ar medicaid dur board meeting july 2008 page 0 of 4 division of medical services ---------------------------- pharmacy unit

AR Medicaid DUR Board meeting July 2008 page 0 of 4

Division of Medical Services
----------------------------
Pharmacy Unit

P.O. Box 1437, Slot S-415 · Little Rock, AR 72203-1437
501-683-4120 · Fax: 501-683-4124
MEMORANDUM
TO: Certified Nurse-Midwife; Child Health Services (EPSDT); Federally
Qualified Health Center (FQHC); Hospital; Nurse Practitioner;
Pharmacy; Physician; Rural Health Clinic and Arkansas Department of
Health
FROM: Suzette Bridges, P.D., Division of Medical Services Pharmacy
Program
DATE: August 1, 2008
SUBJ: Dose edits, quantity edits, and clinical therapeutic duplication
edits for all short-acting and long-acting opioids; clinical edits
and/or claim edits (quantity/dose, age, or gender) on Relistor®
(methylnaltrexone bromide SQ injection, Pepcid® (famotidine) oral
su0spension, Baraclude® (entecavir) tablets, and non-pediculicide
medicated shampoos (Capex® (fluocinolone acetonide), Clobex® shampoo
(clobetasol proprionate), Loprox® shampoo (ciclopirox), selenium
sulfide shampoo, ketoconazole, salicylic acid shampoo), NovoSeven® RT
(Coagulation Factor VIIa Recombinant) Intravenous bolus injection.
The Arkansas Medicaid Drug Utilization Review (DUR) Board voted to
implement approval criteria using clinical edits, age edits, and or
quantity/dose edits for the drugs listed below. Specific criteria for
the clinical edits can be viewed on the Medicaid website at
https://www.medicaid.state.ar.us/Download/provider/pharm/Criteria.doc;
specific claim edits such as quantity/dose edits, age edits, or gender
edits can be viewed on the Medicaid website at
https://www.medicaid.state.ar.us/Download/provider/pharm/ClaimEdits.xls.
Effective, September 24, 2008, the following medications are subject
to prior approval as a condition of coverage or payment under the
Arkansas Medicaid Prescription Drug Program for the following clinical
edits and/or quantity edits:
I.
OPIOID ANALGESIC MEDICATIONS
Both short-acting opioid and long-acting opioid agents have a high
potential for abuse. The AR Medicaid DUR Board has approved the
following edits for oral, transdermal, transmucosal, or buccal
preparations in the opioid analgesic drug class to optimize the number
of units dispensed per prescription without setting a maximum total
daily opioid dose.
1.
Dose-optimization edit of long-acting opioids:
Effective, September 24, 2008, Dose-optimization edits will apply to
all Medicaid-eligible beneficiaries and will require the prescriber to
use the highest strength tablet or capsule necessary to achieve the
total daily opioid dose. For questions regarding long-acting opioids
on the PDL, or questions regarding dose conversions for these agents,
please call the PDL PA Call Center at 1-866-250-2518 (in-state toll
free) or local 501-526-4200. Below is a list of the dose-optimization
edits and allowed quantities per strength for each long-acting opioid
agent.
Please note: the dose-optimization edits for Opana® ER will coincide
with its preferred status of August 1, 2008.
LONG-ACTING OPIOIDS
PDL STATUS
DAILY DOSE EDIT
MORPHINE SULFATE SA TABLET 15MG
Preferred
3 tablets
MORPHINE SULFATE SA TABLET 30MG
Preferred
3 tablets
MORPHINE SULFATE SA TABLET 60MG
Preferred
3 tablets
MORPHINE SULFATE SA TABLET 100MG
Preferred
3 tablets
MORPHINE SULFATE SA TABLET 200MG
Preferred
NO DOSE LIMIT—USE CAUTION
OPANA® (oxymorphone) ER 5 MG TABLET
Preferred
2 tablets
OPANA® (oxymorphone) ER 7.5 MG TABLET
Preferred
2 tablets
OPANA® (oxymorphone) ER 10 MG TABLET
Preferred
2 tablets
OPANA® (oxymorphone) ER 15 MG TABLET
Preferred
2 tablets
OPANA® (oxymorphone) ER 20 MG TABLET
Preferred
2 tablets
LONG-ACTING OPIOIDS
PDL STATUS
DAILY DOSE EDIT
OPANA® (oxymorphone) ER 30 MG TABLET
Preferred
2 tablets
OPANA® (oxymorphone) ER 40 MG TABLET
Preferred
2 tablets
METHADONE 5 MG TABLET
Preferred
NO DOSE LIMIT—USE CAUTION
METHADONE 10 MG TABLET
Preferred
NO DOSE LIMIT—USE CAUTION
AVINZA® (morphine LA) 30MG CAPSULE
Non-Preferred
1 capsule
AVINZA® (morphine LA) 60MG CAPSULE
Non-Preferred
1 capsule
AVINZA® (morphine LA) 90 MG CAPSULE
Non-Preferred
2 capsules
AVINZA® (morphine LA) 120 MG CAPSULE
Non-Preferred
NO DOSE LIMIT—USE CAUTION
FENTANYL 12.5 MCG/HR PATCH (72 HOUR)
Non-Preferred
10 patches per 31 days
FENTANYL 25 MCG/HR PATCH (72 HOUR)
Non-Preferred
10 patches per 31days
FENTANYL 50 MCG/HR PATCH (72 HOUR)
Non-Preferred
10 patches per 31 days
FENTANYL 75 MCG/HR PATCH (72 HOUR)
Non-Preferred
30 patches per 31 days
FENTANYL 100 MCG/HR PATCH (72 HOUR)
Non-Preferred
30 patches per 31days
KADIAN® (morphine LA) 10 MG CAPSULE SR
Non-Preferred
2 capsules
KADIAN® (morphine LA) 20 MG CAPSULE SR
Non-Preferred
2 capsules
KADIAN® (morphine LA) 30 MG CAPSULE SR
Non-Preferred
2 capsules
KADIAN® (morphine LA) 50 MG CAPSULE SR
Non-Preferred
2 capsules
KADIAN® (morphine LA) 60 MG CAPSULE SR
Non-Preferred
2 capsules
KADIAN® (morphine LA) 80 MG CAPSULE SR
Non-Preferred
2 capsules
KADIAN® (morphine LA) 200 MG CAPSULE SR
Non-Preferred
NO DOSE LIMIT—USE CAUTION
OXYCODONE HCL 10MG TAB.SR 12H
Non-Preferred
3 tablets
OXYCODONE HCL 20MG TAB.SR 12H
Non-Preferred
3 tablets
OXYCONTIN® (oxycodone) 30 MG TABLET SA
Non-Preferred
3 tablets
OXYCODONE HCL 40MG TAB.SR 12H
Non-Preferred
3 tablets
OXYCONTIN® (oxycodone) 60 MG TABLET SA
Non-Preferred
3 tablets
OXYCODONE HCL 80MG TAB.SR 12H
Non-Preferred
NO DOSE LIMIT—USE CAUTION
2.
Short-Acting opioids: Daily dose edit and cumulative quantity
limit
Effective, September 24, 2008, all oral short-acting opioids,
including combination products, will have a daily dose edit and a
cumulative quantity edit that will apply to all Medicaid-eligible
beneficiaries. The dose ratio edit for oral products will allow for up
to 6 units per 1 day or a cumulative quantity of up to a total of 186
units per 31 days for the same drug and strength unless a more
restrictive edit is currently in effect. For patients currently
receiving higher total quantities than these amounts of short-acting
opioids, the prescriber may wish to consider the need for a
long-acting opioid or may wish to consider adjusting the current dose
of the long-acting opioid. For questions regarding pharmacy claims or
edits on the short-acting opioids, please call the EDS PA Help Desk at
1-800-707-3854 (in-state toll free) or 501-374-6609, ext. 500 (local
and out-of-state). Dose conversion information is available on the
Medicaid website at
http://www.medicaid.state.ar.us/Download/provider/pharm/OpioidDosingConversionCalculator.xls
3.
Clinical Therapeutic Duplication (TD) Edits:
Effective, September 24, 2008, therapeutic duplication edits will
apply to all Medicaid-eligible beneficiaries for those opioid claims
that have an overlapping days’ supply. THE PRESCRIBING PROVIDER’S NPI
MUST BE MAPPED IN THE MEDICAID SYSTEM TO THE PRESCRIBING PROVIDER’S
MEDICAID PROVIDER ID NUMBER OR TEMPORARY PROVIDER ID NUMBER TO PREVENT
THE MEDICAID SYSTEM FROM REJECTING THE CLAIM DUE TO LACK OF
RECOGNITION OF AR MEDICAID PROVIDER ID. To verify your address and
report your NPI online, logon to the Medicaid website at
https://www.medicaid.state.ar.us/InternetSolution/Provider/npi.aspx#reporting,
or for telephone assistance reporting your NPI, please contact the
Provider Enrollment Unit in-state toll-free (800) 457-4454 or local
and out-of-state (501) 376-2211, select option 0 for "Other inquiries"
and then option 3 for "Provider Enrollment" when prompted.
a.
Short-Acting Opioids: The TD edit will reject subsequent claims
for different short-acting opioids if more than 25% of the days’
supply is remaining on the previous claim. See below for
inferred change in therapy from same prescriber.
b.
To allow for an inferred change in therapy from same prescriber
with overlapping day’s supply in short-acting opioids: one
therapeutic duplication from same prescriber will be allowed for
two different short-acting opioid claims with different dates of
service once per 93 days.
c.
Long-Acting Opioids: The TD edit will reject subsequent claims
for different long-acting opioids if more than 25% of the days’
supply is remaining on the previous claim. See below for
inferred change in therapy from same prescriber.
d.
To allow for an inferred change in therapy from same prescriber
with overlapping day’s supply in long-acting opioids: one
therapeutic duplication from same prescriber will be allowed for
two different long-acting opioid claims with different dates of
service once per 93 days.
e.
Using both Short-Acting and Long-Acting Opioids for drug
regimen:
The TD edit will allow concurrent therapy or overlapping days’ supply
from the same prescriber of one long-acting opioid and one
short-acting opioid for break through pain. The TD edit will reject
claims from different prescribers if more than 25% of the days’ supply
is remaining on either previous claim. The prescriber will need to
call the PA HelpDesk corresponding with the rejected opioid claim: EDS
Prescription Drug PA Help Desk at the in-state toll free number (800)
707-3854 or the local and out-of-state number (501) 374-6609 x 500 for
short-acting opioids, or the PDL PA Call Center at the in-state toll
free number 1-866-250-2518 or the local and out-of-state number (501)
526-4200 for long-acting opioids.
II.
AROMATASE INHIBITORS: Femara® tablets and Arimidex® tablets are
aromatase inhibitors (Type 2 “non-steroidal inhibitors”) indicated
for the adjuvant treatment of postmenopausal women with hormone
receptor positive early breast cancer. Review of SmartPA profiles
indicates that one or more of these medications is being used
off-label for a non-covered service of infertility treatments
through the Medicaid Pharmacy Program. The approval criteria for
either drug will require the patient’s Medicaid diagnosis history
to include a diagnosis of female metastatic breast cancer and will
reject all claims where the diagnosis is absent.
III.
TARGETED IMMUNE MODULATORS Change to existing criteria:
Humira or Enbrel: Children < 18 years of age with a submitted ICD-9
diagnosis code of rheumatoid arthritis in AR Medicaid diagnosis
history will not be required to meet the criterion of having received
>180 days of DMARD drug therapy in the past 365 days with one of the
following drugs: gold compounds, hydroxychloroquine, penicillamine,
methotrexate, azathioprine, sulfasalazine, or leflunomide.
IV.
RELISTOR® (methylnaltrexone bromide) SQ injection: RELISTOR® is
indicated for the treatment of opioid-induced constipation in
patients with advanced illness who are receiving palliative care,
when response to laxative therapy has not been sufficient. The
approval criteria will require a diagnosis code of 1) malignant
cancer ICD9 code in Medicaid history, AND 2) at least one opioid
drug claim in Medicaid drug profile history in the previous 30
days, AND 3) a trial of at least one claim of either glycolax or
lactulose in AR Medicaid drug profile history in previous 30 days.
The quantity edit limit will allow up to 2 kits or up to 15 vials
per 31 days of therapy.
V.
PEPCID® (famotidine) 40 MG/5 ML ORAL SUSPENSION: Approval criteria
will require a trial of 2 claims of ranitidine oral syrup in
previous 60 days in addition to the existing criteria to identify
those who cannot swallow solid oral dosage forms (< 6 yrs of age
or NPO).
VI.
BARACLUDE® (entecavir) TABLETS: BARACLUDE® is indicated for the
treatment of chronic hepatitis B virus infection in adults with
evidence of active viral replication and either evidence of
persistent elevations in serum aminotransferases (ALT or AST) or
histologically active disease. The BARACLUDE® package insert has a
black box warning stating “there is a potential for the
development of resistance to HIV (human immunodeficiency virus)
nucleoside reverse transcriptase inhibitors if BARACLUDE® is used
to treat chronic hepatitis B virus infection in patients with HIV
infection that is not being treated”. Clinical criteria will
reject claims at point-of-sale for BARACLUDE® if the Medicaid drug
profile indicates that an HIV positive beneficiary is
HIV-treatment-naïve or if no antiretroviral drug claim is present
in the Medicaid drug profile in previous 45 days.
VII.
NON-PEDICULICIDE MEDICATED SHAMPOOS: The approved quantity edit
for the following shampoos is one bottle per 31 days: Capex®
Shampoo 0.01% (fluocinolone acetonide), Clobex® .05% shampoo
(clobetasol proprionate), Loprox® 1% shampoo (ciclopirox),
selenium sulfide shampoos, ketoconazole 2% shampoo, Salicylic Acid
6% shampoo.
VIII.
ADDITIONAL INFORMATION:
As a reminder, Medicare-Medicaid beneficiaries (duals) are not
eligible for Medicaid prescription drug benefits after January 1, 2006
except for the optional drugs listed in the 1927(d) list.
The State was notified by Centers for Medicare & Medicaid Services
(CMS) that effective January 1, 2006, the State will no longer be able
to reimburse for drugs use to treat erectile dysfunction.
The EDS Prescription Drug Help Desk will be available for assistance
at 1-800-707-3854.
This advance notice is to provide you the opportunity to contact,
counsel and change patients’ prescriptions.
If you need this material in an alternative format, such as large
print, please contact our Americans with Disabilities Act Coordinator
at 501-682‑8323 (Local); 1-800-482-5850, extension 2-8323 (Toll-Free)
or to obtain access to these numbers through voice relay,
1-800-877-8973 (TTY Hearing Impaired).
If you have questions regarding this transmittal, please contact the
EDS Provider Assistance Center at 1‑800‑457‑4454 (Toll‑Free) within
Arkansas or locally and out-of-state at (501) 376‑2211.Arkansas
Medicaid provider manuals (including update transmittals), official
notices and remittance advice (RA) messages are available for
downloading from the Arkansas Medicaid website:
www.medicaid.state.ar.us.

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