virginia medicaid produr program update presented to: pdl/pa- implementation advisory group javier...
TRANSCRIPT
Virginia Medicaid ProDUR Program Update
Presented to:PDL/PA- Implementation Advisory Group
Javier Menendez, Pharmacy Manager
Department of Medical Assistance Service
June 22, 2004
Richmond, Virginia
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Presentation Outline
Background on the ProDUR Program
DUR Board
ProDUR enhancements
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Background on the ProDUR Program
ProDUR is a review by the pharmacist of the prescription medication order and the patient’s drug therapy before each prescription is filled. This review is for the health and safety of the Medicaid patient.
The review includes an examination of the patient’s profile to determine the possibility of potential drug therapy problems due to therapeutic duplication, drug-disease contraindications, drug-drug interactions, drug-allergy interactions, drug dosage or duration of drug treatment.
ProDUR is used by commercial carriers, Medicaid managed care organizations and DMAS. This is in compliance of state regulations 12 VAC 30-130-280 through 130-410 and The Omnibus Reconciliation Act of 1990.
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Presentation Outline
Background on the ProDUR Program
DUR Board
ProDUR enhancements
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DUR Board
5 Physicians
2 Nurses
6 Pharmacists
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Members of DUR Board
Member Background Geneva Briggs (PharmD) (Chairman) DUR Board Kelly Goode (PharmD) Virginia Pharmacist Assoc. Sandra Dawson (Rph) VaPha-Consultant Pharmacist Mark Johnson (PharmD) Shenandoah University Bill Rock (PharmD) VA Hospital Jennifer Edwards (PharmD) Va. Assoc. Chain Drugs Jane Settle (NP) Virginia Nurses Association Elaine Ferray (MS) Virginia Nurses Association Thomas Moffatt (MD) Medical Society of Virginia Robert O Friedel (MD) Medical Society of Virginia Matthew Goodman (MD) UVA School of Medicine Catherine Kelso (MD) MCV Jason Lynam (MD) UVA School of Medicine
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DUR Board Quarterly Meetings
August 7th 2003
November 6, 2003
February 5th, 2004
May 6, 2004
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Presentation Outline
Background on the ProDUR Program
DUR Board
ProDUR enhancements
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ProDUR Enhancements
February 1st, 2004, certain edits enhanced from
Message Only to Provider Level Override.
DD(drug-drug), MC(drug-disease), PG(pregnancy) and
TD (therapeutic duplication)now require intervention and
outcome codes.
FHSC has complete prescription history for all recipients,
many recipients use multiple providers for prescription
services
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11 Drug Classes Deny for Therapeutic Duplication
Anti-Ulcer Agents
Ace Inhibitors
Angiotensin II Receptor Blockers
Antidepressants
Benzodiazepine
NSAIDS
Calcium Channel Blockers
Narcotics
Thiazide Diuretics
Loop Diuretics
Potassium-Sparing Diuretics
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ProDUR Enhancements
June 14th, 2004, ER (early refill) edits enhanced from Provider Level Override With Intervention and Outcome Codes, to required telephone call.
The Early Refill (ER) alerts occur when the prescription is presented for refill before 75% of the medication is used in compliance with the directions and quantity (days supply).
Requires POS/RPH to call FHSC for PA
FHSC has complete prescription history for all recipients
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Early Refills
30 days x .75 = 23 days
23 days / 365 days = 15.8 scripts/year
An Extra 3 scripts at $55/script (avg. Rx $) for 10% of the FFS population (23,000) would equal $3,795,000.00
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Why enhance ER edit to telephone call required?
From January 2004 through May 2004 DMAS has made > $3,500,000.00 in override payments.
Most state Medicaid plans require a telephone call for this override (Tennessee, South Carolina, Missouri, Massachusetts, Maryland, Michigan, Ohio, Iowa, Alabama)
Most MCOs have this as standard including Sentara, Anthem, VA Premier, Unicare and CareNet.
Most commercial plans have this as standard ( Aetna, BCBS, Cigna, United Healthcare )
Pro-DUR Reasonfor Service(Conflict Code)NCPDP Field 439
Current Claims Disposition
New Claims Disposition Professional Service(Intervention Code)NCPDP Field 440942)
Pro-DUR Result of Service(Outcome Code)NCPDP Field 441
DD Message only Provider override AS = Patient assessmentCC = Coordination of careDE = Dosing evaluation/DeterminationMØ = Prescriber consultedMR = Medication ReviewPØ = Patient Consulted
1A 1B 1C 1D 1E 1F 1G 1H 1J 1K2A 2B 3A 3B 3C 3D 3F 3G 3H 3J3K 3M 3NNote: These are ALL of the OutcomeCodes as defined by NCPDP(See definitions below)
ER2 Deny – provider
override allowed
Call in to FHSC Call in to FHSC800xxxxxxxxx
Call in to FHSC800xxxxxxx
MC Message only Provider override AS = Patient assessmentCC = Coordination of careDE = Dosing evaluation/DeterminationMØ = Prescriber consultedMR = Medication ReviewPØ = Patient Consulted
1A 1B 1C 1D 1E 1F 1G 1H 1J 1K2A 2B 3A 3B 3C 3D 3F 3G 3H 3J3K 3M 3NNote: These are ALL of the OutcomeCodes as defined by NCPDP(See definitions below)
TD (denials) Deny for 11 drug classes – provider override allowed
Provider Override for 11 drug classes:
Anti-Ulcer AgentsACE Inhibitors Angiotensin II Receptor BlockersAntidepressantsBenzodiazepinesNSAIDs (includes salicylates and COX-2s)Calcium Channel BlockersThiazide Diuretics
Loop DiureticsPotassium-Sparing DiureticsNarcotics*note: some of these classes are in the PDL
AS = Patient assessmentCC = Coordination of careDE = Dosing evaluation/DeterminationMØ = Prescriber consultedMR = Medication ReviewPØ = Patient Consulted
1A 1B 1C 1D 1E 1F 1G 1H 1J 1K2A 2B 3A 3B 3C 3D 3F 3G 3H 3J3K 3M 3NNote: These are ALL of the OutcomeCodes as defined by NCPDP(See definitions below)
PG Message only Provider override AS = Patient assessmentCC = Coordination of careDE = Dosing evaluation/DeterminationMØ = Prescriber consultedMR = Medication ReviewPØ = Patient Consulted
1A 1B 1C 1D 1E 1F 1G 1H 1J 1K2A 2B 3A 3B 3C 3D 3F 3G 3H 3J3K 3M 3NNote: These are ALL of the OutcomeCodes as defined by NCPDP(See definitions below)