26, 27, 2E, 2H, 36, 60, 63, 64, 66, 67, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6R, 6V, 6W, 6X, 6Y, C1, C2, C3, C4, C7, C8, D2, D3, D4, D5, D6, and D7. Table 1.4: Global Medi-Cal Pharmacy Utilization Measures for the SPD Population




Total Eligible Beneficiaries 2,473,060 2,493,646 -0.8% Total Utilizing Beneficiaries 921,025 983,392 -6.3% Total Paid Rx Claims 7,658,744 8,214,149 -6.8% Average Paid Rx Claims per Eligible Beneficiary 3.10 3.29 -6.0% Average Paid Rx Claims per Utilizing Beneficiary 8.32 8.35 -0.4% Fee-for-Service Enrollees Total Eligible Beneficiaries 520,379 534,836 -2.7% Total Utilizing Beneficiaries 99,887 113,916 -12.3% Total Paid Rx Claims 468,749 526,058 -10.9% Average Paid Rx Claims per Eligible Beneficiary 0.90 0.98 -8.4% Average Paid Rx Claims per Utilizing Beneficiary 4.69 4.62 1.6% Managed Care Plan Enrollees Total Eligible Beneficiaries 1,987,770 1,995,982 -0.4% Total Utilizing Beneficiaries 825,749 874,757 -5.6% Total Paid Rx Claims 7,189,993 7,688,532 -6.5% Average Paid Rx Claims per Eligible Beneficiary 3.62 3.85 -6.1% Average Paid Rx Claims per Utilizing Beneficiary 8.71 8.79 -0.9%


6

Table 1.5 shows pharmacy utilization within the Other Populations (OTHER) population, which consists of all aid codes not categorized under ACA, OTLIC, or SPD. Table 1.5: Global Medi-Cal Pharmacy Utilization Measures for the OTHER Population




Total Eligible Beneficiaries 7,632,370 7,988,743 -4.5% Total Utilizing Beneficiaries 2,254,040 2,395,229 -5.9% Total Paid Rx Claims 8,408,429 9,015,799 -6.7% Average Paid Rx Claims per Eligible Beneficiary 1.10 1.13 -2.4% Average Paid Rx Claims per Utilizing Beneficiary 3.73 3.76 -0.9% Fee-for-Service Enrollees Total Eligible Beneficiaries 1,680,249 1,789,809 -6.1% Total Utilizing Beneficiaries 251,842 270,460 -6.9% Total Paid Rx Claims 730,779 784,737 -6.9% Average Paid Rx Claims per Eligible Beneficiary 0.43 0.44 -0.8% Average Paid Rx Claims per Utilizing Beneficiary 2.90 2.90 0.0% Managed Care Plan Enrollees Total Eligible Beneficiaries 6,150,490 6,424,164 -4.3% Total Utilizing Beneficiaries 2,012,911 2,137,466 -5.8% Total Paid Rx Claims 7,677,650 8,230,965 -6.7% Average Paid Rx Claims per Eligible Beneficiary 1.25 1.28 -2.6% Average Paid Rx Claims per Utilizing Beneficiary 3.81 3.85 -1.0%


7

Table 2.1 – 2.3. Pharmacy Utilization by Age Group in the Medi-Cal Population. These tables present pharmacy utilization data in the Medi-Cal program broken out by age group, including the percent change from the prior-year quarter. Beneficiaries with enrollments in both FFS and MCP during the quarter may be counted in both Table 2.2 and Table 2.3, as enrollment status may change. Table 2.1: Pharmacy Utilization by Age Group for the Entire Medi-Cal Population

Age Group (years)

Current Quarter

2019 Q1 Total Paid Claims

Prior-Year Quarter


% Change from

Prior Year

Current Quarter 2019 Q1

Total Utilizing Beneficiaries



% Change from

Prior Year

0 – 12 3,499,907 3,740,250 -6.4% 1,181,987 1,261,799 -6.3% 13 – 18 1,484,582 1,509,209 -1.6% 454,481 466,280 -2.5% 19 – 39 5,694,641 5,906,638 -3.6% 1,285,221 1,330,182 -3.4% 40 – 64 13,966,931 14,716,231 -5.1% 1,615,190 1,679,481 -3.8% 65+ 2,378,235 2,441,091 -2.6% 432,010 453,944 -4.8% Total* 27,024,296 28,313,422 -4.6% 4,968,889 5,191,689 -4.3% * Unknowns represent less than 1% of total Table 2.2: Pharmacy Utilization by Age Group for the Medi-Cal FFS Population Only

Age Group (years)

Current Quarter


Prior-Year Quarter


% Change from

Prior Year





% Change from

Prior Year

0 – 12 213,055 240,801 -11.5% 80,384 90,375 -11.1% 13 – 18 99,567 105,220 -5.4% 26,430 27,779 -4.9% 19 – 39 477,113 511,293 -6.7% 153,612 165,558 -7.2% 40 – 64 713,444 748,325 -4.7% 153,615 160,107 -4.1% 65+ 190,537 210,375 -9.4% 62,219 69,944 -11.0% Total* 1,693,716 1,816,014 -6.7% 476,260 513,763 -7.3% * Unknowns represent less than 1% of total Table 2.3: Pharmacy Utilization by Age Group for the Medi-Cal MCP Population Only

Age Group (years)

Current Quarter


Prior-Year Quarter


% Change from

Prior Year





% Change from

Prior Year

0 – 12 3,284,316 3,492,065 -5.9% 1,105,707 1,175,056 -5.9% 13 – 18 1,384,654 1,402,753 -1.3% 429,246 439,501 -2.3% 19 – 39 5,216,704 5,388,110 -3.2% 1,141,785 1,173,817 -2.7% 40 – 64 13,252,007 13,964,202 -5.1% 1,474,462 1,533,688 -3.9% 65+ 2,187,104 2,229,763 -1.9% 371,056 385,646 -3.8% Total* 25,324,785 26,476,893 -4.4% 4,522,256 4,707,708 -3.9% * Unknowns represent less than 1% of total


8

Table 3. Top 20 Drug Therapeutic Categories in the Medi-Cal Population. This table presents the top 20 drug therapeutic categories in the Medi-Cal program, by total utilizing beneficiaries. The current quarter is compared to the prior-year quarter in order to illustrate changes in utilization for these drugs. The prior-year quarter ranking of the drug therapeutic category is listed for reference.

Table 3: Top 20 Drug Therapeutic Categories by Total Utilizing Beneficiaries for the Entire Medi-Cal Population

Rank

Last Year Rank Drug Therapeutic Category Description

Current Quarter


% Change from Prior

Year

Current Quarter

2019 Q1 Total Utilizing

Beneficiaries

% Utilizing Beneficiaries with a Paid

Claim

% Change from Prior

Year

1 1 NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS 1,459,200 -5.6% 1,140,140 23.0% -0.3%

2 2 PENICILLIN ANTIBIOTICS 806,622 -6.2% 742,973 15.0% -0.3% 3 3 BETA-ADRENERGIC AGENTS,

INHALED, SHORT ACTING 790,797 -6.9% 527,063 10.6% -0.3%

4 4 ANTIHISTAMINES - 2ND GENERATION 742,786 -4.0% 496,750 10.0% 0.2%

5 5 ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) 919,232 -2.1% 490,461 9.9% 0.5%

6 6 ANTICONVULSANTS 921,160 -1.5% 416,276 8.4% 0.3% 7 8 PLATELET AGGREGATION

INHIBITORS 692,603 -6.8% 370,561 7.5% -0.1% 8 16 VITAMIN D PREPARATIONS 605,516 7.3% 334,881 6.7% 0.8% 9 10 ANTIHYPERTENSIVES, ACE

INHIBITORS 627,090 -7.7% 329,576 6.6% 0.0%

10 12 SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) 671,532 -1.2% 322,330 6.5% 0.2%

11 7 OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS 513,849 -20.4% 316,930 6.4% -1.4%

12 11 TOPICAL ANTI-INFLAMMATORY STEROIDAL 395,467 -3.8% 316,519 6.4% 0.1%

13 13 PROTON-PUMP INHIBITORS 565,436 -4.7% 315,678 6.4% 0.1% 14 9 MACROLIDE ANTIBIOTICS 335,378 -10.8% 311,329 6.3% -0.5% 15 14 LAXATIVES AND CATHARTICS 442,511 -6.0% 299,713 6.0% -0.1% 16 17 ANTIHYPERGLYCEMIC, BIGUANIDE

TYPE 558,106 -5.2% 297,430 6.0% 0.1%

17 15 ANALGESIC/ANTIPYRETICS,NON-SALICYLATE 342,476 -5.2% 296,145 6.0% 0.0%

18 20 GLUCOCORTICOIDS 341,494 -1.6% 279,066 5.6% 0.1% 19 18 NASAL ANTI-INFLAMMATORY

STEROIDS 371,869 -3.2% 277,916 5.6% 0.1%

20 19 ANTIHISTAMINES - 1ST GENERATION 381,524 -6.3% 268,828 5.4% -0.1%


9

Tables 4.1 – 4.4. Top 20 Drug Therapeutic Categories in the Medi-Cal Population by Population Aid Code Group, Stratified by Program. These tables present the top 20 drug therapeutic categories in the Medi-Cal program by total utilizing beneficiaries from each population aid code group, stratified by Medi-Cal program. Mean days’ supply per beneficiary is included for reference. Table 4.1 presents the top 20 drug therapeutic categories in the Affordable Care Act (ACA) population, which consists of the following Adult Expansion aid codes: M1, M2, L1, and 7U.

Table 4.1: Top 20 Drug Therapeutic Categories by Total ACA Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program

Current Quarter 2019 Q1 Mean Days’ Supply per

Utilizing Beneficiary Total Utilizing Beneficiaries

Rank Drug Therapeutic Category Description All

Medi-Cal FFS MCP All

Medi-Cal % FFS % MCP

1 NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS 38 18 39 368,745 22.2% 23.1%

2 ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) 92 73 93 272,274 12.3% 17.4%

3 ANTIHYPERTENSIVES, ACE INHIBITORS 97 73 98 184,678 11.4% 11.6% 4 ANTICONVULSANTS 81 56 82 175,574 10.3% 11.1%

5 ANTIHYPERGLYCEMIC, BIGUANIDE TYPE 95 73 97 164,333 10.1% 10.3%

6 PENICILLIN ANTIBIOTICS 19 9 19 162,562 10.3% 10.1% 7 PROTON-PUMP INHIBITORS 79 77 80 154,477 5.1% 10.0%

8 SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) 82 56 83 150,497 7.2% 9.6%

9 OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS 34 6 36 141,319 8.1% 8.9%

10 BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING 43 26 44 133,578 6.6% 8.5%

11 PLATELET AGGREGATION INHIBITORS 94 68 95 128,875 4.5% 8.3% 12 CALCIUM CHANNEL BLOCKING AGENTS 92 71 93 128,279 6.6% 8.2% 13 ANTIHISTAMINES - 2ND GENERATION 61 45 61 125,693 3.2% 8.2% 14 VITAMIN D PREPARATIONS 80 55 80 123,239 0.4% 8.3% 15 BETA-ADRENERGIC BLOCKING AGENTS 89 65 90 112,673 5.4% 7.2% 16 BLOOD SUGAR DIAGNOSTICS 81 40 81 101,901 0.1% 6.9% 17 SKELETAL MUSCLE RELAXANTS 45 32 46 99,686 2.4% 6.5%

18 TOPICAL ANTI-INFLAMMATORY STEROIDAL 35 25 35 96,482 3.0% 6.3%

19 MACROLIDE ANTIBIOTICS 20 6 21 94,758 5.2% 6.0% 20 INSULINS 79 60 81 94,493 6.2% 5.9%


10

Table 4.2 presents the top 20 drug therapeutic categories in the Optional Targeted Low Income Children (OTLIC) population, which consists of the following OTLIC aid codes: 2P, 2R, 2S, 2T, 2U, 5C, 5D, E2, E5, E6, E7, H1, H2, H3, H4, H5, M5, T0, T1, T2, T3, T4, T5, T6, T7, T8, and T9.

Table 4.2: Top 20 Drug Therapeutic Categories by Total OTLIC Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program







2 PENICILLIN ANTIBIOTICS 17 10 17 52,551 23.7% 22.4%


4 ANTIHISTAMINES - 2ND GENERATION 47 32 47 33,998 6.9% 14.7% 5 NASAL ANTI-INFLAMMATORY STEROIDS 51 51 19,469 3.3% 8.4%

6 ANALGESIC/ANTIPYRETICS,NON-SALICYLATE 25 8 25 19,233 7.9% 8.2%

7 MACROLIDE ANTIBIOTICS 24 6 24 18,457 7.3% 7.9% 8 ANTIVIRALS, GENERAL 26 5 26 16,993 7.0% 7.3%


10 NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. 43 10 44 15,287 5.4% 6.5%

11 GLUCOCORTICOIDS 26 8 27 14,016 6.4% 6.0% 12 ANTIEMETIC/ANTIVERTIGO AGENTS 14 5 14 12,558 4.9% 5.4% 13 GLUCOCORTICOIDS, ORALLY INHALED 58 43 58 11,766 3.6% 5.1% 14 ANTIHISTAMINES - 1ST GENERATION 29 17 30 11,742 4.5% 5.0% 15 TOPICAL ANTIBIOTICS 35 25 36 11,188 1.6% 4.8%

16 CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION 20 10 20 9,788 5.5% 4.2%

17 NON-OPIOID ANTITUS-1ST GEN.ANTIHISTAMINE-DECONGEST 32 11 32 8,895 0.1% 3.9%

18 RESPIRATORY AIDS,DEVICES,EQUIPMENT 34 16 34 8,642 0.1% 3.8%

19 LEUKOTRIENE RECEPTOR ANTAGONISTS 58 46 58 8,590 3.3% 3.7%

20 OPHTHALMIC ANTIBIOTICS 23 12 23 8,350 4.0% 3.6%


11

Table 4.3 presents the top 20 drug therapeutic categories in the Seniors and Persons with Disabilities (SPD) population, which consists of the following SPD aid codes: 10, 13, 14, 16, 17, 1E, 1H, 20, 23, 24, 26, 27, 2E, 2H, 36, 60, 63, 64, 66, 67, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6R, 6V, 6W, 6X, 6Y, C1, C2, C3, C4, C7, C8, D2, D3, D4, D5, D6, and D7.

Table 4.3: Top 20 Drug Therapeutic Categories by Total SPD Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program





Medi-Cal % FFS % MCP 1 PLATELET AGGREGATION INHIBITORS 88 84 88 206,977 25.1% 22.1% 2 ANTICONVULSANTS 92 77 92 158,700 12.9% 17.8%

3 ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) 93 74 93 142,834 6.3% 16.6%

4 VITAMIN D PREPARATIONS 79 68 79 138,603 1.0% 16.7% 5 LAXATIVES AND CATHARTICS 59 67 58 120,896 13.7% 13.0%


7 ANTIHISTAMINES - 2ND GENERATION 69 68 69 102,884 13.2% 10.9%

8 ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST 86 76 85 85,960 5.9% 9.8%

9 PROTON-PUMP INHIBITORS 87 69 87 84,950 3.7% 9.9% 10 ANTIHYPERTENSIVES, ACE INHIBITORS 95 74 96 82,794 4.4% 9.5% 11 CALCIUM CHANNEL BLOCKING AGENTS 92 73 93 81,640 4.1% 9.4%



14 CALCIUM REPLACEMENT 78 83 77 76,875 6.8% 8.5% 15 BETA-ADRENERGIC BLOCKING AGENTS 90 71 91 68,938 3.5% 8.0%

16 ANTIHYPERGLYCEMIC, BIGUANIDE TYPE 95 73 96 68,024 3.3% 7.9%


18 BLOOD SUGAR DIAGNOSTICS 77 N/A 77 59,598 N/A 7.2% 19 ANTIHISTAMINES - 1ST GENERATION 58 46 59 58,627 4.9% 6.5% 20 INSULINS 78 62 78 50,198 3.2% 5.7%


12

Table 4.4 presents the top 20 drug therapeutic categories in the Other Populations (OTHER) population, which consists of all aid codes not categorized under ACA, OTLIC, or SPD.

Table 4.4: Top 20 Drug Therapeutic Categories by Total OTHER Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program







2 PENICILLIN ANTIBIOTICS 20 10 21 478,519 15.2% 21.9%


4 ANTIHISTAMINES - 2ND GENERATION 51 42 51 236,206 4.1% 11.2%

5 ANALGESIC/ANTIPYRETICS,NON-SALICYLATE 29 10 31 204,840 6.4% 9.4%

6 MACROLIDE ANTIBIOTICS 27 7 28 165,880 5.6% 7.6%


8 GLUCOCORTICOIDS 32 10 34 147,231 5.0% 6.7% 9 NASAL ANTI-INFLAMMATORY STEROIDS 53 38 53 127,530 1.5% 6.1%

10 ANTIVIRALS, GENERAL 30 10 32 126,847 4.0% 5.8% 11 ANTIEMETIC/ANTIVERTIGO AGENTS 18 9 19 126,252 5.8% 5.6% 12 ANTIHISTAMINES - 1ST GENERATION 34 21 35 125,589 3.7% 5.8%


14 NON-OPIOID ANTITUSSIVE-1ST GEN ANTIHISTAMINE COMB. 46 11 49 102,550 2.9% 4.7%

15 CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION 23 9 25 102,505 5.6% 4.4%


17 LAXATIVES AND CATHARTICS 38 34 39 89,207 3.9% 4.0% 18 CONTRACEPTIVES,ORAL 90 74 92 87,384 4.0% 3.9% 19 ANTICONVULSANTS 83 60 86 81,531 3.5% 3.6% 20 OPHTHALMIC ANTIBIOTICS 26 14 27 81,220 2.7% 3.7%


13

Table 5. Top 20 Drugs in the Medi-Cal Population. This table presents the top 20 drugs in the Medi-Cal program, by total utilizing beneficiaries. The current quarter is compared to the prior-year quarter in order to illustrate changes in utilization for these drugs. The prior-year quarter ranking of each drug is listed for reference.

Table 5: Top 20 Drugs by Total Utilizing Beneficiaries for the Entire Medi-Cal Population

Rank

Last Year Rank Drug Description

Current Quarter 2019 Q1 Total Paid Claims


Current Quarter 2019 Q1 Total

Utilizing Beneficiaries

% Utilizing Beneficiaries with a Paid

Claim

% Change from Prior

Year 1 1 IBUPROFEN 1,113,196 -5.1% 904,900 18.2% -0.2% 2 2 AMOXICILLIN 610,011 -6.1% 559,192 11.3% -0.2% 3 3 ALBUTEROL SULFATE 803,584 -7.3% 540,566 10.9% -0.4% 4 4 LORATADINE 523,194 -7.2% 349,363 7.0% -0.1% 5 5 ASPIRIN 637,260 -7.8% 344,244 6.9% -0.2%

6 7 FLUTICASONE PROPIONATE 452,052 4.4% 329,890 6.6% 0.5%

7 10 ATORVASTATIN CALCIUM 608,085 7.0% 327,056 6.6% 0.8%

8 9 METFORMIN HCL 558,106 -5.2% 297,430 6.0% 0.1% 9 6 AZITHROMYCIN 318,267 -10.9% 296,926 6.0% -0.5%

10 8 ACETAMINOPHEN 342,489 -5.2% 296,155 6.0% 0.0% 11 12 LISINOPRIL 482,335 -5.4% 252,508 5.1% 0.1%

12 11 HYDROCODONE/ ACETAMINOPHEN 376,890 -20.4% 223,751 4.5% -0.9%

13 16 AMLODIPINE BESYLATE 407,286 -1.8% 213,089 4.3% 0.2%

14 14 OMEPRAZOLE 380,217 -6.2% 212,564 4.3% 0.0%

15 13 PROMETHAZINE/ DEXTROMETHORPHAN 235,776 -10.8% 211,834 4.3% -0.3%

16 17 GABAPENTIN 425,922 -0.7% 208,466 4.2% 0.2%

17 19 CHOLECALCIFEROL (VITAMIN D3) 353,068 9.8% 201,890 4.1% 0.6%

18 15 BLOOD SUGAR DIAGNOSTIC 353,949 -5.1% 201,377 4.1% 0.0%

19 18 CEPHALEXIN 205,651 -5.0% 191,180 3.9% 0.0%

20 20 LEVOTHYROXINE SODIUM 345,604 -4.2% 167,664 3.4% 0.1%


14

Tables 6.1 – 6.4. Top 20 Drugs in the Medi-Cal Population, by Population Aid Code Group and Program. These tables present utilization of the top 20 drugs in the Medi-Cal program by total utilizing beneficiaries from each population aid code group, stratified by Medi-Cal program. Mean days’ supply per beneficiary is included for reference. Table 6.1 presents the top 20 drugs in the Affordable Care Act (ACA) population, which consists of the following Adult Expansion aid codes: M1, M2, L1, and 7U.

Table 6.1: Top 20 Drugs by Total ACA Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program



Rank Drug Description All


Medi-Cal % FFS % MCP 1 IBUPROFEN 32 15 33 250,033 17.1% 15.5% 2 ATORVASTATIN CALCIUM 92 78 93 183,824 8.7% 11.7% 3 METFORMIN HCL 95 73 97 164,333 10.1% 10.3% 4 LISINOPRIL 99 73 100 143,625 9.2% 9.0% 5 ALBUTEROL SULFATE 43 26 44 133,741 6.6% 8.5% 6 ASPIRIN 93 65 94 115,055 3.6% 7.5% 7 AMLODIPINE BESYLATE 92 72 92 112,978 5.7% 7.2% 8 OMEPRAZOLE 78 38 78 105,338 0.2% 7.1% 9 GABAPENTIN 78 53 79 105,166 5.6% 6.7%

10 AMOXICILLIN 22 8 23 104,953 6.4% 6.6% 11 FLUTICASONE PROPIONATE 56 54 56 102,098 2.2% 6.7% 12 BLOOD SUGAR DIAGNOSTIC 81 39 81 101,894 0.1% 6.9% 13 HYDROCODONE/ACETAMINOPHEN 38 6 40 99,566 5.7% 6.5% 14 AZITHROMYCIN 20 5 21 88,709 4.8% 5.6% 15 LORATADINE 64 45 64 87,415 3.1% 5.7% 16 LEVOTHYROXINE SODIUM 100 76 101 82,133 4.0% 5.3% 17 LOSARTAN POTASSIUM 97 79 98 80,950 3.5% 5.2% 18 HYDROCHLOROTHIAZIDE 99 67 100 72,835 3.7% 4.6% 19 CHOLECALCIFEROL (VITAMIN D3) 74 57 74 72,635 0.1% 4.9% 20 LANCETS 77 39 77 69,757 0.1% 4.7%


15

Table 6.2 presents the top 20 drugs in the Optional Targeted Low Income Children (OTLIC) population, which consists of the following OTLIC aid codes: 2P, 2R, 2S, 2T, 2U, 5C, 5D, E2, E5, E6, E7, H1, H2, H3, H4, H5, M5, T0, T1, T2, T3, T4, T5, T6, T7, T8, and T9.

Table 6.2: Top 20 Drugs by Total OTLIC Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program





Medi-Cal % FFS % MCP 1 IBUPROFEN 26 9 26 55,530 20.2% 23.8% 2 AMOXICILLIN 18 10 18 42,650 18.5% 18.2% 3 ALBUTEROL SULFATE 36 26 36 35,518 15.5% 15.2% 4 FLUTICASONE PROPIONATE 52 39 52 24,360 6.0% 10.5% 5 LORATADINE 47 32 47 22,845 6.7% 9.8% 6 ACETAMINOPHEN 25 8 25 19,234 7.9% 8.2% 7 AZITHROMYCIN 24 5 25 18,151 7.1% 7.8% 8 OSELTAMIVIR PHOSPHATE 27 5 27 16,094 6.7% 6.9% 9 PROMETHAZINE/DEXTROMETHORPHAN 43 10 44 15,284 5.4% 6.5%

10 CETIRIZINE HCL 46 33 46 10,922 0.2% 4.7% 11 CEPHALEXIN 20 10 20 9,771 5.5% 4.1% 12 ONDANSETRON 12 4 12 8,887 2.9% 3.8% 13 MONTELUKAST SODIUM 58 46 58 8,588 3.3% 3.7% 14 AMOXICILLIN/POTASSIUM CLAV 11 10 11 8,287 4.3% 3.5% 15 TRIAMCINOLONE ACETONIDE 30 22 30 7,835 3.2% 3.3% 16 DIPHENHYDRAMINE HCL 27 14 27 6,903 2.6% 3.0% 17 HYDROCORTISONE 26 18 26 6,691 2.6% 2.9% 18 BROMPHENIRAMINE/PSEUDOEPHED/DM 29 10 29 6,069 0.1% 2.6% 19 CLINDAMYCIN PHOSPHATE 46 33 46 5,470 0.8% 2.4% 20 BENZOYL PEROXIDE 42 29 42 5,369 1.1% 2.3%


16

Table 6.3 presents the top 20 drugs in the Seniors and Persons with Disabilities (SPD) population, which consists of the following SPD aid codes: 10, 13, 14, 16, 17, 1E, 1H, 20, 23, 24, 26, 27, 2E, 2H, 36, 60, 63, 64, 66, 67, 6A, 6C, 6E, 6G, 6H, 6J, 6N, 6P, 6R, 6V, 6W, 6X, 6Y, C1, C2, C3, C4, C7, C8, D2, D3, D4, D5, D6, and D7.

Table 6.3: Top 20 Drugs by Total SPD Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program





Medi-Cal % FFS % MCP 1 ASPIRIN 87 84 87 197,151 25.0% 20.9% 2 ATORVASTATIN CALCIUM 93 73 94 92,377 4.3% 10.7% 3 CHOLECALCIFEROL (VITAMIN D3) 78 36 78 84,891 0.5% 10.2% 4 LORATADINE 71 68 72 78,936 12.9% 8.0% 5 ALBUTEROL SULFATE 54 37 54 77,656 4.0% 9.0% 6 DOCUSATE SODIUM 69 69 69 74,049 12.2% 7.5% 7 IBUPROFEN 40 21 41 70,735 2.8% 8.3% 8 AMLODIPINE BESYLATE 92 73 93 69,577 3.5% 8.1% 9 METFORMIN HCL 95 73 96 68,024 3.3% 7.9%

10 GABAPENTIN 86 66 87 66,044 3.2% 7.7% 11 BLOOD SUGAR DIAGNOSTIC 77 46 77 59,579 0.1% 7.2% 12 LISINOPRIL 98 73 99 59,418 3.3% 6.8% 13 OMEPRAZOLE 84 57 84 54,117 0.2% 6.5% 14 ERGOCALCIFEROL (VITAMIN D2) 81 65 81 51,549 0.3% 6.2% 15 HYDROCODONE/ACETAMINOPHEN 61 26 63 48,132 1.8% 5.6% 16 FERROUS SULFATE 80 74 80 46,243 7.2% 4.7% 17 LOSARTAN POTASSIUM 95 47 96 44,992 1.8% 5.3% 18 FLUTICASONE PROPIONATE 65 35 65 43,957 1.4% 5.2% 19 PROMETHAZINE/DEXTROMETHORPHAN 27 13 30 43,092 6.8% 4.4% 20 LEVOTHYROXINE SODIUM 99 81 99 42,548 2.8% 4.8%


17

Table 6.4 presents the top 20 drugs in the Other Populations (OTHER) population, which consists of all aid codes not categorized under ACA, OTLIC, or SPD.

Table 6.4: Top 20 Drug by Total OTHER Utilizing Beneficiaries for the Entire Medi-Cal Population, by Program





Medi-Cal % FFS % MCP 1 IBUPROFEN 30 12 32 530,087 21.0% 23.7% 2 AMOXICILLIN 22 10 23 379,532 11.2% 17.5% 3 ALBUTEROL SULFATE 40 27 42 295,125 9.2% 13.5% 4 ACETAMINOPHEN 29 10 31 204,844 6.4% 9.4% 5 LORATADINE 52 41 52 161,475 4.0% 7.5% 6 FLUTICASONE PROPIONATE 54 42 54 160,754 2.8% 7.7% 7 AZITHROMYCIN 27 6 29 159,932 5.2% 7.3% 8 OSELTAMIVIR PHOSPHATE 30 5 32 105,327 3.0% 4.9% 9 PROMETHAZINE/DEXTROMETHORPHAN 46 11 49 102,497 2.9% 4.7%

10 CEPHALEXIN 23 9 25 102,216 5.6% 4.4% 11 AMOXICILLIN/POTASSIUM CLAV 11 10 11 80,932 3.0% 3.6% 12 FERROUS SULFATE 69 65 70 78,949 6.6% 3.1% 13 ONDANSETRON 14 5 15 75,916 2.5% 3.5% 14 HYDROCODONE/ACETAMINOPHEN 34 5 39 75,041 4.4% 3.2% 15 DIPHENHYDRAMINE HCL 31 19 31 73,088 1.8% 3.4% 16 CETIRIZINE HCL 49 52 49 72,516 0.1% 3.6% 17 HYDROCORTISONE 29 19 30 69,896 2.8% 3.1% 18 TRIAMCINOLONE ACETONIDE 34 24 35 67,548 2.0% 3.1% 19 METFORMIN HCL 93 71 97 66,334 4.5% 2.9% 20 PREDNISONE 30 6 33 56,728 1.7% 2.5%

DUR Quarterly Report – Version 1.0 July 29, 2019 2019 Q2 (APRIL – JUNE 2019)

1

QUARTERLY SUMMARY MEDI-CAL FEE-FOR-SERVICE PROGRAM DRUG USE REVIEW REPORT PERIOD: 2nd QUARTER 2019 (APRIL – JUNE 2019)

Executive Summary

The DUR quarterly report provides information on both prospective and retrospective drug utilization for all claims processed by the Medi-Cal Fee-for-Service (FFS) program, including the carved-out drug claims for the Medi-Cal Managed Care Plans (MCPs). For this quarterly report, the prospective and retrospective data cover the second quarter of 2019 (2019 Q2). All tables can be found in Appendix A and definitions of selected terms can be found in Appendix B. Prospective DUR As shown in Table 1.1, in comparison to the prior quarter (2019 Q1), in 2019 Q2 overall drug claims and DUR drug claims decreased by 1%, while total DUR alerts and total alert overrides increased by 1%. In comparison to the prior-year quarter (2018 Q2), overall drug claims increased slightly (< 1%) while total DUR drug claims decreased by 2%. A comparison between 2019 Q2 and 2019 Q1 showed very little change among the summary of alert transactions by therapeutic problem (Table 1.2) and among the top 10 drugs for each of the 12 prospective DUR alerts (Tables 2.1-2.12). Retrospective DUR Due to a slight lag in processing time, the aggregate tables contain complete retrospective claims data, while the stratified tables are not yet complete for 2019 Q2. For this report, the stratified tables represent 95.7% of total paid claims represented in the aggregated tables. In 2019 Q2, approximately 15% of eligible Medi-Cal FFS enrollees had a paid claim through the Medi-Cal fee-for-service program, compared with only 2% of Medi-Cal MCP enrollees (Table 3.2 and Table 3.3). Among all Medi-Cal beneficiaries with a paid claim through the Medi-Cal fee-for-service program in 2019 Q2, 57% were FFS enrollees and 36% were MCP enrollees (numbers add up to less than 100% due to the lag in processing time). As shown in Table 4.2, the greatest decrease in utilizing beneficiaries and paid claims processed by the FFS program in comparison to the prior-year quarter was within the FFS population. A review of FFS paid claims for the Medi-Cal MCP population (Table 4.3) shows that in comparison to the prior-year quarter, there was an increase in total utilizing beneficiaries and total paid claims in all three of the adult age groups. Of note, Table 5.2 and Table 6.2 show the top 20 drug therapeutic drug categories and top 20 drugs of Medi-Cal FFS program enrollees, while Table 5.3 and Table 6.3 show the top 20 drug therapeutic drug categories and top 20 drugs by beneficiaries enrolled in Medi-Cal MCPs. These tables give a more in-depth look at the impact of carved-out drugs on tables showing overall pharmacy utilization in the Medi-Cal fee-for-service program (Table 5.1 and Table 6.1). A review of the top 20 drug therapeutic categories in the FFS population (Table 5.2) by percentage of utilizing beneficiaries with a paid claim showed an across-the-board increase in average paid claims per day and total percentage of utilizing beneficiaries with a paid claim in comparison to both last month and last year for PROTON-PUMP INHIBITORS, which may be attributed to the addition of OMEPRAZOLE to the Medi-Cal fee-for-service List of Contract Drugs (CDL), effective May 1, 2019. Table 6.3 shows significant across-the-board increases in the MCP population during 2019 Q2 for NALOXONE, which was the subject of California legislation that became effective the first day of 2019 Q1 and BICTEGRAVIR/EMTRICITABINE/TENOFOVIR ALAFENAMIDE, which was approved by the FDA during 2018 Q1.


2

Appendix A: Prospective and Retrospective DUR Tables

Tables 1.1-1.2. Summary of Prospective DUR Alert Transactions in the Medi-Cal Fee-for-Service Program. Table 1.1 provides summary level data on pharmacy claims and DUR alert activities, including data and percent change from the prior quarter. Alerts are generated after adjudication of drug claims which exceed or otherwise fall outside of certain prescribed parameters.

Table 1.1: Summary of Alert Transactions

Category


(Apr – Jun 2019)

Prior Quarter 2019 Q1

(Jan – Mar 2019)

% Change from Prior

Quarter


(Apr – Jun 2018)

% Change from

Prior-Year Quarter

Drug Claims 7,891,599 8,000,439 -1.4% 7,872,048 0.2% DUR Drug Claims 3,723,043 3,753,849 -0.8% 3,807,244 -2.2% Total Alerts 1,063,242 1,054,056 0.9% 1,072,091 -0.8% Total Alert Overrides 685,078 680,252 0.7% 678,835 0.9% Total Alert Cancels 227 276 -17.8% 353 -35.7%

Note: Drug claims receiving multiple alerts can be adjudicated by pharmacists by responding to only one conflict code, followed by an intervention code and outcome code. The remaining alerts on the claim cannot be tracked as they are overridden by the pharmacist’s response to a single alert. For example, a single claim can generate up to eight different alerts, but the pharmacist can override all eight alerts by choosing to override only one alert. In addition, the number of cancelled alerts may be underrepresented due to the system’s inability to capture claims that were not adjudicated.

Table 1.2 provides a summary of the number of drug claims and alerts generated for each therapeutic problem type (sorted by alert frequency). Total alerts not adjudicated may be overrepresented, as claims with multiple alerts that have been adjudicated under one alert will show up as not adjudicated for the remaining alerts.

Table 1.2: Summary of Alert Transactions by Therapeutic Problem Type – 2019 Q2

Therapeutic Problem Type Total Alerts

Total Alert Over-rides

% Alert Over-rides

Total Alert

Cancels % Alert Cancels

Total Alerts

Not Adjud-icated

% Alerts

Not Adjud-icated

Therapeutic Duplication (TD) 336,869 256,273 76.1% 39 0.0% 80,557 23.9% Early Refill (ER) 278,730 95,694 34.3% 94 0.0% 182,942 65.6% Ingredient Duplication (ID) 198,715 145,999 73.5% 21 0.0% 52,695 26.5% Late Refill (LR) 108,153 84,440 78.1% 35 0.0% 23,678 21.9% Total High Dose (HD) 45,284 29,285 64.7% 6 0.0% 15,993 35.3% Additive Toxicity (AT) 35,094 28,347 80.8% 10 0.0% 6,737 19.2% Drug-Pregnancy (PG) 19,964 13,730 68.8% 4 0.0% 6,230 31.2% Total Low Dose (LD) 14,375 9,642 67.1% 4 0.0% 4,729 32.9% Drug-Drug (DD) 5,256 3,982 75.8% 2 0.0% 1,272 24.2% Drug-Disease (MC) 2,275 1,642 72.2% 0 0.0% 633 27.8% Drug-Age (PA) 265 183 69.1% 0 0.0% 82 30.9% Drug-Allergy (DA) 172 102 59.3% 0 0.0% 70 40.7%


3

Tables 2.1-2.12. Prospective DUR Alert Transactions by Therapeutic Problem Type in the Medi-Cal Fee-for-Service Program. Each of the following tables provides greater detail of each of the 12 DUR alerts with the top 10 drugs generating each respective alert. For each of the top 10 drugs, data are provided for the total number of adjudicated alerts, alert overrides, alert cancels, paid claims, and the percentage of paid claims with alert overrides. Tables are listed in order of DUR alert priority, which is determined by the DUR Board. Table 2.1: Top 10 Drugs by Therapeutic Problem Type – Drug-Allergy (DA) – 2019 Q2

Rank Drug Generic Name/Ingredient Name

Total Adjudicated

Alerts Total Alert Overrides

Total Alert Cancels

Total Paid

Claims

% of Paid Claims

with Alert Overrides

1 PHENYTOIN SODIUM EXTENDED 61 61 0 1,567 3.9% 2 PHENYTOIN 16 16 0 654 2.4% 3 OXYCODONE HCL 11 11 0 4,002 0.3% 4 OXYCODONE HCL/ACETAMINOPHEN 10 10 0 3,870 0.3% 5 AMOXICILLIN 6 6 0 33,768 0.0% 6 ARIPIPRAZOLE 4 4 0 105,711 0.0% 7 IBUPROFEN 4 4 0 77,882 0.0% 8 ZIPRASIDONE HCL 4 4 0 15,667 0.0% 9 AMOXICILLIN/POTASSIUM CLAV 2 2 0 11,209 0.0%

10 BUPRENORPHINE 2 2 0 5,134 0.0% Table 2.2: Top 10 Drugs by Therapeutic Problem Type – Drug-Pregnancy (PG) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 IBUPROFEN 12,506 12,502 4 77,882 16.1% 2 NORETHINDRONE 2,148 2,146 2 5,998 35.8% 3 NAPROXEN 371 370 1 12,179 3.0% 4 MISOPROSTOL 359 359 0 468 76.7% 5 METHYLERGONOVINE MALEATE 307 307 0 130 236.2% 6 LISINOPRIL 122 122 0 32,189 0.4% 7 METHIMAZOLE 121 121 0 1,497 8.1% 8 FERROUS SULFATE 101 101 0 35,794 0.3% 9 DOCUSATE SODIUM 99 99 0 36,244 0.3%

10 INDOMETHACIN 89 89 0 769 11.6% Table 2.3: Top 10 Drugs by Therapeutic Problem Type – Drug-Disease (MC) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 POTASSIUM CHLORIDE 389 388 1 3,113 12.5% 2 METFORMIN HCL 319 319 0 41,187 0.8% 3 HALOPERIDOL 290 290 0 17,739 1.6% 4 PROPRANOLOL HCL 115 115 0 4,089 2.8% 5 CARBAMAZEPINE 57 57 0 2,630 2.2% 6 METOPROLOL SUCCINATE 56 56 0 6,408 0.9% 7 METOPROLOL TARTRATE 54 54 0 6,549 0.8% 8 NORGESTIMATE-ETHINYL ESTRADIOL 49 49 0 12,955 0.4% 9 DILTIAZEM HCL 48 48 0 1,332 3.6%

10 HALOPERIDOL DECANOATE 45 45 0 4,494 1.0%


4

Table 2.4: Top 10 Drugs by Therapeutic Problem Type – Drug-Drug Interaction (DD) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 GEMFIBROZIL 469 469 0 2,012 23.3% 2 ATORVASTATIN CALCIUM 309 309 0 32,435 1.0% 3 ELVITEG/COB/EMTRI/TENOF ALAFEN 280 280 0 10,413 2.7% 4 SIMVASTATIN 220 220 0 8,369 2.6% 5 AMLODIPINE BESYLATE 183 183 0 21,851 0.8% 6 DARUNAVIR ETHANOLATE 110 110 0 2,509 4.4%

7 BUPRENORPHINE HCL/ NALOXONE HCL 107 107 0 43,806 0.2%

8 LURASIDONE HCL 85 85 0 41,946 0.2% 9 NALTREXONE HCL 59 59 0 7,383 0.8%

10 PIOGLITAZONE HCL 55 55 0 2,537 2.2% Table 2.5: Top 10 Drugs by Therapeutic Problem Type – Therapeutic Duplication (TD) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 QUETIAPINE FUMARATE 40,864 40,861 3 140,191 29.1% 2 OLANZAPINE 27,316 27,314 2 82,380 33.2% 3 ARIPIPRAZOLE 24,809 24,803 6 105,711 23.5% 4 RISPERIDONE 21,287 21,282 5 81,818 26.0% 5 HALOPERIDOL 14,736 14,733 3 17,739 83.1% 6 LURASIDONE HCL 13,281 13,280 1 41,946 31.7% 7 CLOZAPINE 11,943 11,943 0 21,120 56.5% 8 PALIPERIDONE PALMITATE 7,862 7,862 0 20,025 39.3% 9 CHLORPROMAZINE HCL 5,974 5,972 2 6,147 97.2%

10 ZIPRASIDONE HCL 5,134 5,133 1 15,667 32.8% Table 2.6: Top 10 Drugs by Therapeutic Problem Type – Overutilization (ER) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 QUETIAPINE FUMARATE 9,303 9,292 11 140,191 6.6% 2 ARIPIPRAZOLE 6,731 6,727 4 105,711 6.4% 3 RISPERIDONE 4,518 4,517 1 81,818 5.5% 4 OLANZAPINE 4,506 4,502 4 82,380 5.5% 5 BENZTROPINE MESYLATE 3,959 3,958 1 54,568 7.3% 6 LITHIUM CARBONATE 2,671 2,671 0 29,357 9.1% 7 LURASIDONE HCL 2,357 2,356 1 41,946 5.6% 8 METFORMIN HCL 1,988 1,985 3 41,187 4.8%

9 BUPRENORPHINE HCL/ NALOXONE HCL 1,852 1,852 0 43,806 4.2%

10 ASPIRIN 1,818 1,817 1 46,680 3.9%


5

Table 2.7: Top 10 Drugs by Therapeutic Problem Type – Underutilization (LR) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 ARIPIPRAZOLE 14,231 14,230 1 105,711 13.5% 2 QUETIAPINE FUMARATE 13,605 13,604 1 140,191 9.7% 3 RISPERIDONE 7,927 7,927 0 81,818 9.7% 4 OLANZAPINE 6,850 6,849 1 82,380 8.3% 5 BENZTROPINE MESYLATE 5,988 5,986 2 54,568 11.0% 6 LURASIDONE HCL 4,973 4,972 1 41,946 11.9% 7 LITHIUM CARBONATE 3,615 3,614 1 29,357 12.3% 8 ATORVASTATIN CALCIUM 3,167 3,162 5 32,435 9.7% 9 LEVOTHYROXINE SODIUM 2,706 2,705 1 23,796 11.4%

10 GABAPENTIN 2,348 2,345 3 24,089 9.7% Table 2.8: Top 10 Drugs by Therapeutic Problem Type – Additive Toxicity (AT) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 GABAPENTIN 2,133 2,129 4 24,089 8.8% 2 LITHIUM CARBONATE 1,672 1,672 0 29,357 5.7% 3 LORAZEPAM 1,416 1,416 0 7,126 19.9% 4 BACLOFEN 1,390 1,388 2 12,964 10.7% 5 QUETIAPINE FUMARATE 1,274 1,273 1 140,191 0.9% 6 HYDROCODONE/ACETAMINOPHEN 1,109 1,109 0 24,517 4.5% 7 CLONAZEPAM 1,086 1,086 0 5,835 18.6% 8 ARIPIPRAZOLE 765 765 0 105,711 0.7% 9 TRAZODONE HCL 627 627 0 10,633 5.9%

10 BUSPIRONE HCL 619 619 0 3,473 17.8% Table 2.9: Top 10 Drugs by Therapeutic Problem Type – Ingredient Duplication (ID) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 QUETIAPINE FUMARATE 30,475 30,472 3 140,191 21.7% 2 OLANZAPINE 15,153 15,152 1 82,380 18.4% 3 ARIPIPRAZOLE 12,816 12,815 1 105,711 12.1% 4 RISPERIDONE 11,328 11,327 1 81,818 13.8% 5 ALBUTEROL SULFATE 6,813 6,813 0 41,688 16.3% 6 CLOZAPINE 6,527 6,527 0 21,120 30.9% 7 LURASIDONE HCL 6,449 6,447 2 41,946 15.4% 8 ZIPRASIDONE HCL 3,179 3,179 0 15,667 20.3% 9 LEVOTHYROXINE SODIUM 3,144 3,143 1 23,796 13.2%

10 BENZTROPINE MESYLATE 2,325 2,325 0 54,568 4.3%


6

Table 2.10: Top 10 Drugs by Therapeutic Problem Type – Drug-Age (PA) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 AMITRIPTYLINE HCL 160 160 0 2,984 5.4% 2 ACETAMINOPHEN WITH CODEINE 39 39 0 5,689 0.7% 3 CODEINE PHOSPHATE/GUAIFENESIN 16 16 0 2,933 0.5% 4 ARIPIPRAZOLE 9 9 0 105,711 0.0% 5 DOXEPIN HCL 8 8 0 413 1.9% 6 OLANZAPINE 8 8 0 82,380 0.0% 7 QUETIAPINE FUMARATE 8 8 0 140,191 0.0% 8 HALOPERIDOL 4 4 0 17,739 0.0% 9 TRIHEXYPHENIDYL HCL 4 4 0 4,575 0.1%

10 BENZTROPINE MESYLATE 3 3 0 54,568 0.0% Table 2.11: Top 10 Drugs by Therapeutic Problem Type – High Dose (HD) – 2019 Q2


Total Adjudicated


Total Alert Cancels

Total Paid

Claims

% of Paid Claims


1 OLANZAPINE 6,947 6,947 0 82,380 8.4% 2 RISPERIDONE 2,183 2,182 1 81,818 2.7% 3 IBUPROFEN 2,095 2,095 0 77,882 2.7% 4 QUETIAPINE FUMARATE 1,416 1,416 0 140,191 1.0% 5 GABAPENTIN 1,079 1,079 0 24,089 4.5% 6 AMOXICILLIN/POTASSIUM CLAV 800 800 0 11,209 7.1% 7 AMOXICILLIN 796 796 0 33,768 2.4% 8 HYDROCODONE/ACETAMINOPHEN 789 789 0 24,517 3.2% 9 ARIPIPRAZOLE 609 609 0 105,711 0.6%

10 FAMOTIDINE 450 450 0 13,437 3.3% Table 2.12: Top 10 Drugs by Therapeutic Problem Type – Low Dose (LD) – 2019 Q2

Rank Rank Rank Rank Rank Rank Rank 1 AZITHROMYCIN 837 837 0 19,115 4.4% 2 DIVALPROEX SODIUM 740 740 0 10,464 7.1% 3 ERYTHROMYCIN ETHYLSUCCINATE 509 509 0 1,816 28.0% 4 DULOXETINE HCL 451 451 0 4,075 11.1% 5 AMOXICILLIN/POTASSIUM CLAV 307 307 0 11,209 2.7% 6 BUPROPION HCL 306 306 0 5,745 5.3% 7 AMOXICILLIN 244 244 0 33,768 0.7% 8 ALBUTEROL SULFATE 233 233 0 41,688 0.6% 9 SULFAMETHOXAZOLE/TRIMETHOPRIM 207 207 0 15,104 1.4%

10 IMIPRAMINE HCL 156 156 0 283 55.1%


7

Tables 3.1-3.3. Summary of Medi-Cal Fee-for-Service Pharmacy Utilization. These tables shows pharmacy utilization in the Medi-Cal Fee-for-Service program, including the percent change from the prior quarter and prior-year quarter. Beneficiaries with enrollments in both FFS and MCP during the quarter may be counted in both Table 3.2 and Table 3.3, as enrollment status may change.

Table 3.1: Fee-for-Service Pharmacy Utilization Measures for the Entire Medi-Cal Population

Category

Current Quarter

2019 Q2 Prior Quarter

2019 Q1


% Change from Prior

Quarter

% Change from Prior-

Year Quarter Total Eligible Beneficiaries 15,166,109 15,370,922 15,665,526 -1.3% -3.2% Total Utilizing Beneficiaries 786,322 815,347 810,781 -3.6% -3.0% Total Paid Rx Claims 2,629,074 2,682,194 2,716,614 -2.0% -3.2% Average Paid Rx Claims per Eligible Beneficiary 0.17 0.17 0.17 -0.7% 0.0% Average Paid Rx Claims per Utilizing Beneficiary 3.34 3.29 3.35 1.6% -0.2%

Table 3.2: Fee-for-Service Pharmacy Utilization Measures for the Medi-Cal FFS Population Only*

Category

Current Quarter


2019 Q1


% Change from Prior

Quarter


Year Quarter Total Eligible Beneficiaries 3,022,209 3,172,884 3,194,870 -4.7% -5.4% Total Utilizing Beneficiaries 445,361 467,591 458,034 -4.8% -2.8% Total Paid Rx Claims 1,591,997 1,653,677 1,636,421 -3.7% -2.7% Average Paid Rx Claims per Eligible Beneficiary 0.53 0.52 0.51 1.1% 2.8% Average Paid Rx Claims per Utilizing Beneficiary 3.57 3.54 3.57 1.1% 0.1%

*Complete (100%) utilization data for this stratified table is not yet available.

Table 3.3: Fee-for-Service Pharmacy Utilization Measures for the Medi-Cal MCP Population Only*

Category

Current Quarter


2019 Q1


% Change from Prior

Quarter


Year Quarter Total Eligible Beneficiaries 12,557,813 12,598,676 12,893,677 -0.3% -2.6% Total Utilizing Beneficiaries 285,948 286,579 275,164 -0.2% 3.9% Total Paid Rx Claims 925,271 918,913 927,708 0.7% -0.3% Average Paid Rx Claims per Eligible Beneficiary 0.07 0.07 0.07 1.0% 2.4% Average Paid Rx Claims per Utilizing Beneficiary 3.24 3.21 3.37 0.9% -4.0%

*Complete (100%) utilization data for this stratified table is not yet available.


8

Tables 4.1-4.3. Fee-for-Service Pharmacy Utilization by Age Group in the Medi-Cal Population. These tables present pharmacy utilization data in the Medi-Cal Fee-for-Service program, broken out by age group, including the percent change from the prior quarter and prior-year quarter. Beneficiaries with enrollments in both FFS and MCP during the quarter may be counted in both Table 4.2 and Table 4.3, as enrollment status may change.

Table 4.1: Fee-for-Service Pharmacy Utilization by Age Group for the Entire Medi-Cal Population Age

Group (years)


Total Paid Claims

% Change from Prior

Quarter


Year Quarter

Current Quarter Total Utilizing Beneficiaries

% Change from Prior

Quarter


Year Quarter 0 – 12 260,081 -14.2% -10.0% 82,605 -16.4% -8.4% 13 – 18 173,992 -1.6% -3.8% 44,747 -3.4% -2.5% 19 – 39 819,489 0.2% 0.1% 263,748 -0.6% -0.3% 40 – 64 1,115,760 0.0% -0.8% 289,007 -1.3% 2.3% 65+ 193,279 -0.8% -6.6% 63,580 -1.9% -6.9% Total 2,629,074 -2.0% -3.2% 786,322 -3.6% -3.0%

Table 4.2: Fee-for-Service Pharmacy Utilization by Age Group for the Medi-Cal FFS Population Only* Age

Group (years)


Total Paid Claims

% Change from Prior

Quarter


Year Quarter


% Change from Prior

Quarter


Year Quarter 0 – 12 162,302 -19.6% -6.3% 62,259 -19.0% -5.8% 13 – 18 91,756 -5.3% -1.0% 24,297 -6.6% -0.1% 19 – 39 462,378 -1.2% -2.2% 148,942 -1.7% -2.9% 40 – 64 691,743 -1.1% -1.2% 149,767 -1.4% 0.4% 65+ 183,818 -1.9% -7.0% 60,096 -2.2% -7.7% Total 1,591,997 -3.7% -2.7% 445,361 -4.8% -2.8% *Complete (100%) utilization data for this stratified table is not yet available.

Table 4.3: Fee-for-Service Pharmacy Utilization by Age Group for the Medi-Cal MCP Population Only* Age

Group (years)


Total Paid Claims

% Change from Prior

Quarter


Year Quarter


% Change from Prior

Quarter


Year Quarter 0 – 12 85,286 -4.8% -12.7% 18,513 -6.7% -11.8% 13 – 18 77,608 0.9% -6.1% 20,119 -0.7% -4.9% 19 – 39 338,950 1.9% 4.3% 108,125 1.8% 7.1% 40 – 64 413,693 0.8% 0.0% 135,625 -0.8% 5.3% 65+ 9,734 2.4% 7.9% 3,566 1.1% 10.3% Total 925,271 0.7% -0.3% 285,948 -0.2% 3.9% *Complete (100%) utilization data for this stratified table is not yet available.


9

Tables 5.1-5.3. Top 20 Fee-for-Service Drug Therapeutic Categories in the Medi-Cal Population. These tables present utilization of the top 20 drug therapeutic categories in the Medi-Cal Fee-for-Service program, by total utilizing beneficiaries. The current quarter is compared to the prior quarter and prior-year quarter in order to illustrate changes in utilization and reimbursement dollars paid to pharmacies for these top utilized drugs. The prior-year quarter ranking of the drug therapeutic category is listed for reference.

Table 5.1: Top 20 Fee-for-Service Drug Therapeutic Categories by Total Utilizing Beneficiaries for the Entire Medi-Cal Population

Rank



Total Paid Claims

% Change

from Prior

Quarter

% Change

from Prior-Year

Quarter

Current Quarter

Total Utilizing Benefici-

aries

% Utilizing Benefici-

aries with a Paid

Claim

% Change


aries from Prior

Quarter

% Change Utilizing


aries Prior- Year

Quarter

1 1 ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST

413,616 1.3% 0.6% 139,918 17.8% 0.7% 0.6%

2 2 NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS 95,820 -9.3% -0.2% 82,024 10.4% -0.7% 0.3%

3 4 ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED 112,267 2.5% 2.4% 48,485 6.2% 0.3% 0.3%

4 3 CONTRACEPTIVES,ORAL 62,477 -10.5% -23.2% 46,769 5.9% -0.4% -1.6% 5 5 PENICILLIN ANTIBIOTICS 49,138 -17.1% -1.2% 44,530 5.7% -0.9% 0.1%

6 6 PLATELET AGGREGATION INHIBITORS 49,451 -0.9% -11.5% 33,491 4.3% 0.1% -0.4%

7 9 ANTIHISTAMINES - 2ND GENERATION 47,394 17.8% 3.9% 32,956 4.2% 0.8% 0.4%

8 8 ANTICONVULSANTS 83,955 0.6% -5.0% 32,227 4.1% 0.2% 0.1%

9 11 ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) 45,473 1.6% -0.1% 30,668 3.9% 0.2% 0.2%

10 14 BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING 42,581 -16.1% 1.5% 29,068 3.7% -0.7% 0.2%

11 13 ANTIHYPERTENSIVES, ACE INHIBITORS 43,081 -0.9% -4.9% 28,745 3.7% 0.1% 0.0%

12 15 ANTIHYPERGLYCEMIC, BIGUANIDE TYPE 41,187 0.9% -0.6% 27,912 3.5% 0.2% 0.2%

13 7 OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS 34,078 0.8% -18.5% 27,478 3.5% 0.2% -0.7%

14 12 LAXATIVES AND CATHARTICS 41,960 0.1% -7.9% 27,264 3.5% 0.1% -0.2% 15 10 IRON REPLACEMENT 35,912 -1.1% -11.0% 27,053 3.4% 0.1% -0.3%

16 16 ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC 59,143 0.9% -3.3% 23,280 3.0% 0.1% 0.0%

17 17 CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION 24,661 3.6% -0.6% 23,150 2.9% 0.2% 0.1%

18 25 ANTIEMETIC/ANTIVERTIGO AGENTS 27,410 -1.5% 21.2% 21,641 2.8% 0.0% 0.6%

19 61 OPIOID ANTAGONISTS 25,463 -7.0% 185.7% 21,409 2.7% -0.2% 1.9%

20 19 SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) 36,720 -0.6% -0.9% 20,432 2.6% 0.1% 0.1%


10

Table 5.2: Top 20 Fee-for-Service Drug Therapeutic Categories by Total Utilizing Beneficiaries for the Medi-Cal FFS Population Only

Rank



Total Paid

Claims

% Change

from Prior

Quarter

% Change

from Prior-Year

Quarter

Current Quarter


aries


aries with a Paid

Claim

% Change Total

Utilizing Benefici-

aries from Prior

Quarter

% Change Utilizing


aries Prior- Year

Quarter

1 1 NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANALGESICS 94,146 -9.2% 0.0% 82,611 18.6% -9.3% 0.1%

2 2 PENICILLIN ANTIBIOTICS 48,122 -17.0% -0.3% 44,781 10.1% -16.8% 0.1%

3 3 PLATELET AGGREGATION INHIBITORS 48,445 -1.1% -11.4% 33,514 7.5% -2.1% -10.6%

4 5 ANTICONVULSANTS 68,569 -0.5% -3.7% 33,405 7.5% 0.0% -1.1%

5 6 ANTIHISTAMINES - 2ND GENERATION 46,213 18.5% 4.2% 32,572 7.3% 19.6% 9.6%

6 7 ANTIHYPERLIPIDEMIC-HMGCOA REDUCTASE INHIB(STATINS) 44,861 0.7% 0.2% 30,441 6.8% 1.1% 3.4%

7 4 OPIOID ANALGESIC AND NON-SALICYLATE ANALGESICS 33,521 0.4% -18.1% 27,746 6.2% 1.2% -18.3%

8 11 BETA-ADRENERGIC AGENTS, INHALED, SHORT ACTING 38,864 -17.1% 2.4% 27,474 6.2% -19.8% 3.0%

9 10 ANTIHYPERTENSIVES, ACE INHIBITORS 39,630 -1.6% -4.7% 27,030 6.1% -1.3% -1.5%

10 12 ANTIHYPERGLYCEMIC, BIGUANIDE TYPE 38,758 0.6% -0.5% 26,682 6.0% 1.0% 2.6%

11 9 LAXATIVES AND CATHARTICS 39,588 -0.2% -7.5% 26,415 5.9% -1.1% -7.0% 12 8 IRON REPLACEMENT 34,601 -0.7% -9.7% 26,294 5.9% -1.6% -8.5%

13 18 ANTIEMETIC/ANTIVERTIGO AGENTS 26,170 -1.9% 23.3% 22,647 5.1% -3.1% 26.8%

14 13 CEPHALOSPORIN ANTIBIOTICS - 1ST GENERATION 23,483 3.5% 0.3% 22,063 5.0% 3.4% -0.2%

15 15 SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) 36,077 -1.4% -1.1% 20,424 4.6% -1.5% 0.1%

16 14 PRENATAL VITAMIN PREPARATIONS 21,273 -2.0% -11.7% 19,083 4.3% -2.0% -10.3%

17 17 ANTIHISTAMINES - 1ST GENERATION 25,335 -3.2% -4.4% 18,632 4.2% -4.0% -2.5%

18 20 PROTON-PUMP INHIBITORS 26,852 17.0% 41.0% 18,522 4.2% 25.6% 59.9%

19 16 TOPICAL ANTI-INFLAMMATORY STEROIDAL 20,967 0.9% -8.6% 18,272 4.1% 1.1% -8.2%

20 19 GLUCOCORTICOIDS 21,762 -12.0% 5.5% 17,833 4.0% -13.3% 6.9%


11

Table 5.3: Top 20 Fee-for-Service Drug Therapeutic Categories by Total Utilizing Beneficiaries for the Medi-Cal MCP Population Only

Rank



Total Paid

Claims

% Change

from Prior

Quarter

% Change

from Prior-Year

Quarter

Current Quarter


aries


aries with a Paid

Claim

% Change Total

Utilizing Benefici-

aries from Prior

Quarter

% Change Utilizing


aries Prior- Year

Quarter

1 1 ANTIPSYCHOTIC,ATYPICAL,DOPAMINE,SEROTONIN ANTAGNST 377,643 1.4% 0.9% 144,177 50.4% 0.5% 0.4%

2 2 ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED 103,624 2.8% 2.5% 45,281 15.8% 1.9% 3.0%

3 3 ANTIPARKINSONISM DRUGS,ANTICHOLINERGIC 54,150 0.9% -2.8% 21,419 7.5% 0.5% -2.3%

4 11 OPIOID ANTAGONISTS 22,855 -8.5% 182.6% 19,245 6.7% -11.3% 235.2%

5 4 OPIOID WITHDRAWAL THERAPY AGENTS, OPIOID-TYPE 48,136 8.8% 26.4% 14,987 5.2% 7.5% 25.6%

6 5 BIPOLAR DISORDER DRUGS 27,056 0.5% -4.0% 11,226 3.9% -0.3% -5.1%

7 9 ARV-NUCLEOSIDE,NUCLEOTIDE RTI,INTEGRASE INHIBITORS 23,860 8.6% 40.1% 10,107 3.5% 7.5% 37.2%

8 6 INSULINS 20,299 -4.2% -10.8% 10,059 3.5% -5.2% -11.7%

9 7 ANTIVIRALS, HIV-SPEC, NUCLEOSIDE-NUCLEOTIDE ANALOG

19,848 -4.9% -20.6% 9,588 3.4% -3.9% -15.3%

10 8 ANTIPSYCHOTICS,DOPAMINE ANTAGONISTS,BUTYROPHENONES

21,419 -0.2% -10.4% 8,505 3.0% -0.8% -6.5%

11 10 ANTICONVULSANTS 15,407 -0.3% -9.4% 6,391 2.2% -1.1% -8.7%

12 13 ANTIPSYCHOTICS,PHENOTHIAZINES 11,502 -1.5% -9.1% 4,269 1.5% -2.8% -11.4%

13 12 ANTIVIRALS,HIV-1 INTEGRASE STRAND TRANSFER INHIBTR 9,797 -2.6% -21.4% 4,263 1.5% -2.9% -18.4%

14 14 ANTIRETROVIRAL-NRTIS AND INTEGRASE INHIBITORS COMB 8,531 -2.6% -20.3% 3,517 1.2% -4.1% -19.1%

15 17 OPIOID ANALGESICS 6,150 8.5% 5.2% 3,127 1.1% 8.4% 5.4%

16 16 ARTV NUCLEOSIDE,NUCLEOTIDE,NON-NUCLEOSIDE RTI COMB

6,270 -5.0% -26.7% 2,648 0.9% -7.0% -24.1%

17 15 ANTIVIRALS, HIV-SPEC, NON-PEPTIDIC PROTEASE INHIB 5,391 -1.8% -37.7% 2,274 0.8% -0.1% -36.0%

18 18 ANTICONVULSANT - BENZODIAZEPINE TYPE 4,519 -12.7% -2.4% 2,034 0.7% -13.7% -1.9%

19 19 VITAMIN D PREPARATIONS 3,581 1.6% -3.3% 1,998 0.7% -0.6% -2.1% 20 20 HEPATITIS B TREATMENT AGENTS 4,350 4.1% 35.1% 1,916 0.7% 2.4% 33.2%


12

Tables 6.1-6.3. Top 20 Fee-for-Service Drugs in the Medi-Cal Population. These tables present the utilization of the top 20 drugs in the Medi-Cal Fee-for-Service program, by total utilizing beneficiaries. The current quarter is compared to the prior quarter and prior-year quarter in order to illustrate changes in utilization for these drugs. The prior-year quarter ranking of each drug is listed for reference.

Table 6.1: Top 20 Fee-for-Service Drugs by Total Utilizing Beneficiaries for the Entire Medi-Cal Population

Rank



Total Paid

Claims

% Change from Prior

Quarter

% Change from

Prior-Year Quarter

Current Quarter


aries

% Utilizing Benefici- aries with

a Paid Claim

% Change Total

Utilizing Benefici-

aries from Prior

Quarter

% Change Utilizing


aries Prior-Year

Quarter 1 1 IBUPROFEN 77,882 -11.3% 0.2% 68,904 8.8% -0.8% 0.3% 2 2 QUETIAPINE FUMARATE 140,191 0.9% 0.3% 53,471 6.8% 0.2% 0.2% 3 3 ARIPIPRAZOLE 105,711 2.2% 1.4% 45,866 5.8% 0.3% 0.3% 4 5 RISPERIDONE 81,818 1.0% -2.0% 32,916 4.2% 0.2% 0.0% 5 4 ASPIRIN 46,680 -1.2% -13.2% 32,333 4.1% 0.1% -0.4% 6 7 OLANZAPINE 82,380 1.6% 4.0% 31,529 4.0% 0.2% 0.3% 7 6 AMOXICILLIN 33,768 -19.3% -2.9% 31,162 4.0% -0.8% 0.0% 8 9 LORATADINE 42,236 8.4% -4.3% 29,135 3.7% 0.4% 0.0% 9 10 ALBUTEROL SULFATE 41,688 -17.5% 2.0% 29,069 3.7% -0.8% 0.2%

10 11 METFORMIN HCL 41,187 0.9% -0.6% 27,912 3.5% 0.2% 0.2% 11 8 FERROUS SULFATE 35,794 -1.1% -11.1% 27,013 3.4% 0.1% -0.3% 12 12 DOCUSATE SODIUM 36,244 -0.2% -8.5% 24,520 3.1% 0.1% -0.2% 13 14 CEPHALEXIN 24,580 3.5% -0.8% 23,130 2.9% 0.2% 0.1% 14 15 LISINOPRIL 32,189 -0.7% -2.8% 21,993 2.8% 0.1% 0.1%

15 17 ATORVASTATIN CALCIUM 32,435 3.7% 7.9% 21,900 2.8% 0.2% 0.4%

16 16 BENZTROPINE MESYLATE 54,568 0.7% -2.2% 21,591 2.7% 0.1% 0.0%

17 13 HYDROCODONE/ ACETAMINOPHEN 24,517 1.5% -17.2% 20,333 2.6% 0.1% -0.4%

18 19 AZITHROMYCIN 19,115 -26.5% 3.0% 17,610 2.2% -0.7% 0.1% 19 18 LURASIDONE HCL 41,946 2.6% 3.6% 17,599 2.2% 0.1% 0.1% 20 113 NALOXONE HCL 18,080 -12.4% 517.9% 16,997 2.2% -0.2% 1.8%


13

Table 6.2: Top 20 Fee-for-Service Drugs by Total Utilizing Beneficiaries for the Medi-Cal FFS Population Only

Rank



Total Paid

Claims

% Change from Prior

Quarter

% Change from

Prior-Year Quarter

Current Quarter


aries


a Paid Claim

% Change Total

Utilizing Benefici-

aries from Prior

Quarter

% Change Utilizing


aries Prior-Year

Quarter 1 1 IBUPROFEN 76,722 -11.1% 0.5% 67,941 15.3% -11.2% 0.5% 2 2 ASPIRIN 45,725 -1.2% -13.2% 31,795 7.1% -2.4% -12.4% 3 3 AMOXICILLIN 33,199 -19.1% -2.1% 30,715 6.9% -19.0% -1.7% 4 4 LORATADINE 41,583 8.8% -4.3% 28,765 6.5% 7.1% -1.8% 5 6 ALBUTEROL SULFATE 38,824 -18.2% 2.3% 27,798 6.2% -21.0% 2.6% 6 8 METFORMIN HCL 38,758 0.6% -0.5% 26,682 6.0% 1.0% 2.6% 7 5 FERROUS SULFATE 34,566 -0.7% -9.6% 26,274 5.9% -1.6% -8.5% 8 7 DOCUSATE SODIUM 35,720 -0.4% -8.2% 24,146 5.4% -1.0% -7.5% 9 10 CEPHALEXIN 23,406 3.5% 0.1% 22,045 5.0% 3.5% -0.2%

10 12 ATORVASTATIN CALCIUM 32,022 2.7% 8.4% 21,611 4.9% 3.2% 11.7%

11 11 LISINOPRIL 31,009 -1.2% -2.4% 21,357 4.8% -1.2% 0.6%

12 9 HYDROCODONE/ ACETAMINOPHEN 24,057 1.0% -16.7% 19,914 4.5% 1.9% -16.4%

13 20 PRENATAL VITAMIN NO 95 17,385 5.4% 118.8% 15,657 3.5% 5.8% 124.2%

14 19 FLUTICASONE PROPIONATE 18,862 36.5% 64.9% 15,323 3.4% 38.5% 68.1%

15 15 AZITHROMYCIN 15,518 -29.7% 8.5% 14,394 3.2% -30.0% 8.8% 16 13 FOLIC ACID 24,079 -1.2% -6.4% 14,176 3.2% -2.1% -5.3% 17 14 AMLODIPINE BESYLATE 21,322 -0.5% 0.0% 14,070 3.2% -0.1% 3.3% 18 16 GABAPENTIN 23,342 3.3% 3.0% 13,841 3.1% 3.9% 6.0% 19 18 PREDNISONE 16,175 -4.4% 7.1% 13,298 3.0% -4.9% 8.8%

20 17 LEVOTHYROXINE SODIUM 20,772 -1.1% -4.1% 12,366 2.8% -0.9% -0.9%


14

Table 6.3: Top 20 Fee-for-Service Drugs by Total Utilizing Beneficiaries for the Medi-Cal MCP Population Only

Rank



Total Paid

Claims

% Change from Prior

Quarter

% Change from

Prior-Year Quarter

Current Quarter


aries


a Paid Claim

% Change Total

Utilizing Benefici-

aries from Prior

Quarter

% Change Utilizing


aries Prior-Year

Quarter 1 1 QUETIAPINE FUMARATE 129,125 1.1% 0.6% 49,338 17.3% 0.0% -0.3% 2 2 ARIPIPRAZOLE 97,290 2.5% 1.4% 42,360 14.8% 1.5% 1.7% 3 3 RISPERIDONE 72,709 1.0% -1.9% 29,355 10.3% 0.0% -2.0% 4 4 OLANZAPINE 74,336 1.8% 4.7% 28,446 10.0% 1.5% 4.4%

5 5 BENZTROPINE MESYLATE 50,042 0.6% -1.8% 19,832 6.9% 0.4% -1.3%

6 6 LURASIDONE HCL 39,340 2.3% 3.3% 16,532 5.8% 1.8% 2.1% 7 19 NALOXONE HCL 16,205 -14.6% 497.5% 15,217 5.3% -15.5% 501.2%

8 8 BUPRENORPHINE HCL/ NALOXONE HCL 40,621 8.9% 26.7% 12,139 4.3% 7.7% 25.5%

9 7 LITHIUM CARBONATE 26,777 0.7% -3.9% 11,116 3.9% -0.2% -5.2%

10 10 PALIPERIDONE PALMITATE 19,038 3.7% 10.1% 8,105 2.8% 2.0% 11.2%

11 9 HALOPERIDOL 16,119 -2.1% -16.9% 6,344 2.2% -2.7% -13.3%

12 11 EMTRICITABINE/ TENOFOVIR (TDF) 11,772 -1.3% -8.6% 6,206 2.2% 0.3% -3.0%

13 20 BICTEGRAV/EMTRICIT/ TENOFOV ALA 14,151 22.7% 328.4% 5,957 2.1% 20.8% 265.5%

14 12 ZIPRASIDONE HCL 14,577 -0.5% -10.0% 5,333 1.9% -2.0% -11.9% 15 15 INSULIN LISPRO 8,775 -3.4% -6.9% 4,113 1.4% -3.9% -6.7% 16 18 NALTREXONE HCL 6,650 10.4% 23.7% 4,028 1.4% 9.0% 25.5%

17 13 ELVITEG/COB/EMTRI/ TENOF ALAFEN 9,134 -6.6% -27.6% 3,882 1.4% -6.9% -25.7%

18 14 INSULIN GLARGINE, HUM.REC.ANLOG 7,022 -6.1% -14.0% 3,770 1.3% -7.3% -14.9%

19 16 ABACAVIR/DOLUTEGRAVIR/LAMIVUDI 8,531 -2.6% -20.3% 3,517 1.2% -4.1% -19.1%

20 17 DOLUTEGRAVIR SODIUM 8,021 -3.1% -19.4% 3,431 1.2% -3.8% -16.7%


15

APPENDIX B: Definition of terms. Adjudicate: To pay or deny drug claims after evaluating the claim for coverage requirements Beneficiary: A person who has been determined eligible for Medi-Cal, as according to the California Code of Regulations 50024 Eligible beneficiary: A Medi-Cal beneficiary that qualifies for drug benefits Quarter: One fourth, ¼, 25% or .25 of a year measured in months. Reimbursement: The reimbursement paid to Medi-Cal pharmacy providers for legend and nonlegend drugs dispensed to Medi-Cal Fee-for-Service (FFS) beneficiaries. Reimbursement is determined in accordance with CA Welfare and Institutions Code Section 14105.45(b)(1). Drug therapeutic category: Drug therapeutic categories are grouping of drugs at various hierarchy levels and characteristics that may be similar in chemical structure, pharmacological effect, clinical use, indications, and/or other characteristics of drug products. Utilizing beneficiary: A Medi-Cal beneficiary with at least one prescription filled during the measurement period

Version 1.0: Last updated August 13, 2019 Page 1 of 4

MEDI-CAL FEE-FOR-SERVICE PROGRAM PHYSICIAN-ADMINISTERED DRUGS

CALENDAR YEAR 2018 Utilization of physician-administered drugs in the Medi-Cal Fee-for-Service program during the calendar year of 2018 is presented below, stratified by category. In order to show changes in utilization over time, Table 1 shows the comparison to the prior year (2017).

Table 1: Utilization of Physician-Administered Drugs

Category Total


% Change

from 2017

Total Paid Claims

% Change

from 2017

Total Reimbursement

Dollars Paid

% Change

from 2017

PHYSICIAN ADMINISTERED DRUG - NDC NOT REQUIRED (vaccines, hyaluronate)*

217,614 27.7% 658,425 47.7% $9,790,220 37.0%

PHYSICIAN ADMINISTERED DRUG - NDC REQUIRED 735,868 -5.3% 2,424,226 -3.7% $305,528,944 6.0% MISCELLANEOUS PRODUCT - REPORTING REQUIRED (supplies, immune globulin, IV solutions)

405,561 -1.2% 933,826 -0.7% $10,590,675 -6.1%

TOTAL 1,359,043 0.1% 4,016,477 2.9% $325,909,839 6.2% *Effective July 1, 2017, Child Health and Disability Prevention (CHDP) claims processing officially transitioned to HIPAA compliant billing formats, including a change where providers are required to enter modifier SL (state-supplied vaccine) on vaccines supplied by the Vaccines for Children (VFC) program. While providers billing VFC procedure codes are reimbursed for vaccine administration costs only, these claims appear beginning in 2017 Q3. The following three tables show the top 20 physician-administered drugs by total utilizing beneficiaries (Table 2), total reimbursement dollars paid (Table 3), and reimbursement paid per utilizing beneficiary (Table 4). Each table has the comparison to the prior year, for reference. In addition, the prior-year ranking is given to show changes in utilization of a drug over time.


Table 2: Top 20 Physician-Administered Drugs by Total Utilizing Beneficiaries

Rank

Last Year Rank

HCPCS Code Drug Description

2018 Total Utilizing

Beneficiaries

% Change Total


from 2017

2018 Total Reimbursement Dollars Paid

2018 Total Paid Claims

1 1 J3490 LEVONORGESTREL 105,332 0.5% $2,669,307 123,155

2 2 J3490 MEDROXYPROGES-TERONE ACETATE 84,965 -3.5% $11,629,044 152,221

3 4 J1885 KETOROLAC TROMETHAMINE 74,515 2.9% $429,670 83,352

4 6 J7040 0.9 % SODIUM CHLORIDE 72,174 47.4% $624,742 93,039

5 3 J2405 ONDANSETRON HCL/PF 64,469 -16.2% $354,869 82,147

6 5 S4993 LEVONORGESTREL-ETHIN ESTRADIOL 63,232 -10.1% $8,505,643 70,765

7 7 Z7610 ACETAMINOPHEN 56,779 19.5% $447,209 67,862 8 14 90670 PCV13 VACCINE IM* 50,984 38.7% $578,850 63,496

9 10 J0696 CEFTRIAXONE SODIUM 42,775 0.7% $264,127 47,340

10 15 Z7610 IBUPROFEN 41,778 17.1% $305,189 43,825 11 11 Q0144 AZITHROMYCIN 41,473 -1.6% $223,933 45,858

12 8 Q9967 LOCM 300399MG/ML IODINE,1ML 39,549 -11.4% $194,110 47,225

13 20 90680 RV5 VACC 3 DOSE LIVE ORAL* 38,874 47.4% $582,050 49,941

14 12 J7307 ETONOGESTREL 37,778 -6.8% $29,591,211 37,778 15 9 J3490 ULIPRISTAL ACETATE 37,341 -13.7% $1,183,702 45,054

16 23 90744 HEPB VACC 3 DOSE PED/ADOL IM* 34,068 47.9% $335,084 37,568

17 13 J2270 MORPHINE SULFATE 34,022 -15.2% $247,546 38,234

18 18 J1100 DEXAMETHASONE SODIUM PHOSPHATE 28,584 -0.7% $182,261 37,119

19 17 Z7610 HYDROCODONE/ ACETAMINOPHEN 28,417 -4.2% $286,714 31,808

20 19 J3010 FENTANYL CITRATE/PF 27,898 5.0% $140,930 31,070

*Effective July 1, 2017, Child Health and Disability Prevention (CHDP) claims processing officially transitioned to HIPAA compliant billing formats, including a change where providers are required to enter modifier SL (state-supplied vaccine) on vaccines supplied by the Vaccines for Children (VFC) program. While providers billing VFC procedure codes are reimbursed for vaccine administration costs only, these claims appear beginning in 2017 Q3.


Table 3: Top 20 Physician-Administered Drugs by Total Reimbursement Dollars Paid

Rank

Last Year Rank


2018 Total Reimbursement

Dollars Paid

% Change Total Reimbursement

Dollars from 2017

2018 Total Utilizing Beneficiaries*

2018 Total Paid Claims

1 1 J7307 ETONOGESTREL $29,591,211 -5.2% 37,778 37,778

2 2 J7189 COAGULATION FACTOR VIIA,RECOMB (NOVOSEVEN®)

$19,436,934 8.3% 179 569

3 11 J1428 ETEPLIRSEN1 $18,139,029 116.4% 40 1,434 4 3 J7298 LEVONORGESTREL $12,122,522 -3.6% 16,133 16,135

5 4 J3490 MEDROXYPROGESTERONE ACETATE $11,629,044 3.1% 84,965 152,221

6 5 J9355 TRASTUZUMAB $10,575,203 1.4% 511 3,168

7 6 Q4081 EPOETIN ALFA (100 UNITS ESRD) $9,251,311 -6.3% 3,680 177,019

8 7 J1745 INFLIXIMAB $9,062,548 -6.8% 757 4,288

9 8 S4993 LEVONORGESTREL-ETHIN ESTRADIOL $8,505,643 -9.5% 63,232 70,765

10 12 J2505 PEGFILGRASTIM $8,442,854 11.8% 866 2,413

11 9 J7300 COPPER INTRAUTERINE DEVICE $8,394,245 -10.3% 12,121 12,303

12 13 J7192

ANTIHEMOPH.FVIII,FULL LENGTH (INCLUDES ADVATE®, HELIXATE®, AND KOGENATE®)

$7,732,161 4.8% 263 1,032

13 15 J1300 ECULIZUMAB $7,696,317 15.6% 45 609

14 10 J9019 ASPARAGINASE (ERWINIA CHRYSAN) $7,666,135 -17.8% 73 808

15 14 J7304 NORELGESTROMIN/ ETHIN.ESTRADIOL $7,260,080 5.0% 9,559 12,015

16 16 J9306 PERTUZUMAB $6,085,924 17.2% 264 4,916 17 18 J9035 BEVACIZUMAB $4,742,757 6.1% 1,241 3,780 18 20 J1743 IDURSULFASE $3,636,601 0.6% < 20 450 19 17 J7301 LEVONORGESTREL $3,436,312 -25.3% 4,704 4,731 20 23 90378 PALIVIZUMAB $3,329,047 0.1% 793 1,608 *Cells with numbers less than 20 have been changed for privacy 1In 2018 there were approximately twice as many paid claims claims (n=1,434), when compared to 2017 (n=741).


Table 4: Top 20 Physician-Administered Drugs by Reimbursement Paid per Utilizing Beneficiary

Rank

Last Year Rank


2018 Reimbursement Dollars Paid per

Utilizing Beneficiary

% Change Reimbursement Dollars Paid per

Utilizing Beneficiary from 2017

2018 Total Paid

Claims*

2018 Total Utilizing

Beneficiaries* 1 5 J1428 ETEPLIRSEN $453,476 94.7% 1434 40 2 N/A Q2040 TISAGENLECLEUCEL1 $420,140 N/A < 20 < 20 3 1 J1322 ELOSULFASE ALFA $381,607 -29.6% 212 < 20 4 2 J1458 GALSULFASE $373,435 -0.9% 249 < 20

5 4 J7181 FACTOR XIII A-SUBUNIT,RECOMB (TRETTEN®)

$366,465 12.4% < 20 < 20

6 23 J7185 ANTIHEMOPH.FVIII,B-DOMAIN DEL (XYNTHA®) $289,926 486.1% < 20 < 20

7 N/A C9014 CERLIPONASE ALFA2 $288,679 N/A 356 < 20 8 3 J1743 IDURSULFASE $279,739 -14.9% 450 < 20 9 N/A J2326 NUSINERSEN SODIUM/PF3 $175,559 N/A 27 < 20

10 8 J1300 ECULIZUMAB $171,029 5.3% 609 45 11 9 J3590 CERLIPONASE ALFA2 $143,298 20.0% 32 < 20

12 16 J7201 FACTOR IX REC, FC FUSION PROTN (ALPROLIX®) $130,875 41.9% 23 < 20

13 13 J7202 FACTOR IX RECOM,ALBUMIN FUSION (DELVION®) $126,439 30.8% 84 < 20

14 12 J1786 IMIGLUCERASE $120,935 21.4% 222 < 20 15 11 J0221 ALGLUCOSIDASE ALFA $117,978 16.0% 129 < 20

16 15 J7189 COAGULATION FACTOR VIIA,RECOMB (NOVOSEVEN®)

$108,586 16.2% 569 179

17 10 J9019 ASPARAGINASE (ERWINIA CHRYSAN) $105,016 -4.3% 808 73

18 7 J3385 VELAGLUCERASE ALFA $100,651 -46.2% 37 < 20 19 14 J1931 LARONIDASE $86,682 -7.7% 443 < 20

20 26 J7195 FACTOR IX HUMAN RECOMBINANT (BENEFIX®) $85,338 97.8% 113 < 20

*Cells with numbers less than 20 have been changed for privacy

1Code Q2040 was effective August 1, 2017. 2Code C9014 was effective January 1, 2018, however code J3590 was still accepted for this drug for part of 2018. 3Code J2326 was effective January 1, 2018.

Ivana Thompson, Pharm.D.

Harry Hendrix, Pharmacy Benefits Division Chief

September 17, 2019

Pharmacy Update

2Global Medi-Cal DUR Board Meeting

09-17-2019

• H.R. 6 - SUPPORT for Patients and Communities

Act

• Medi-Cal Rx

Pharmacy Updates


09-17-2019

States are required to implement the requirements established in H.R. 6,

Substance Use-Disorder Prevention that Promotes Opioid Recovery and

Treatment (SUPPORT) for Patients and Communities” Act

Title 1 - Section 1004: Medicaid Drug Review and Utilization

Requirements:

• Safety Edits for subsequent opioid fills and maximum daily

morphine equivalent that exceed state-defined limitations

• Automated process that monitors when an individual is concurrently

prescribed opioids and benzodiazepines or antipsychotics

• Monitoring antipsychotic prescribing for children

• Process that identifies potential fraud or abuse by enrolled

individuals and pharmacies

• Report DUR activities to the Secretary annually

H.R. 6 – SUPPORT Act

https://www.congress.gov/115/bills/hr6/BILLS-115hr6enr.pdf


09-17-2019

o On January 7, 2019, Governor Gavin Newsom issued

Executive Order N-01-19 for the purpose of achieving cost-

savings for drug purchases made by the state

o A primary component of the Executive Order requires that all

Medi-Cal pharmacy services be transitioned from managed

care (MC) to fee-for-service (FFS) by January 1, 2021

o The Medi-Cal pharmacy benefits and services administered

by DHCS in the FFS delivery system will be identified

collectively as Medi-Cal Rx

Medi-Cal Rx


09-17-2019

Medi-Cal Rx will, among other things:

o Standardize the Medi-Cal pharmacy benefit statewide,

under one delivery system

o Improve access to pharmacy services with a pharmacy

network that includes nearly all California pharmacies

o Apply statewide utilization management protocols to all

outpatient drugs

o Strengthen California’s ability to negotiate state

supplemental drug rebates with drug manufacturers

Medi-Cal Rx (cont.)


09-17-2019

• On August 22, 2019, DHCS released Request for Proposal (RFP) #19-96125, for the takeover, operation, and eventual turnover of administration of the Medi-Cal Rx program.

• Final RFP Proposals are due by 4:00 PM PDT on October 1, 2019.

• For more information, please visit one of the two websites:

o DHCS’ procurement

o FI$Cal/Cal eProcure

• Questions regarding this RFP should be submitted via email to: [email protected]

Medi-Cal Rx (cont. 2)

https://www.dhcs.ca.gov/provgovpart/rfa_rfp/Pages/CSBmcrxHome.aspx

https://caleprocure.ca.gov/event/4260/19-96125



09-17-2019

• DHCS is committed to working with its external partners

(including but not limited to, Managed Care Plans

(MCPs), Counties, Providers, Consumer Advocates, and

Beneficiaries) to ensure a smooth and successful

transition.

• For general questions relating to Medi-Cal Rx (not RFP-

related), please direct your comments and questions

to [email protected].

Stakeholder Engagement
