PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE …...PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY ANNUAL REPORT TO THE PENNSYLVANIA GENERAL ASSEMBLY JANUARY 1 - DECEMBER 31, 2015

PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY

ANNUAL REPORT TO THE PENNSYLVANIA GENERAL ASSEMBLY

JANUARY 1 - DECEMBER 31, 2015

For the Pennsylvania Department of Aging Director Thomas M. Snedden Outreach and Enrollment Manager Rose M. Paulus Administrative Officer Janis L. Rhodes Operations Manager Rebecca D. Lorah, MPA Administrative Assistant Carol Bebawi Administrative Assistant Megan McDaniel Research and Evaluation Chief Theresa V. Brown, MPA Program Analyst Ellaheh Otarod, MBA Program Analyst Antonino G. Vetrano, MPA

Pennsylvania Department of Aging The PACE Program

Forum Place Building 555 Walnut Street

5th Floor Harrisburg, PA 17101-1919

717-787-7313 [email protected]

For Magellan Medicaid Administration, Inc. Officer in Charge Keira M. O’Brien Director, PACE Operations Bradley I. Kohler Assistant Director, PACE Operations Jean B. Sanders Cardholder Services Manager Janet N. Casterella Health Outcomes Scientist Jian Ding, PhD Clinical Pharmacist Judith Dooley, RPh Provider Services Manager Richard J. Flage Senior Health Outcomes Scientist Debra A. Heller, PhD, MPH Medicare Part D Manager Lisa M. Irwin Clinical Pharmacist Michelle LaSure, RPh Clinical Pharmacist Colleen M. Moyer, RPh Business Services Manager Donald G. Smith LAN/WAN Manager W. Todd Spacht Quality Assurance Manager Lisa Spiegel Systems Manager John K. Wheeler

Magellan Medicaid Administration 4000 Crums Mill Road, Suite 301

Harrisburg, PA 17112 717-651-3600

Any questions or comments pertaining to information within this report may be addressed to the Pennsylvania Department of Aging at the address given above.

TABLE OF CONTENTS

Frequently Requested Program Statistics ......................................................................................... 1

History ............................................................................................................................................... 3

Administration ................................................................................................................................... 5

Section 1 – Program Research Highlights .............................................................................. 7-16 Section 2 – Financial Data by Date of Service ...................................................................... 17-32

Table 2.1A Historical Claim and Expenditure Data for PACE Enrolled ........................... 19-20 and Participating Cardholders by Semi-Annual Period Based On Date of Service January 1991 - December 2015 Table 2.1B Historical Claim and Expenditure Data for PACENET Enrolled .................... 21-22 and Participating Cardholders by Semi-Annual Period Based On Date of Service July 1996 - December 2015 Figure 2.1 PACE and PACENET Claim Distribution by Amount Paid per Claim ................ 23 January - December 2015 Figure 2.2 Distribution of PACE Annual Benefit .................................................................. 24 January - December 2015 Figure 2.3 Distribution of PACENET Annual Benefit .......................................................... 25 January - December 2015 Table 2.2 Total Prescription Cost, Expenditures, Offsets, and Recoveries ....................... 26 January - December 2015 Figure 2.4 PACE and PACENET Enrollment, Claims, and ................................................. 27 Claims Expenditures by Calendar Year 1988-2015 Figure 2.5A PACE Total Enrolled and Participating Cardholders ......................................... 28 By Month January 2005 – January 2016 Figure 2.5B PACENET Total Enrolled and Participating Cardholders .................................. 29 By Month January 2005 – January 2016 Figure 2.6A PACE Average Wholesale Price (AWP) and .................................................... 30 Average Manufacturer’s Price (AMP), Brand Products Only, by Quarter

January 2000 – December 2015

Figure 2.6B PACE Average Wholesale Price (AWP) and ................................................ 31

Average Manufacturer’s Price (AMP), Generic Products Only, by Quarter

January 2000 – December 2015

Section 3 – Program Data by Date of Payment ..................................................................... 33-46

Table 3.1 PACE and PACENET Claims and Expenditures Paid by Fiscal Year .......... 35-37 July 1984 - December 2015 Table 3.2A PACE High Expenditure and High Volume Claims ....................................... 38-40 January - December 2015 Table 3.2B PACENET High Expenditure and High Volume Claims ................................ 41-43 January - December 2015 Table 3.3 PACE and PACENET Number and Percent of ............................................ 44-45 Expenditures and Claims by Manufacturer January - December 2015 Table 3.4 Manufacturers' Rebate Cash Receipts by Quarter/Year .................................... 46 Billed and by Fiscal Year Received January 1991 - December 2015

Section 4 – Cardholder Utilization Data ................................................................................. 47-62

Table 4.1 PACE and PACENET Cardholder Enrollments by Quarter .......................... 49-51 July 1984 – December 2015 Table 4.2A PACE Cardholder Enrollment, Participation, Utilization, ............................... 52-53 and Expenditures by Demographic Characteristics January - December 2015 Table 4.2B PACENET Cardholder Enrollment, Participation, Utilization, ....................... 54-55 and Expenditures by Demographic Characteristics January - December 2015 Figure 4.1A Percent of Enrolled PACE Cardholders by Income ........................................... 56 and Marital Status January - December 2015 Figure 4.1B Percent of Enrolled PACENET Cardholders by Income .................................... 57 and Marital Status January - December 2015 Table 4.3 Other Prescription Insurance Coverage of PACE and ....................................... 58 PACENET Enrolled Cardholders January - December 2015 Table 4.4 Part D Cardholder Enrollment, Participation, and Expenditures ................... 59-60 January - December 2015

Table 4.5 Annual Drug Expenditures for PACE/PACENET Enrolled ................................. 61 By Total Drug Spend, Part D Status, and LIS Status January - December 2015 Figure 4.2 PACE Generic Utilization Rates by Quarter ...................................................... 62 December 1988 - December 2015

Section 5 – County Data .......................................................................................................... 63-70

Table 5.1 Number and Percent of PACE and PACENET Cardholders ........................ 65-67 and Number of Providers by County January - December 2015 Figure 5.1 PACE and PACENET Cardholder, Claim, and Provider .................................... 68 Information by County Type (Percent of County Population Living in Urban Area) January - December 2015 Figure 5.2 Percent of Elderly Enrolled in PACE/PACENET and ......................................... 69 Percent Urban Population by County January - December 2015

Section 6 - Provider Data ......................................................................................................... 71-80

Table 6.1 PACE Claims by Product and Provider Type .................................................... 73 January - December 2015 Table 6.2 PACE Expenditures and Average State Share by Product and ........................ 74 Provider Type January - December 2015 Table 6.3 PACENET Claims and Expenditures by Provider Type ..................................... 75 January - December 2015 Table 6.4 PACENET Claims Volume by Phase of Coverage, ........................................... 76 Product Type, and Provider Type January - December 2015 Table 6.5 PACENET Expenditures by Phase of Coverage, ......................................... 77-78 Product Type, and Provider Type January - December 2015 Table 6.6 Average Cardholder and State Share Cost per PACENET ............................... 79 Claim by Phase of Coverage, Product Type, and Provider Type January - December 2015

Section 7 - Therapeutic Class Data and Drug Utilization Review Data ............................... 81-90

Table 7.1A Number and Percent of PACE Claims, State Share Expenditures, .............. 83-84 and Cardholders with Claims by Therapeutic Class January – December 2015

Table 7.1B Number and Percent of PACENET Claims, State Share .............................. 85-86 Expenditures, and Cardholders with Claims by Therapeutic Class January – December 2015 Figure 7.1 Percent of PACE State Share Expenditures by Therapeutic Class ................... 87 January - December 2015 Figure 7.2 Number and Percent of PACE and PACENET Claims ................................. 88-89 with a Prospective Review Message by Therapeutic Class January - December 2015

Section 8 - Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) .............. 91-94 Appendix A - The PACE Application Center 2015 Report, ...................................................... 95-107

University of Pennsylvania and PACE/PACENET Behavioral Health Lab Program 2015 Report, and The PACE Academic Detailing Program Impact Analysis, January 2013 - December 2015

Appendix B - The PACE/PACENET Medical Exception Process.................................................. 108

Appendix C - American Hospital Formulary Service (AHFS) Classifications ................................ 109

Appendix D - PACE Prospective Drug Utilization Review Criteria ........................................ 110-143

Appendix E - State Funded Pharmacy Programs Utilizing the PACE Program Platform ...... 144-147

FREQUENTLY REQUESTED PROGRAM STATISTICS

The table below provides frequently requested Program information and lists references within the Annual Report for additional details.

2015 PACE AND PACENET SUMMARY PACE PACENET REFER TO: DEMOGRAPHIC DATA Total enrolled for 2015 118,769 176,438 Tables 4.2, A and B % Participating 76.8% 79.3% Tables 4.2, A and B Avg. age for enrolled 79.6 yrs. 78.5 yrs. Tables 4.2, A and B Female, avg. age 80.4 yrs. 78.9 yrs. Male, avg. age 76.9 yrs. 77.7 yrs. % Female 76.7% 66.3% Tables 4.2, A and B % Own residence 52.4% 66.3% Tables 4.2, A and B % Rent 29.2% 22.0% Tables 4.2, A and B % Married 9.0% 35.3% Tables 4.2, A and B Avg. Income $11,898 $21,058 Tables 4.2, A and B % Cardholders in urban counties 41.3 % 37.3 % Table 5.1 % Cardholders in rural counties 13.6 % 14.2 % Table 5.1 BENEFIT DATA Avg. total expenditures per enrolled cardholder $2,076 $2,372 Table 4.4 Avg. total expenditures per participant $2,701 $2,991 Table 4.4 Avg. total expenditures per claim $76.39 $86.22 Table 4.4 Avg. state share per enrolled cardholder $670 $684 Table 4.4 Avg. state share per participant $872 $862 Table 4.4 Avg. state share per claim $24.67 $24.85 Table 4.4 Avg. cardholder share per enrolled cardholder $138 $255 Table 4.4 Avg. cardholder share per participant $179 $322 Table 4.4 Avg. cardholder share per claim $5.06 $9.27 Table 4.4 Avg. TPL share per enrolled cardholder $1,268 $1,433 Table 4.4 Avg. TPL share per participant $1,650 $1,807 Table 4.4 Avg. TPL share per claim $46.66 $52.09 Table 4.4

2015 percent change in state share per claim 15.5%

increase 7.3%

increase Figure 2.1, 2014 and 2015

Avg. claims per participant 35.4 34.7 Tables 4.2, A and B Avg. number of therapeutic classes per participant 5.0 5.1 Tables 7.1, A and BUTILIZATION DATA (by date of payment) Total claims 3,236,154 4,849,682 Tables 6.1 and 6.4 Avg. claims per cardholder 27.2 27.5 Tables 6.1 and 6.4 Avg. deductible claims per cardholder - 4.4 Table 6.4 Avg. copaid claims per cardholder - 23.1 Table 6.4 Generic utilization rate 84.3% 83.6% Tables 6.1 and 6.4 PAYMENT DATA Total Program payout $77.32 M $121.41 M Table 3.1 Avg. weekly Program payout $1.49 M $2.33 M Table 3.1 Avg. annual Program payout per pharmacy $25,604 $40,201 Tables 3.1 and 5.1 % Program payout to chain pharmacies 58.2% 60.2% Tables 6.2 and 6.3

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PENNSYLVANIA PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY History The Pharmaceutical Assistance Contract for the Elderly (PACE) Program was enacted in November 1983, and implemented on July 1, 1984. Its purpose is to assist qualified state residents who are 65 years of age or older in paying for their prescription medications. The PACE legislation was amended in 1987 for reauthorization and, in 1992, for the manufacturers’ rebate reauthorization and additional cost containment initiatives. The legislature expanded income eligibility for PACE on four occasions: 1985, 1991, 1996, and 2003. The 1996 legislation also created the PACE Needs Enhancement Tier (PACENET). In July 2001, Act 2001-77, the Pennsylvania Master Tobacco Settlement, increased PACENET income eligibility by $1,000. Recognizing that the nominal increases in Social Security income were making enrollees ineligible for PACE, the legislature also created a limited PACE moratorium, effective January 1, 2001, until December 31, 2002, which permitted enrollees to remain in benefit even though their incomes exceeded the eligibility limits. Late in 2002, Act 2002-149 extended the moratorium for the PACE enrollment and expanded it to include the PACENET enrollment as well. While this moratorium expired on December 31, 2003, cardholders who were enrolled prior to the expiration, and had their eligibility periods extending into 2004, were permitted to remain in the Program until their eligibility end date. In November 2003, Act 2003-37 enabled an unprecedented expansion for enrollment eligibility in the Programs, modified the $500 annual PACENET deductible, and changed the PACE copay structure. The legislation raised the income limits for PACE to $14,500 for individuals and $17,700 for married couples; it boosted the income cap for PACENET to $23,500 for single persons and to $31,500 for married couples. With a $480 deductible divided into monthly $40 amounts, PACENET paid benefits after the first $40 in prescription costs each month. Beginning in 2004, PACE and PACENET had a two-tiered prescription copayment structure. The PACE copayment became $6 for generic drugs and $9 for brand name products. The PACENET copayment remained at the original amounts of $8 for generics and $15 for brand name drugs. Act 37 required both Programs to adjust the copayments to reflect increasing drug prices over time. Act 37 instituted Federal Upper Limits (FUL) in the provider reimbursement formula and raised the dispensing fee fifty cents. The Program began to reimburse pharmacies the lesser of three prices: the Average Wholesale Price (AWP) minus 10%, plus a $4.00 dispensing fee; the Usual and Customary charge to the cash-paying public; or, the most current FUL established in the Medicaid program, plus a $4.00 dispensing fee. All payment methods include the subtraction of the cardholder’s copayment. The federal Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a new outpatient prescription drug benefit, Part D of Medicare. Prior to the full implementation of Medicare Part D and beginning in June 2004, low income, non-HMO, PACE enrollees (134,393 cardholders over 18 months) were auto-enrolled into the interim Medicare Drug Discount Card and Transitional Assistance Program. They received a discount card that allowed for $600 per year in drug expenses in 2004 and again in 2005. Additional cardholders, estimated at 30,000, received this assistance through cards issued by their HMO. The PACE Program covered the Medicare drug card copayments for the auto-enrolled cardholders. The Medicare Transitional Assistance Program was a source of significant drug coverage for cardholders, with known savings in Program benefit payments of $112 million for the auto-enrolled cardholders. The Medicare Part D drug benefit began in January 2006. The PACE Program elected to be a qualified State Pharmacy Assistance Program which, along with the

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passage of state Act 111 in July 2006, allowed for the creation of PACE Plus Medicare. The successful launch of “PACE Plus Medicare” on September 1, 2006, saw thousands of cardholders take advantage of the features of both PACE and Medicare Part D. With the goal of providing seamless coverage, PACE provides benefits when Medicare Part D does not, for example, during the deductible and the coverage gap, for drugs excluded under MMA, for drugs not in a plan’s formulary, and for copayment differentials between the Part D plan coverage and the PACE and PACENET copayments. The Program pays the Medicare premiums for Part D coverage for PACE cardholders. Act 111 also eliminated the monthly deductible for PACENET cardholders. PACENET cardholders who choose to forego Part D coverage are now responsible for a monthly benchmark premium payment ($32.59 in 2006; $28.45 in 2007; $26.59 in 2008; $29.23 in 2009; $32.09 in 2010; $34.07 in 2011, $34.32 in 2012; $36.57 in 2013; $35.50 in 2014; $33.91 in 2015; and, $35.30 in 2016) to the Program. The benchmark annual premium payment remains lower than the prior $40 per month deductible. Act 111 of 2006 recreated the PACE and PACENET moratoriums thereby permitting some 14,000 seniors to maintain their PACE or PACENET status despite disqualifying increases in their overall income due to Social Security cost-of-living increases. The PACE moratorium expired at the end of 2006; the PACENET moratorium continued through 2007. The Act revised provider reimbursement by adjusting the Average Wholesale Price formula from AWP minus 10% to AWP minus 12%, plus a $4.00 dispensing fee. Act 69 of 2008 recreated the PACE and PACENET moratoriums, thereby permitting 15,400 seniors to maintain their Program enrollment in 2010 despite disqualifying increases in their overall 2008 income due to Social Security cost-of-living increases. Act 21 of 2011 extended the moratorium until December 31, 2013, allowing 31,000 persons to remain enrolled. Act 12 of 2014 established the moratorium expiration date for December 31, 2015, preserving the enrollment for 28,000 older adults. This Act also instituted the exclusion of Medicare Part B premium costs from the definition of total income used for income eligibility determination. As of May 2014, 46,000 cardholders retained their enrollment in the Program due to these two provisions of Act 12. Act 91 in 2015 extended the PACE and PACENET moratoriums until December 2017. In July of 2015, 10,000 cardholders retained enrollment due to the Part B premium exclusion provision and 11,400 older persons remained enrolled due to the Social Security cost-of-living exclusion. PACE covers all medications requiring a prescription in the Commonwealth, as well as insulin, insulin syringes, and insulin needles, unless a manufacturer does not participate in the Manufacturers’ Rebate Program. PACE does not cover experimental medications, medications for hair-loss or wrinkles, or over-the-counter (OTC) medications that can be purchased without a prescription. With appropriate documentation, PACE covers Drug Efficacy Study Implementation (DESI) medications. PACE requires generic substitution of brand multi-source products when an approved, Food and Drug Administration (FDA) A-rated generic is available. At the time of dispensing, a cardholder may encounter a prospective drug utilization review edit; PACE will not reimburse the prescription unless the pharmacist or physician documents the medical necessity for it. The Department of Aging recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. Appendix A contains a description of the PACE/PACENET medical exception process. With the advent of PACE Plus, cardholders enrolled in Part D plans conform to the reimbursement limits established by the plans, some of which allow up to a ninety-day supply. Otherwise, cardholders not enrolled in a Part D Plan receive a thirty-day supply or 100 units (tablets or capsules) whichever is less. The Program guarantees reimbursement to the provider (including nearly 2,900 Pennsylvania pharmacies) within 21 days, paying interest on any unpaid balance after 21 days. Six types of providers dispense PACE/PACENET-funded prescriptions to

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cardholders. The majority of providers are either independent pharmacies or chain pharmacies. Other provider types include institutional pharmacies, nursing home pharmacies, mail order pharmacies, and dispensing physicians. All providers may offer mail order services if they are enrolled as a mail order pharmacy and if they follow specialized program requirements pertaining to record keeping and cardholder verification procedures. Manufacturers for innovator products pay the Program a rebate similar to the federal “best price” Medicaid rebate. Generic manufacturers paid an 11% rebate based on the average manufacturer price (AMP). An inflation penalty applies to innovator products if annual price increases exceed the consumer price index. The inflation penalty rebate was discontinued for generic products at the end of 2006. Effective January 2010, the federal Medicaid flat rebate rate increased from 15.1% of the AMP to 23.1%, and the generic rate increased from 11% to 13%. Administration The Pennsylvania Department of Aging administers the PACE/PACENET Program. A contractor directly responsible to the Department assists in conducting many of the day-to-day operations. Four primary operational responsibilities of the Program are to process applications, reimburse providers for prescriptions, protect enrollees from adverse drug events, and obtain the most cost-efficient reimbursement possible for the Program. Administrative responsibilities include research and policy development, monitoring and evaluating operations and ensuring that the mandates of the Act and Program regulations are met. Activities in these areas include conducting audits of not only the providers, but also of the cardholders and the contracting agency. The Program routinely reviews medication utilization profiles of the cardholders and dispensing practices of the providers and physicians. The Department also evaluates the procedures used to implement the Program, identifies any trends which may be relevant for future administration, and carefully scrutinizes all expenditures. The Department of Aging receives funds through restricted revenue accounts to serve as the administrative and fiscal agent for other Commonwealth-sponsored drug reimbursement programs. Pharmaceutical claims for the Chronic Renal Disease Program, Cystic Fibrosis Program, Spina Bifida Program, Metabolic Conditions Program, including Maple Syrup Urine Disease Program and the Phenylketonuria Program (all within the Department of Health), and the two Special Pharmaceutical Benefits Programs (Department of Health for SP1 and Department of Human Services for SP2) are processed through the PACE/PACENET system. The program also adjudicates claims for two programs in the Department of Insurance, the Workers’ Compensation Security Fund and the Pennsylvania Automobile Catastrophic Loss Benefits Continuation Fund. The PACE Program serves as the fiscal agent for the General Assistance Program (Department of Human Services), the Special Pharmaceutical Benefits Program, and the Chronic Renal Disease Program for the collection of rebates from pharmaceutical manufacturers. The Program processes eligibility applications for the Chronic Renal Disease Program and for the SP1 Program. The PACE Program conducts benefit outreach and assistance for persons identified by the Board of Probation and Parole. Prescription claim processing and program management support is provided to the Department of Corrections. The Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) is available to assist all adult Pennsylvanians with the cost of prescription drugs. PA PAP outreaches to those who are uninsured or under-insured by helping them to apply for prescription assistance through various programs. Details about the Clearinghouse are found in Section 8 of this report.

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6

SECTION 1

PROGRAM RESEARCH HIGHLIGHTS

7

8

INTERV

ENTIONS, GEN

ERAL

PRO

GRA

M ASSESSM

ENTS, A

ND M

EDICAT

ION ADHER

ENCE

STU

DIES

CURR

ENT PA

CE/PAC

ENET

COLLAB

ORA

TIVE

RESEA

RCH AND EVA

LUAT

ION PRO

JECT

S, 2008 – 2016, A

UGUST 2016 UPD

ATE

INTERV

ENTIONS

TOPIC

TITLE / RE

SEAR

CH GRO

UP

DESCR

IPTION

ASSESSMEN

T FO

R DEP

RESSION,

ANXIETY, AND

SLEEP

DISORD

ERS

TELEPH

ONE‐BA

SED

BEHAV

IORA

L HEA

LTH

ASSESSMEN

T FO

R SENIORS

ON

NEW

PSYCH

OTR

OPIC

MED

ICAT

ION

Beha

vioral Health

Lab

oratory,

Med

ical Schoo

l, University

of

Penn

sylvan

ia

Results from aPACE statew

ide collaborative care program

by the Beh

avioral H

ealth Laboratory (begun in

2008) support

concerns related to psychotropic m

edication prescribing in the elderly and raise additional questions about off‐label or

inappropriate prescribing. Overall, 45.0%

of p

articipan

ts did not m

eet criteria fo

r any

men

tal health

disorde

r with

low

symptom

s ind

icated

. (About 42% of Phase II participants were minim

ally sym

ptomatic.) Ju

st 6% m

et th

e crite

ria fo

r anxiety

disorders. The study found that older, community dwelling patients received new

psychotropic m

edications in excess of

what m

ight be expected based

on their relatively low sym

ptom burden

. Many reported

that the prescription was for a

psychosocial stressor (43.8%), while 15.8% were unaw

are of the reason for the prescription.

Interven

tion aims includ

e assigning individu

als with

clin

ically significan

t sym

ptom

s to minim

al m

onito

ring or m

onito

ring

with

care man

agem

ent a

nd social service su

pport in orde

r to de

term

ine whe

ther th

e clinical se

rvices are im

pacting

outcom

es. Outcomes analyses show that enhanced care managem

ent im

proves symptoms and overall functioning relative

to standard m

onitoring services alone. In the high sym

ptom group, care managem

ent advice has led to referrals to specialist

care. With low sym

ptom patients, the assessmen

t explores reasons for the psychotropic m

edication and consideration of

discontinuation after persisten

ce of measured low sym

ptoms.

Care m

anagem

ent cases are asked

at the

nine week follo

w up ab

out the

ir satisfaction level. The

re is a very high

level of

enrollee satisfaction with

the care m

anagem

ent service (>

95%

satisfaction).

A recen

t analysis of patient chronic pain found significant differences in levels of dep

ression, anxiety, and quality of life

between those who experience interferen

ce of pain versus those who do not.

Two programs, SUSTAIN and

CRE

ST (see

App

endix), p

romote no

n‐ph

armacological interven

tions th

rough assessmen

t and

assistan

ce with

add

ressing psycho

social stressors. W

ith SUSTAIN, in 2015, the Beh

avioral H

ealth Laboratory completed 634

initial assessm

ents for new

patients and caregivers. Five initial assessm

ents were direct referrals from the prescribing

physician or from the PACE Application Center. There were 2,442 follow‐up assessm

ents with cardholders and caregivers.

Among them

, 240 cardholders received

care managem

ent services; 289 cardholders received

sym

ptom and m

edication

monitoring services; 29 cardholders were referred

to specialty men

tal health services; 19 caregivers participated

in the

Telehealth Education Program

for caregivers of persons with dem

entia. This p

rivate‐pu

blic partnership re

ceived

the Bron

ze

Award as part o

f the

nationa

lly re

cognized

2015 Am

erican

Psychiatric Associatio

n Ac

hievem

ent A

wards.

In 2015, CREST assessed

139 cardholders and/or their caregivers. Of the 83 caregivers in this group, 66 caregivers worked

directly with a beh

avioral health provider in

care managem

ent and CREST ed

ucation services. There were 25 cardholders

who failed the initial m

emory screening and did not iden

tify a caregiver.

There were three project papers published

in 2015 in

peer‐review

ed journals (see

Appen

dix).

FALLS

PREV

ENTION

FALLS‐FR

EE PA

Gradu

ate Scho

ol of P

ublic

Health

, University

of P

ittsburgh

The Cen

ters for Disease Control and Prevention provided

funds for this two year research grant. R

esearche

rs at the

Gradu

ate Scho

ol of P

ublic Health

at the

University

of P

ittsburgh

and

the PA

Dep

artm

ent o

f Aging

examined

cou

nty level

falls incide

nce an

d the effect of the

Dep

artm

ent’s

Hea

lthy Step

s for Older Adu

lts and

Hea

lthy Steps in Motion projects. A

phy sician ed

ucation compo

nent includ

ed su

rveying ph

ysicians who

see

older adu

lts in

their p

ractice an

d offerin

g mailed

and on

line ed

ucationa

l materials (h

ealth

yaging.pitt.edu

) with

CME/CEU credits. Findings from the evaluation of the

Healthy Step

s program

s were incorporated into the well‐received

Preventing Falls Among the Elderly m

odule developed

for

the PACE Program

’s academ

ic detailing effort in

2014.

9

ACAD

EMIC

DETAILING

UPD

ATING PHY

SICIAN

S AB

OUT

CHAN

GING THE

RAPIES IN

CO

MPLICAT

ED DISEA

SE STA

TES

The Division of Pha

rmaco‐

epidem

iology and

Pha

rmaco‐

econ

omics o

f the

Brig

ham and

Wom

en’s Hospital/Harvard

Med

ical Schoo

l and

Alosa Health

PACE

offersa long

‐stand

ing ph

ysician ed

ucation program. Ph

ysicians at the

Harvard M

edical Schoo

ltrain Pen

nsylvania‐

based clinical edu

cators to

meet o

ne‐on‐on

e with

clin

icians who

care for a

large nu

mbe

r of p

atients e

nrolled in PAC

E.

During the office visits, begun in

2005, the ed

ucators provide objective, research‐based

inform

ation about effective drugs

and non‐m

edication therapeutic options for common chronic conditions. Edu

cators have logged

nearly

19,600 visits.

During 2015

, five mod

ules accou

nted

for 9

5% of the

2,653

visits

during the year to

over 9

00 practition

ers.

The Alzheimer’s and

related disorders m

odule (113 visits) helps primary care practitioners to m

anage Alzheimer’s disease

and other form

s of cognitive im

pairm

ent in their practice. It covers definitions, differential diagnosis, and risk factors for

dem

entia and m

ild cognitive im

pairm

ent. Clinicians hear recommen

dations about screen

ing and evaluation. The materials

summarize curren

t eviden

ce for non‐pharmacologic al and pharmacological m

anagem

ent of cognitive im

pairm

ent.

M

anaging pa

in in

the elde

rly (640 visits) presents the need for safe, effective pain relief am

ong older adults across a

range of settings. Achieving functional goals that do not pose harm from side effects, addiction, or potential overdose is

challenging in this patient population due to such issues as the altered pharmacodynam

ics and pharmacokinetics with age,

the polypharmacy of older adults, potential cognitive deficits, heightened

risk of falls, and organ

‐specific vulnerabilities.

Evaluating an

d man

aging urinary incontinen

ce (780 visits) inform

s health care professionals that urinary incontinen

ce is

more common, m

ore serious, and m

ore treatable than

is often

recognized

. It is not a norm

al part of aging, even though

many patients are reluctant to discuss the topic. Doing so and form

ulating an

adeq

uate treatm

ent plan can

be

transform

ative. Referen

ce cards for clinicians and education m

aterials for family m

embers are part of the module.

The atria

l fi brillatio

n mod

ule (842 visits) focuses on the updated

stroke tool, CHADS 2‐VASc, promotes a bleed

ing risk tool,

HAS‐BLED, and updates prescribers on the novel oral anticoagulants which had

been approved since the previous version of

this m

odule. Even

though

elderly patients have increased bleed

ing risk, they ben

efit from anticoagulation. Providing this

module to prescribers raises awaren

ess of the ben

efits of starting older patients on anticoagulation.

Treating he

art failure in

prim

ary care (1

46 visits) updates clinicians on the American

College of Cardiology Foundation

and American

Heart Association heart failure stages. The module was very timely, as a med

ication for reduced ejection

fraction heart failure was recen

tly approved. Given

the focus on hospital readmissions, this topic is well received in

the field.

Clinicians express apprec iation for the patient brochures and the lifestyle tear‐off pieces.

For each topic, staff develops print materials, trains the educators, m

anages the interven

tion, and offers continuing

education credits. The physician faculty develops content based

upon common drugs used by and conditions affecting the

elderly. Educators distribute documen

ts to physicians during face‐to‐face meetings: comprehen

sive reviews of biomed

ical

literature, known as eviden

ce docum

ents; distillations of key inform

ation used as the basis for the discussion between

practitioner and the ed

ucator, known as summary do

cumen

ts; p

atient or caregiver brochures geared to the lay public,

including resources for additional inform

ation and support; and, lam

inated

, pocket‐sized

quick reference cards o

n treatmen

t and drug efficacy. These materials are fo

und at www.alosafoun

datio

n.org.

In 2015, m

odule evaluation surveys for all topics measured strong physician agreemen

t in response to the questions about

whether the program

ben

efits the well‐being of patients. Satisfaction elemen

ts with the highest agreem

ent scores included

: the PACE academ

ic detailer discussed

the ben

efits of specific therapies; the detailer explained

assessm

ent tools and how I

can use them

in m

y prac tice to select therapy; and, the academ

ic detailer presented eviden

ce on the efficacy and safety of

drugs and therapeu

tic alternatives. Evalua

tions of three

mod

ules, n

on‐steroidal anti‐inflammatory drugs/coxib use, acid

supp

ressing drugs, and

use of a

nti‐p

sychotics, indicate th

at th

e program achieved redu

ctions in

the med

ications ta

rgeted

. In 2008‐2010, a parallel program

delivered

three ed

ucational m

odules that focused on preventing the need for

hospitalizations and institutionalizations: cognitive im

pairm

ent and associated

beh

avioral problems (709 visits), falls and

mobility problems (668 visits), and incontinen

ce (823 visits). These topics have been updated

and relaunched

.

10

ACAD

EMIC

DETAILING

EVAL

UAT

ION

EFFECT

S OF AC

ADEM

IC

DETAILING ON THE

TREA

TMEN

T OF TY

PE 2

DIABE

TES

Wilkes University

Schoo

l of

Pharmacy an

d Magellan

Health

/PAC

E

This program

evaluation study is focusedon the im

pact of the PACE physicianed

ucation program

on the treatm

ent of Type 2

diabetes. The study specifically examines prescribing patterns before and after prescribers participated

in the program

’s

2013 diabe

tes m

anagem

ent m

odule. This m

odule provided

prescribers with inform

ation on the comparative effectiven

ess

and safety of type 2 diabetes m

edications, presented eviden

ce regarding appropriate therapy strategies, and weighed

the

ben

efits, risks, and value of treatm

ent options with the intent to im

prove the quality of prescribing and patient care.

The methodology for this evaluation includes a quasi‐experim

ental design using an

interrupted tim

e‐series to track changes

in several prescribing quality metrics during the year preceding and the year following prescribers’ participation in

the

training module. In addition to the group of prescribers who received the diabetes m

anagem

ent training, the evaluation

analysis also includes a comparison group of PACE/PACEN

ET prescribers who did not receive the training.

The quality metrics iden

tified

for this study include:

Prescribing of metform

in for patients with Type 2 diabetes

Prescribing of HMG‐CoA red

uctase inhibitors (statins) for patients with Type 2 diabetes

Prescribing of either an angiotensin‐converting‐en

zyme (ACE) inhibitor or an

angiotensin II recep

tor blocker (ARB)

for patients who have both Type 2 diabetes and hypertension

Avoidance of long‐acting sulfonylureas (i.e. chlorpropramide, glyburide) in

patients with diabetes

Statistical analyses are in

progress and will be completed during the latter part of 2016.

IMPR

OVING

BRAIN HEA

LTH

AND QUAL

ITY

OF LIFE

THE RH

YTHM EXP

ERIENCE

AND

AFRICA

NA CU

LTURE

TRIAL

‐‐RE

ACT!

University

of P

ittsburgh

and

University

of P

ennsylvania,

Alzheimer’s Associatio

n, and

Magellan Health

/PAC

E

The PACE program

supports research related

to im

proving the lives of cardholders. In

2016, the RE

ACT!

Project began

to

explore whether African

dance or ed

ucation classes im

prove brain health or quality of life for older African

Americans

between 65‐75 years old. Letters to Program

enrollees invite them

to talk with researchers to determine if they are eligible.

The project ran

domly assigns participan

ts to

take

classes in

eith

er African

dan

ce or A

frican

a cultu

re and

edu

catio

n. Classes

are ab

out o

ne hou

r lon

g an

d occur three

days pe

r week for a

total of six m

onths. At the beginning and end of the study,

participants perform

a walking test, complete m

emory tasks, and fill out surveys about their health and m

ood. The study will

exam

ine whether brain health, fitness levels or quality of life im

proves as a result of participating in these activities.

INTERV

ENTION

FOR MILD

COGNITIVE

IMPA

IRMEN

T

INDIVIDUAL

IZE EV

ERYD

AY

ACTIVITIES‐‐IDE

A Occup

ationa

l The

rapy

Dep

artm

ent a

t the

University

of Pittsburgh

and

Magellan

Health

/PAC

E

Older personswith m

ild cognitive im

pairm

ents are at‐risk for increasing disability and dem

entia. Despite the common

conception that individuals with m

ild cognitive im

pairm

ent do not have disability in

daily activities, recen

t research at the

University of Pittsburgh has shown that they dem

onstrate im

paired perform

ance (i.e., preclinical disability) in cognitively‐

focused daily activities, such as grocery shopping and paying pills. The

purpo

se of this s

tudy

is to

examine the efficacy of

the IDEA

interven

tion to optim

ize pe

rforman

ce in

daily activities and

to delay th

e de

cline to fran

k disability in older adu

lts

who

have mild

cognitiv

e im

pairm

ent. Successful interven

ti on may help to offset b

oth fin

ancial and

emotiona

l burde

ns to

family m

embe

rs.

In 2016, PACE sent letters of invitation to cardholders living in Pittsburgh. O

nce enrolled in

the study, participants develop

effective strategies to work through

and around barriers to daily activities. They set a goal to address barriers, develop a plan

to address the goal, do the plan, and check whether the plan req

uires revising. M

ultiple sessions are completed in the home

over a 5‐w

eek period with a registered occupational therapist who encourages family m

embers to participate.

PHYSICAL

AC

TIVITY

AND

BRAIN HEA

LTH

HEA

LTHY BR

AIN RESEA

RCH

STUDY

Physical Activity

and

Weight

Man

agem

ent R

esearch Ce

nter

at th

e University

of P

ittsburgh

an

d Magellan Health

/PAC

E

As a prescription drug program

, PACE is aware of research studies that seek better ways to promote both gen

eral health and

brain health as peo

ple age. An

impo

rtan

t life

style be

havior th

at is link

ed to

improved

brain fu

nctio

n is physical activity

. The majority of studies exam

ining the effect of physical activity on brain health have focused primarily on structured form

s of moderate‐to‐vigorous intensity exercise, and m

any of these studies have used supervised exercise. However, it is unclear

whether brain and cognitive function can

be im

proved or sustained

with different patterns (e.g., multiple, shorter periods) of

physical activity. The

study

seeks to

show

that interm

itten

t physical activity

is effectiv

e for improving brain structure an

d

11

functio

n as well as cognitive

functio

n. Participants are 75 to 85 years old who do not exercise regularly but are able to

participate safely in

moderate intensity exercise. Study mem

bers complete baseline and six‐m

onth assessm

ents. As part of

the study, they also attend health and physical activity classes.

GEN

ERAL

PRO

GRA

M ASSESSM

ENTS

TOPIC

TITLE / RE

SEAR

CH GRO

UP

DESCR

IPTION

IMPR

OVE

D

HEA

LTH

STAT

US AN

D

AVOIDAN

CE

OF NURS

ING

HOME EN

TRY

AND LAT

ER

ENTR

Y INTO

WAIVE

R PR

OGRA

MS

PACE

ENRO

LLMEN

T PR

OVIDE

S AD

VANTA

GE FO

R LO

W

INCO

ME, PRE

‐MED

ICAID

SENIORS

Pe

nnsylvan

ia Dep

artm

ents of

Aging an

d Hum

an Services,

Office of Lon

g Term

Living,

Magellan Health

/PAC

E, M

ercer

Governm

ent H

uman

Services

Consultin

g, and

the Health

Po

licy Institu

te at G

eorgetow

n University

A 2010 analysisdem

onstrates that the PACE Program

supports many seniors prior to their Med

icaid enrollm

ent. Data

compare consumers who “had” and “did not have” PACE in a five year period prior to using long‐term

care or nursing waiver

services. Re

sults

suggest P

ACE en

rollm

ent e

nables sen

iors to

remain in th

e commun

ity longer, w

ith better h

ealth

, and

to

delay en

try into and

utilization of long

‐term care an

d waiver services. Findings include:

Average length of nursing facility stay over a 5‐year period was 40 days less for previous PACE en

rolled.

PACE mem

bers were older at en

try into a nursing facility by 2.8 years.

The ages at waiver en

try show PACE mem

bers were older by 3.1 years.

Later age of entry into nursing facilities provided

an estim

ated

annual savings of $728.8 M

.

Deferred waiver program

produced estim

ated

annual savings of $86.5 M

.

PACE en

rollees who have subsequen

t Med

icaid enrollm

ent have lower costs as a result of earlier PACE coverage.

The Program

takes advantage of its ideal position to educate those PACE seniors, w

ho are specifically known to be

income eligible, about the comprehen

sive health care coverage available through

Med

icaid, producing a unique,

efficien

t outreach and im

proved coordination with M

edicaid.

Analysts at Mercer Governmen

t Human

Services Consulting evaluated

the study and were prepared

to certify results.

SATISFAC

TION

SURV

EYS

PACE

/PAC

ENET

SURV

EY ON

HEA

LTH AND W

ELL‐BE

ING

Magellan Health

/PAC

E

The Survey on Hea

lth and

Well‐B

eing

provides inform

ation ab

out the

cardh

olde

r pop

ulation. Q

uestions m

easure

cardho

lders’ self‐rep

orted he

alth status, self‐rep

orted med

ication ad

herence an

d affordab

ility, and

satisfaction with

their

PACE

/PAC

ENET

coverage. Survey da

ta are freq

uently link

ed with

other im

portan

t data sources, in

clud

ing prescriptio

n records, M

edicare services re

cords, and

vita

l statistics records, and

are used for p

rogram

evaluation an

d original re

search

stud

ies. Included

in the PACE/PACEN

ET new

enrollm

ent application, the optional survey gathers im

portant inform

ation

about a person’s health im

med

iately prior to joining PACE. The optional ren

ewal survey is m

ailed to existing cardholders

throughout the year. Most ren

ewal survey questions are the same as the new

enrollm

ent survey, but a few questions are

different. It provides im

portant inform

ation about the cardholder’s health after being in PACE. A

nnual updates allow the

study of changes over time. The 2012 revised

response rate (after rem

oval of 3,324 deceased cardholders) was 49.9%.

Results

from

5% Ran

dom Sam

ple: N

early 31% of curren

t responden

ts indicated

that they did not complete high school w

ith

11% of curren

t responden

ts indicating that they had

an 8

th grade or less education. Understanding the ed

ucational

background of the population helps to ensure that cardholder communications are at an appropriate reading level. Among

cardholders who were en

rolled in

PACE at the time that they completed the survey, 88% rep

orted

that they were either

“extremely” or “quite a bit” satisfied with PACE. A

mong PACEN

ET enrolled cardholders, 78% were “extremely” or “quite a

bit” satisfied that PACEN

ET. Another 9% of PACE en

rollees and 15% of PACEN

ET enrollees were “m

oderately” satisfied

. These data indicate high levels of satisfaction with both Program

s. Cardholders who responded

to the survey also expressed

a high degree of satisfaction with the combination of PACE/PACEN

ET and M

edicare Part D by scoring a high average

satisfaction that ranged between strongly and somew

hat agree

that the combination works well for them

(1.3 for PACE and

1.5 for PACEN

ET on a 4.0 scale). N

early

41%

of respo

nden

ts self‐rep

orted a fall in th

e pa

st year, with

abo

ut 12%

of

respon

dents indicatin

g more than

one

fall an

d least o

ne injury due

to th

e fall. For global self‐rated health, 38% of

responden

ts had

fair or poor health. PACEN

ET cardholders report “not filling prescriptions due to cost” more frequen

tly

than

PACE cardholders with 12% of them

not filling a prescription two or more tim

es in

past year compared

to 7% for PACE.

12

SELF‐RAT

ED

HEA

LTH

IMPA

CT OF VA

NTA

GE PO

INT

ON THE AS

SOCIAT

ION

BETW

EEN SELF‐RA

TED HEA

LTH

AND M

ORT

ALITY

Magellan Health

/PAC

E an

d Th

e Med

icine, Health

, and

Aging

Project a

t Pen

n State

University

Numerous studies dem

onstrate that self‐rated health predicts m

ortality. The

goa

l of this s

tudy

was to

explore how

self‐

ratin

g vantage po

int a

ffects m

ortality pred

ictio

n. Subjects included

137,188 PACE en

rollees.

Three self‐rated he

alth van

tage points were used

: glob

al, age‐com

parativ

e (others o

f sam

e age) and

time compa

rativ

e (present vs. one

year a

go). M

ultivariate Cox proportional‐hazards regression was used to predict subsequen

t mortality over

two years, controlling for dem

ographics and m

edication‐based

comorbidity.

When

comparing global and age‐comparative ratings, 73% of persons reported

equal global and age‐comparative scores;

19% had

age‐comparative scores that exceeded

global scores; and, 8% indicated

age‐comparative scores worse than

global.

Age comparative scores worse than

global increased risk of mortality, while age‐comparative scores exceed

ing global scores

reduced risk. The im

pact of age‐comparati ve deviation fr om global was stronger in young er age groups. Controlling for

global self‐rated health, self‐assessed

change over the past year in

either direction increased m

ortality risk, but the effect

varied

by age (interaction p < .001), with the greatest im

pact observed

among younger elderly aged 65‐79.

These results

suggest tha

t com

parativ

e ratin

gs are particularly useful w

hen used

alongside

globa

l ratings, and

that

potential age differen

ces in van

tage

point m

eaning

may have a be

aring on

mortality pred

ictio

n.

BERE

AVEM

ENT

AND

MORT

ALITY

MORT

ALITY FO

LLOWING

WIDOWHOOD:

THE RO

LE OF PR

IOR SPOUSA

L HEA

LTH

Magellan Health

/PAC

E, The

Med

icine, Health

, and

Aging

Project a

t Pen

n State

University

, and

Emory

University

Rollin

s Schoo

l of

Public Health

Prior research has shown that widowhood is associated

with increased m

ortality risk; h

owever, it is not clear whether the

rapidity of the predeceased spouse’s health decline affects this risk. This s

tudy

used grou

p‐ba

sed trajectory m

odeling to

describ

e pred

eceased spou

ses’ patterns of health

declin

e, and

examined

associatio

ns with

post‐widow

hood

survival.

Subjects included

9,967 PACE/PACEN

ET cardholders who were widowed

between 2000 and 2006. The predeceased and

bereaved spouses’ health trajectories in

the year before widowhood were evaluated

for three measures: the Combined

Comorbidity Score, inpatient hospitalized

days, and ambulatory visits. M

ultivariate Cox proportional hazards models were

used to evaluate whether the predeceased spouse’s pattern of health decline affected

the subsequen

t survival of the

bereaved spouse, w

hile controlling for the bereaved spouse’s own historical health trajectory and other factors.

Multiple trajectory patterns of health decline before death emerged in

the predeceased sam

ple. Among predeceased

hospice users, stable low and late onset comorbidity patterns were both associated

with greater m

ortality in the bereaved,

relative to chronic high comorbidity (HR=1.47 and 1.62, respectively). Relative to stable m

edium levels of am

bulatory visits

among the predeceased, chronically high visit levels were associated

with a lower m

ortality rate in

the bereaved (HR=0.67),

while very low visit levels were associated

with higher post‐w

idowhood m

ortality in the bereaved (HR=1.32).

These results

dem

onstrate th

e utility of group

‐based

trajectory m

odels for describing pa

tterns of e

nd‐of‐life

declin

e, and

suggest tha

t una

nticipated

deaths m

ay be associated

with

greater post‐widow

hood

mortality risk for b

ereaved spou

ses.

OUTR

EACH

PA

CE APP

LICA

TION CEN

TER

Bene

fits D

ata Trust,

Philade

lphia

The PACE Application Cen

ter conducts data‐driven outreach and application assistance to connect Pen

nsylvanians with

public ben

efit program

s. The Cen

ter submits PACE applications for eligible persons and enrolls eligible persons in the

Med

icare Part D Low Income Subsidy (Extra Help). In 2015, the Cen

ter conducted

mail, telephone, and community‐based

outreach. In one

year, 27

,768

sen

ior h

ouseho

lds ap

plied for a

t least one

ben

efit, delivering $99.0 million in ben

efits.

PACE

Enrollm

ent O

utreach: The Cen

ter uses Property Tax and Ren

t Reb

ate rolls, and energy, food and prescription

assistance listings to iden

tify enrollm

ent candidates. In 2014, th

ere were 341,949 ou

treach attem

pts u

niqu

e to PAC

E an

d 11

,687

PAC

E ap

plications su

bmitted

. Low In

come Subsidy (LIS) O

utreach: The PACE Program

, by wrapping around the Part D ben

efit, incurs costs that could be

offset by LIS ben

efits which provide financial help to low income en

rollees. In 2015, th

e Ce

nter su

bmitted

8,837

ap

plications on be

half of older Pen

nsylvanian

s, as a

result of 113,104

LIS outreach actio

ns.

13

MED

ICAT

ION UTILIZA

TION STU

DIES

TOPIC

TITLE / RE

SEAR

CH GRO

UP

DESCR

IPTION

MED

ICAT

ION

ADHER

ENCE

AN

D HEA

LTH

OUTC

OMES

PROTO

N PUMP INHIBITO

R AD

HER

ENCE

AND FRA

CTURE

RISK

IN THE ELDER

LY

Magellan Health

/PAC

E an

d Th

e Med

icine, Health

, and

Aging

Project a

t Pen

n State University

Results of several recen

t studies suggest that long‐term

use of proton pump inhibitors (PPIs) may be associated

with an

increased risk of fracture. The

goa

l of this s

tudy

was to

examine the relatio

nship be

tween med

ication ad

herence an

d fracture risk amon

g elde

rly PPI users. The study cohort included

1,604 community‐dwelling PPI users and 23,672 non‐users

who were en

rolled in

the PACE Program

. Proportion of Days Covered (PDC) was computed to m

easure adheren

ce based

on prescription refill patterns. Tim

e‐dep

enden

t Cox proportional hazards models were used to estim

ate adjusted

hazard ratios of PPI use/adheren

ce for fracture

risk while controlling for dem

ographics, comorbidity, body mass index, smoking and non‐PPI m

edication use. The overall

inciden

ce of any fracture per 100 person‐years was 8.7 for PPI users and 5.0 for non‐users. A gradient in fracture risk

according to PPI adheren

ce was observed

. Relative to non‐users, fracture hazard ratios associated

with the highest

adheren

ce (PDC > 0.80), interm

ediate (PDC 0.40‐0.79), and lowest (PDC < 0.40) adheren

ce levels were 1.46 (p < 0.0001), 1.30

(p = 0.02), and 0.95 (p = 0.75), respectively.

These results

provide

furthe

r evide

nce that PPI use m

ay increase risk in

the elde

rly, and

highlight th

e ne

ed fo

r clin

icians to

pe

riodically re

assess elderly patients’ individu

alized

needs fo

r ongoing

PPI th

erap

y, while weighing po

tential risks and

be

nefits. The findings were published

in Calcified Tissue

Internationa

l in April 2014.

PHAR

MAC

Y AC

CESS AND

MED

ICAT

ION

ADHER

ENCE

MED

ICAT

ION ADHER

ENCE

IN

PHAR

MAC

Y DE

SERT

AND NON‐

DESER

T AR

EAS

University

of the

Scien

ces in

Philade

lphia an

d Magellan

Health

/PAC

E

This study expanded

the investigation of potential pharmacy desert areas in Pen

nsylvania to address the potential im

pact of

low pharmacy access on m

edication adheren

ce. Th

e stud

y specifically examined

refill adh

eren

ce m

easures for oral

diab

etes m

edications amon

g PA

CE/PAC

ENET

elderly re

siding

in th

ree coun

ties p

reviou

sly iden

tified as poten

tial pha

rmacy

deserts (Forest, M

ifflin, and Sullivan Counties) and in

seven

non‐pharmacy desert counties. Tw

o variations on the proportion

of days covered (PDC), prescription‐based

PDC and interval‐based

PDC, w

ere used to m

easure refill adheren

ce level.

Chi‐square and regression analyses results indicated

that while elderly in

non

‐desert regions had

slightly highe

r adh

eren

ce

levels th

an th

ose living in desert regions, the

se differen

ces were no

t statistically significan

t.

Although

this study did not find statistically significant differences in m

edication adheren

ce as a function of pharmacy desert

region residen

ce, the lim

ited

number of counties examined

may limit the generalizability of the findings. Future research is

planned

to examine pharmacy desert regions and associated

health m

easures across broader regions of the state. The

results of this study were presented at the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) ‐

21st Annual International M

eeting in M

ay 2016.

STAT

IN USE

ASSO

CIAT

ION BETWEEN

STAT

IN USE AND FRA

CTURE

RISK

AMONG THE ELDER

LY

Magellan Health

/PAC

E an

d Th

e Med

icine, Health

, and

Aging

Project a

t Pen

n State University

The im

pact of statins (w

idely used to treat hyperlipidem

ia)on fracture risk is still under deb

ate. The

goa

l of this s

tudy

was to

exam

ine the association be

tween statin use and

fracture risk amon

g the elde

rly by follo

wing 5,524 ne

w statin

users and

27

,089

non

‐users fo

r an average of 3.5 years.

Time‐dep

enden

t Cox proportional hazards models were used to estim

ate adjusted

hazard ratios of statin use for fracture risk

while controlling for dem

ographics, comorbidity, body mass index, smoking status, alcohol use, and certain therapeu

tic

classes. The

incide

nce of any

fracture per 100

person‐years was 3.0 fo

r statin

users and

7.8 fo

r non

‐users. Re

lativ

e to non

‐users, th

e ha

zard ra

tio associated with

statin use was 0.86 (p < 0.00 1

). Statin

users with

highe

r and

lower average daily

dose were associated

with

18%

and

9% decreased

fracture risk, respe

ctively.

The ha

zard ra

tio fo

r atorvastatin

was 0.81 (p < 0.001

), an

d the effects w

ere no

t significan

t for sim

vastatin and

pravastatin.

The protectiv

e effect of statin

user a

ppeared to be stronger amon

g users olde

r tha

n 85

years old. These results suggested

statin use is associated

with red

uced fracture risk am

ong the elderly, and the effect m

ay be dep

enden

t on age and statin

type. The ben

eficial effect of statin on bone may be helpful in the prevention of fractures am

ong elderly.

14

PHAR

MAC

Y AC

CESS

ACCE

SSIBILITY OF PH

ARMAC

Y SERV

ICES IN

HIGH AND LOW

INCO

ME PE

NNSYLV

ANIA

COUNTIES

University

of the

Scien

ces in

Philade

lphia an

d Magellan

Health

/PAC

E

This re

search

build

s on several prio

r studies ofp

harm

acy de

serts, a te

rm used to describe geograph

ic areas whe

re

pharmacy services are sc

arce or d

ifficult to ob

tain. Pharmacy deserts can

occur as a result of large geographic distances

required

to reach pharmacies, or as a result of too few

pharmacies located in

a den

sely‐populated area. O

ne accepted

definition from existing literature specifically iden

tifies pharmacy deserts as low income areas where at least a third of the

population lives more than

one mile from an outpatient pharmacy.

This stud

y compa

red the availability of pha

rmacies an

d the average straight‐line

distance be

tween ho

me reside

nce an

d the ne

arest o

utpa

tient pha

rmacy for P

ACE/PA

CENET

cardh

olde

rs in

five high‐income an

d fiv

e low‐in

come coun

ties.

The average distance to the closest pharmacy was shorter in the low income group, w

hich was influen

ced largely by one

urban

county, Philadelphia County, w

here the average straight‐line distance to the nearest outpatient pharmacy was only 0.1

mile. In con

trast, three lower income rural cou

nties (M

ifflin

, Forest, an

d Sullivan Co

untie

s) were iden

tified as poten

tial

pharmacy de

serts. In these coun

ties, between 56% and

77%

of the

pop

ulation lived

more than

a m

ile away from

the

closest o

utpa

tient pha

rmacy. W

ith an average distance of 4.0 m

iles to the closest pharmacy, Sullivan County dem

onstrated

the lowest apparen

t accessibility. Th

is stud

y confirm

ed th

at geo

grap

hic accessibility varies substantially fo

r PAC

E/PA

CENET

cardho

lders a

cross P

ennsylvania, and

that pha

rmacy de

serts ap

pear to

exist in

several ru

ral areas of the

state. Results

were presented at the AMCP M

anaged

Care & Specialty Pharmacy Annual M

eeting in April 2016.

MED

ICAT

ION

ADHER

ENCE

INITIAL MED

ICAT

ION

ADHER

ENCE

IN THE ELDER

LY

University

of the

Scien

ces in

Philade

lphia an

d Magellan

Health

/PAC

E

Initial m

edication adheren

ce describes the filling of new

med

ication prescriptions. This p

ilot study

explored thefeasibility of

using PA

CE claim

reversals as a proxy indicator o

f initia

l med

ication no

n‐ad

herence. The study specifically evaluated

differences in claim

reversal rates, as well as the timing of reversals, between electronic and non‐electronic prescriptions.

Understanding the potential im

pact of electronic prescribing (e‐prescribing) on initial m

edication adheren

ce is tim

ely given

increases in e‐prescribing which have occurred

in part as a result of provisions of the Med

icare Modernization Act.

Results of chi‐square analyses indicated

that electronic prescription claim

s were more likely than

other prescription origin

types to be reversed

, and that differences am

ong prescription origins were greater for reversals occurring after the

submission day compared

with sam

e‐day reversals. The

autho

rs con

clud

ed th

at electronic prescriptio

ns are associated

with

a highe

r rate of claim

reversals an

d may re

flect poo

rer initia

l adh

eren

ce. Electron

ic prescrip

tions m

ay be more likely

to be forgotten or otherwise no

t picked up

becau

se th

e electron

ic delivery of th

e prescriptio

n to th

e ph

armacy bypa

sses

the pa

tient. The study confirm

ed the im

portance of understanding the potential effect of electronic prescription

transm

ission on initial m

edication adherence in

the elderly. The results are sched

uled to be published

in the September 2016

issue of the Journa

l of M

anag

ed Care & Specialty Pha

rmacy.

15

16

SECTION 2

FINANCIAL DATA

BY DATE OF SERVICE

17

18

TA

BL

E 2

.1A

HIS

TO

RIC

AL

CL

AIM

AN

D E

XP

EN

DIT

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MI-

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AS

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ON

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OF

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RV

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JAN

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199

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5

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SE

MI-

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AT

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HA

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DC

AR

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OLD

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SC

LAIM

SC

AR

DH

OLD

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CA

RD

HO

LDE

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XP

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DIT

UR

ES

PE

R C

LAIM

JAN

-JU

N 1

991

405,

358

337,

684

5,28

0,37

613

.03

15.6

4$1

16,0

74,6

18$2

86.3

5$3

43.7

4$2

1.98

JUL-

DE

C 1

991

394,

055

324,

574

4,67

7,15

911

.87

14.4

1$1

09,8

71,6

50$2

78.8

2$3

38.5

1$2

3.49

JAN

-JU

N 1

992

399,

721

326,

469

4,65

6,98

611

.65

14.2

6$1

16,0

82,5

06$2

90.4

1$3

55.5

7$2

4.93

JUL-

DE

C 1

992

385,

103

313,

430

4,60

2,26

111

.95

14.6

8$1

17,0

81,6

02$3

04.0

3$3

73.5

5$2

5.44

JAN

-JU

N 1

993

376,

916

310,

438

4,40

2,17

111

.68

14.1

8$1

13,0

68,7

54$2

99.9

8$3

64.2

2$2

5.68

JUL-

DE

C 1

993

357,

777

296,

802

4,45

6,22

312

.46

15.0

1$1

16,1

64,3

81$3

24.6

8$3

91.3

9$2

6.07

JAN

-JU

N 1

994

354,

819

293,

462

4,32

0,15

912

.18

14.7

2$1

15,4

13,5

42$3

25.2

7$3

93.2

8$2

6.72

JUL-

DE

C 1

994

340,

607

281,

465

4,40

4,25

712

.93

15.6

5$1

19,1

00,7

41$3

49.6

7$4

23.1

5$2

7.04

JAN

-JU

N 1

995

331,

965

277,

461

4,38

3,96

813

.21

15.8

0$1

21,1

47,2

11$3

64.9

4$4

36.6

3$2

7.63

JUL-

DE

C 1

995

317,

719

263,

576

4,34

7,33

513

.68

16.4

9$1

22,1

58,8

72$3

84.4

9$4

63.4

7$2

8.10

JAN

-JU

N 1

996

306,

062

253,

283

4,24

4,19

013

.87

16.7

6$1

20,8

68,6

54$3

94.9

2$4

77.2

1$2

8.48

JUL-

DE

C 1

996

292,

755

238,

963

4,20

4,46

114

.36

17.5

9$1

20,4

29,8

40$4

11.3

7$5

03.9

7$2

8.64

JAN

-JU

N 1

997

286,

126

236,

157

4,28

6,47

814

.98

18.1

5$1

16,7

32,8

47$4

07.9

8$4

94.3

0$2

7.23

JUL-

DE

C 1

997

276,

180

226,

806

4,35

8,89

215

.78

19.2

2$1

23,4

82,0

56$4

47.1

1$5

44.4

4$2

8.33

JAN

-JU

N 1

998

267,

225

222,

465

4,23

5,61

915

.85

19.0

4$1

26,8

72,5

48$4

74.7

8$5

70.3

0$2

9.95

JUL-

DE

C 1

998

257,

009

213,

694

4,33

1,39

016

.85

20.2

7$1

37,1

46,4

44$5

33.6

3$6

41.7

9$3

1.66

JAN

-JU

N 1

999

246,

467

208,

992

4,31

6,58

817

.51

20.6

5$1

42,4

12,9

78$5

77.8

2$6

81.4

3$3

2.99

JUL-

DE

C 1

999

238,

388

200,

921

4,45

0,89

318

.67

22.1

5$1

53,5

96,6

48$6

44.3

1$7

64.4

6$3

4.51

JAN

-JU

N 2

000

237,

017

202,

683

4,44

9,10

218

.77

21.9

5$1

60,6

15,3

39$6

77.6

5$7

92.4

5$3

6.10

JUL-

DE

C 2

000

230,

752

197,

777

4,53

0,82

919

.64

22.9

1$1

69,8

86,4

76$7

36.2

3$8

58.9

8$3

7.50

JAN

-JU

N 2

001

225,

325

197,

082

4,55

8,33

920

.23

23.1

3$1

78,6

50,9

79$7

92.8

6$9

06.4

8$3

9.19

JUL-

DE

C 2

001

218,

576

190,

540

4,59

0,21

621

.00

24.0

9$1

87,8

20,5

34$8

59.2

9$9

85.7

3$4

0.92

JAN

-JU

N 2

002

216,

719

190,

131

4,55

8,00

021

.03

23.9

7$1

94,7

88,8

89$8

98.8

1$1

,024

.50

$42.

74

JUL-

DE

C 2

002

209,

737

183,

318

4,60

5,90

621

.96

25.1

3$2

03,5

91,4

48$9

70.7

0$1

,110

.59

$44.

20

JAN

-JU

N 2

003

209,

761

182,

654

4,55

2,66

221

.70

24.9

3$2

08,1

03,6

30$9

92.1

0$1

,139

.33

$45.

71

JUL-

DE

C 2

003

207,

144

180,

460

4,68

3,17

322

.61

25.9

5$2

21,5

12,8

77$1

,069

.37

$1,2

27.4

9$4

7.30

JAN

-JU

N 2

004

215,

486

189,

762

4,67

5,69

921

.70

24.6

4$2

09,7

31,9

50$9

73.3

0$1

,105

.24

$44.

86

JUL-

DE

C 2

004

209,

237

183,

970

4,63

9,59

422

.17

25.2

2$1

78,1

65,4

48$8

51.5

0$9

68.4

5$3

8.40

EX

PE

ND

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RE

S

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NR

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RV

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JAN

UA

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199

1 -

DE

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MB

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JAN

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N 2

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209,

512

182,

450

4,60

2,80

221

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25.2

3$1

66,4

96,0

79$7

94.6

9$9

12.5

6$3

6.17

JUL-

DE

C 2

005

203,

956

177,

667

4,62

8,80

922

.70

26.0

5$2

08,6

31,7

07$1

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$1,1

74.2

9$4

5.07

JAN

-JU

N 2

006

199,

426

172,

092

4,48

2,46

122

.48

26.0

5$1

96,3

69,2

22$9

84.6

7$1

,141

.07

$43.

81

JUL-

DE

C 2

006

194,

884

164,

174

4,07

1,75

520

.89

24.8

0$1

26,4

33,8

82$6

48.7

6$7

70.1

2$3

1.05

JAN

-JU

N 2

007

203,

104

167,

796

3,61

9,45

617

.82

21.5

7$8

1,20

2,59

5$3

99.8

1$4

83.9

4$2

2.44

JUL-

DE

C 2

007

183,

839

150,

273

3,48

7,88

218

.97

23.2

1$9

8,98

4,30

5$5

38.4

3$6

58.7

0$2

8.38

JAN

-JU

N 2

008

164,

728

133,

656

3,01

4,59

618

.30

22.5

5$7

0,09

6,78

1$4

25.5

3$5

24.4

6$2

3.25

JUL-

DE

C 2

008

160,

802

125,

319

2,87

8,01

717

.90

22.9

7$7

6,07

0,50

0$4

73.0

7$6

07.0

1$2

6.43

JAN

-JU

N 2

009

145,

634

119,

773

2,68

2,43

618

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22.4

0$5

5,42

6,88

9$3

80.5

9$4

62.7

7$2

0.66

JUL-

DE

C 2

009

141,

988

114,

169

2,54

6,78

117

.94

22.3

1$6

3,03

5,61

4$4

43.9

5$5

52.1

3$2

4.75

JAN

-JU

N 2

010

138,

520

113,

130

2,37

9,42

717

.18

21.0

3$5

6,13

1,54

0$4

05.2

2$4

96.1

7$2

3.59

JUL-

DE

C 2

010

134,

104

106,

535

2,17

5,10

616

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20.4

2$6

1,57

2,76

7$4

59.1

4$5

77.9

6$2

8.31

JAN

-JU

N 2

011

128,

440

103,

356

2,22

1,68

017

.30

21.5

0$4

5,30

7,89

8$3

52.7

6$4

38.3

7$2

0.39

JUL-

DE

C 2

011

125,

096

98,2

652,

061,

534

16.4

820

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$42,

777,

764

$341

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$435

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$20.

75

JAN

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N 2

012

119,

166

95,4

072,

091,

129

17.5

521

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$42,

297,

874

$354

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$443

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$20.

23

JUL-

DE

C 2

012

116,

822

91,0

201,

943,

206

16.6

321

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$37,

252,

376

$318

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$409

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$19.

17

JAN

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N 2

013

114,

935

88,4

421,

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685

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$36,

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$321

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$418

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$19.

41

JUL-

DE

C 2

013

109,

907

83,7

561,

767,

781

16.0

821

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$35,

191,

933

$320

.20

$420

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$19.

91

JAN

-JU

N 2

014

119,

491

90,2

231,

810,

547

15.1

520

.07

$36,

412,

429

$304

.73

$403

.58

$20.

11

JUL-

DE

C 2

014

117,

577

87,6

271,

730,

400

14.7

219

.75

$39,

226,

755

$333

.63

$447

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$22.

67

JAN

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N 2

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113,

731

84,9

521,

673,

305

14.7

119

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$40,

128,

728

$352

.84

$472

.37

$23.

98

JUL-

DE

C 2

015

109,

981

80,5

211,

553,

820

14.1

319

.30

$39,

473,

690

$358

.91

$490

.23

$25.

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25

JAN - JUN JUL - DECCALENDAR

YEAR

TOTAL PRESCRIPTION COST (DATE OF SERVICE) 334,560,882$ 330,425,451$ 664,986,333$ MEDICARE PART D PREMIUMS 5,399,004 18,662,531 24,061,535

GROSS CLAIMS/PREMIUMS SUBTOTAL 339,959,886 349,087,982 689,047,868 96.8%

MHS CONTRACT OPERATIONS (INCLUDES POSTAGE) 8,439,664 6,756,666 15,196,330

GROSS CONTRACT SUBTOTAL 8,439,664 6,756,666 15,196,330 2.1%

PDA ADMINISTRATION PERSONNEL 562,025 542,056 1,104,081 OPERATIONS 96,083 11,151 107,234

GROSS PDA ADMIN. SUBTOTAL 658,108 553,207 1,211,315 0.2%

OTHER ADMINISTRATION AUDITS 377,500 307,500 685,000 THIRD PARTY RECOVERY 433,004 1,018,708 1,451,712

GROSS OTHER ADMIN. SUBTOTAL 810,504 1,326,208 2,136,712 0.3%

BEHAVIORAL HEALTH INTERVENTIONS 222,111 412,378 634,489 0.1%

ENROLLMENT OUTREACH 1,218,616 1,060,326 2,278,942 0.3%

PRESCRIBER EDUCATION 750,000 625,000 1,375,000 0.2%

GROSS EXPENDITURES 352,058,889 359,821,767 711,880,656 100.0%

PRESCRIPTION COST OFFSETS PART D/OTHER PAYER OFFSETS (203,500,728) (199,905,352) (403,406,081) -56.7% CARDHOLDER COPAYMENTS (31,638,432) (29,710,323) (61,348,755) -8.6%

TOTAL OFFSETS (235,139,161) (229,615,675) (464,754,836) -65.3%

RECOVERIES MANUFACTURER REBATES (17,319,292) (23,778,295) (41,097,587) REFUNDS FROM PROVIDERS (2,336) (3,807) (6,143) AUDIT ADJUSTMENTS IN CHECKWRITES (500,726) (241,809) (742,535) THIRD-PARTY REIMBURSEMENTS AND TRANSFERS (16,620,266) 7,708,858 (8,911,408)

COMBINED RECOVERIES (34,442,620) (16,315,053) (50,757,673)

PRIOR YEARS' FUL REIMBURSEMENT REVISION 606,370 - 606,370 PRIOR YEARS' REBATE REFUNDS 382,611 113,686 496,297

NET RECOVERIES (33,453,639) (16,201,367) (49,655,006) -7.0%

NET PRESCRIPTION CLAIM EXPENDITURES STATE SHARE FOR RX BEFORE RECOVERIES 99,421,721 100,809,776 200,231,498 28.1% STATE SHARE FOR RX AFTER RECOVERIES 65,968,083 84,608,409 150,576,492 21.2%

NET STATE EXPENDITURES INCLUDING PREMIUMS

AND ADMINISTRATION 83,466,090$ 114,004,725$ 197,470,814$ 27.7%

AUDIT ADJUSTMENTS ARE BY RECOVERY DATE; AUDITS OCCURRED IN CY 2014 - 2015. REBATES ($41.1 M) ARE 20.5% OF TOTAL STATE SHARE PRESCRIPTION DRUG COST ($200.2 M). TOTAL PRESCRIPTION COST DOES NOT INCLUDE CLAIMS PROCESSED ONLY BY OTHER PAYERS.

TABLE 2.2TOTAL PRESCRIPTION COST, EXPENDITURES, OFFSETS, AND RECOVERIES

JANUARY - DECEMBER 2015

EXPENDITURES, RECOVERIES, OFFSETS% OF TOTAL

GROSS EXPENDITURES

NOTES: TABLE USES DATE OF SERVICE REFERENCE CLAIM COST FILE FOR ANNUAL DRUG EXPENDITURES.

26

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SECTION 3

PROGRAM DATA BY DATE OF

PAYMENT

33

34

PAGE 1

PACE PACENET

NUMBER OF SEMI-ANNUAL PROCESSED

PERIOD CLAIMS EXPENDITURES

JUL-DEC 1984 26 2,101,419 $20,714,685 $9.86

JAN-JUN 1985 26 3,475,440 $36,579,102 $10.53

1st YEAR TOTAL 5,576,859 $57,293,787 $10.27

JUL-DEC 1985 26 4,372,468 $50,616,334 $11.58

JAN-JUN 1986 26 4,966,536 $61,368,193 $12.36

2nd YEAR TOTAL 9,339,004 $111,984,527 $11.99

JUL-DEC 1986 26 5,237,141 $68,786,114 $13.13

JAN-JUN 1987 26 5,257,747 $72,761,148 $13.84

3rd YEAR TOTAL 10,494,888 $141,547,262 $13.49

JUL-DEC 1987 27 5,515,827 $80,237,477 $14.55

JAN-JUN 1988 25 5,440,743 $84,469,697 $15.53

4th YEAR TOTAL 10,956,570 $164,707,174 $15.03

JUL-DEC 1988 27 6,055,327 $99,192,197 $16.38

JAN-JUN 1989 26 5,937,088 $103,781,619 $17.48

5th YEAR TOTAL 11,992,415 $202,973,816 $16.93

JUL-DEC 1989 26 5,709,497 $106,600,899 $18.67

JAN-JUN 1990 26 5,544,295 $110,848,137 $19.99

6th YEAR TOTAL 11,253,792 $217,449,036 $19.32

JUL DEC 1990 26 5 352 797 $112 293 188 $20 98

CLAIM **PROCESSEDPER PROCESSED

CLAIM *OF

TABLE 3.1PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR

JULY 1984 - DECEMBER 2015

NUMBER NUMBER OF

EXPENDITURESPER PROCESSED

STATE SHARE STATE SHAREAVERAGE AVERAGE

WEEKS CLAIMS

JUL-DEC 1990 26 5,352,797 $112,293,188 $20.98

JAN-JUN 1991 26 5,453,044 $117,814,625 $21.61

7th YEAR TOTAL 10,805,841 $230,107,813 $21.29

JUL-DEC 1991 26 5,073,452 $115,304,410 $22.73

JAN-JUN 1992 26 4,816,750 $115,596,910 $24.00

8th YEAR TOTAL 9,890,202 $230,901,320 $23.35

JUL-DEC 1992 26 4,724,142 $115,980,339 $24.55

JAN-JUN 1993 26 4,403,096 $108,876,491 $24.73

9th YEAR TOTAL 9,127,238 $224,856,830 $24.64

JUL-DEC 1993 26 4,729,097 $118,778,523 $25.12

JAN-JUN 1994 26 4,341,896 $111,401,456 $25.66

10th YEAR TOTAL 9,070,993 $230,179,979 $25.38

JUL-DEC 1994 26 4,721,702 $122,294,905 $25.90

JAN-JUN 1995 27 4,228,653 $111,136,630 $26.28

11th YEAR TOTAL 8,950,355 $233,431,535 $26.08

JUL-DEC 1995 26 4,895,160 $131,701,547 $26.90

JAN-JUN 1996 26 4,443,096 $121,066,818 $27.25

12th YEAR TOTAL 9,338,256 $252,768,365 $27.07

JUL-DEC 1996 26 4,334,551 $119,612,179 $27.60 540 $23 $0.04

JAN-JUN 1997 26 4,523,225 $116,697,725 $25.80 74,647 $586,350 $7.85

13th YEAR TOTAL 8,857,776 $236,309,904 $26.68 75,187 $586,373 $7.80

JUL-DEC 1997 26 4,546,360 $121,880,844 $26.81 150,263 $2,680,675 $17.84

JAN-JUN 1998 26 4,497,031 $126,776,785 $28.19 171,797 $2,860,833 $16.65

14th YEAR TOTAL 9,043,391 $248,657,629 $27.50 322,060 $5,541,508 $17.21

35

PAGE 2

PACE PACENET



JUL-DEC 1998 26 4,504,394 $134,229,706 $29.80 233,277 $4,737,561 $20.31

JAN-JUN 1999 26 4,220,448 $139,246,165 $32.99 256,109 $5,410,383 $21.13

15th YEAR TOTAL 8,724,842 $273,475,871 $31.34 489,386 $10,147,944 $20.74

JUL-DEC 1999 26 4,456,680 $153,781,999 $34.51 310,165 $7,421,422 $23.93

JAN-JUN 2000 26 4,453,977 $160,846,800 $36.11 339,250 $8,389,295 $24.73

8,910,657 $314,628,799 $35.31 649,415 $15,810,717 $24.35

JUL-DEC 2000 26 4,538,814 $170,118,213 $37.48 382,379 $10,200,170 $26.68

JAN-JUN 2001 26 4,536,651 $177,830,053 $39.20 420,529 $11,319,858 $26.92

9,075,465 $347,948,266 $38.34 802,908 $21,520,028 $26.80

JUL-DEC 2001 26 4,635,934 $189,489,307 $40.87 480,559 $13,924,106 $28.97

JAN-JUN 2002 26 4,554,962 $194,745,251 $42.75 542,321 $16,348,022 $30.14

9,190,896 $384,234,558 $41.81 1,022,880 $30,272,128 $29.59

JUL-DEC 2002 26 4,615,282 $203,947,092 $44.19 615,169 $20,100,929 $32.68

JAN-JUN 2003 26 4,554,809 $208,208,623 $45.71 644,320 $21,608,906 $33.54

19th YEAR TOTAL 9,170,091 $412,155,715 $44.95 1,259,489 $41,709,835 $33.12

JUL-DEC 2003 26 4,688,095 $221,734,037 $47.30 722,537 $25,698,628 $35.57

JAN-JUN 2004 26 4,581,399 $205,908,844 $44.94 1,268,014 $47,385,206 $37.37

20th YEAR TOTAL 9,269,494 $427,642,881 $46.13 1,990,551 $73,083,834 $36.72

STATE SHARE

TABLE 3.1

AVERAGE

PER PROCESSEDWEEKS CLAIM *

STATE SHARE NUMBER OF

PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR JULY 1984 - DECEMBER 2015

CLAIMS

18th YEAR TOTAL

EXPENDITURES CLAIM **

17th YEAR TOTAL

16th YEAR TOTAL

AVERAGENUMBER

OF PROCESSED PER PROCESSED

JUL-DEC 2004 26 4,646,945 $178,347,082 $38.38 1,922,663 $71,852,034 $37.37

JAN-JUN 2005 26 4,613,122 $166,886,748 $36.18 2,178,944 $81,479,300 $37.39

21st YEAR TOTAL 9,260,067 $345,233,830 $37.28 4,101,607 $153,331,334 $37.38

JUL-DEC 2005 26 4,632,516 $208,781,508 $45.07 2,451,200 $96,468,947 $39.36

JAN-JUN 2006 26 4,484,886 $196,409,910 $43.79 2,708,585 $100,489,805 $37.10

9,117,402 $405,191,418 $44.44 5,159,785 $196,958,752 $38.17

JUL-DEC 2006 26 4,074,738 $126,753,319 $31.11 2,686,230 $77,256,980 $28.76

JAN-JUN 2007 26 3,642,398 $82,054,486 $22.53 2,633,012 $59,270,762 $22.51

23rd YEAR TOTAL 7,717,136 $208,807,805 $27.06 5,319,242 $136,527,742 $25.67

JUL-DEC 2007 26 3,491,014 $99,077,033 $28.38 2,688,584 $85,271,656 $31.72

JAN-JUN 2008 26 3,015,416 $70,145,582 $23.26 2,947,413 $67,641,825 $22.95

24th YEAR TOTAL 6,506,430 $169,222,615 $26.01 5,635,997 $152,913,481 $27.13

JUL-DEC 2008 26 2,882,322 $76,213,073 $26.44 3,082,226 $89,890,137 $29.16

JAN-JUN 2009 26 2,675,602 $55,324,827 $20.68 2,960,252 $66,702,151 $22.53

25th YEAR TOTAL 5,557,924 $131,537,900 $23.67 6,042,478 $156,592,288 $25.92

JUL-DEC 2009 26 2,560,054 $63,361,329 $24.75 3,031,954 $91,430,885 $30.16

JAN-JUN 2010 26 2,380,428 $56,111,899 $23.57 2,824,223 $76,675,981 $27.15

26th YEAR TOTAL 4,940,482 $119,473,228 $24.18 5,856,177 $168,106,866 $28.71

JUL-DEC 2010 26 2,182,334 $61,837,441 $28.34 2,853,692 $101,435,537 $35.55

JAN-JUN 2011 26 2,226,942 $45,437,610 $20.40 3,102,948 $65,404,599 $21.08

27th YEAR TOTAL 4,409,276 $107,275,051 $24.33 5,956,640 $166,840,136 $28.01

JUL-DEC 2011 26 2,067,181 $42,933,134 $20.77 3,072,410 $63,057,042 $20.52JAN-JUN 2012 26 2,093,727 $42,352,837 $20.23 3,035,747 $64,106,702 $21.12

28th YEAR TOTAL 4,160,908 $85,285,971 $20.50 6,108,157 $127,163,744 $20.82

22nd YEAR TOTAL

36

PAGE 3

PACE PACENET



JUL-DEC 2012 26 1,924,040 $36,823,185 $19.14 2,963,999 $58,046,309 $19.58JAN-JUN 2013 26 1,853,713 $36,063,995 $19.46 2,897,931 $57,828,530 $19.96

29th YEAR TOTAL 3,777,753 $72,887,180 $19.29 5,861,930 $115,874,839 $19.77

JUL-DEC 2013 26 1,597,139 $31,742,735 $19.87 2,702,648 $55,057,471 $20.37JAN-JUN 2014 26 1,618,419 $32,581,671 $20.13 2,725,253 $59,253,137 $21.74

30th YEAR TOTAL 3,215,558 $64,324,406 $20.00 5,427,901 $114,310,608 $21.06

JUL-DEC 2014 26 1,502,786 $33,987,697 $22.62 2,747,734 $64,145,379 $23.34JAN-JUN 2015 26 1,624,984 $38,884,586 $23.93 2,416,591 $58,704,418 $24.29

3,127,770 $72,872,283 $23.30 5,164,325 $122,849,797 $23.79

JUL-DEC 2015 26 1,516,584 $38,439,507 $25.35 2,460,486 $62,701,593 $25.481,516,584 $38,439,507 $25.35 2,460,486 $62,701,593 $25.48

CUMULATIVE TOTAL 252,346,315 $6,763,806,260 $26.80 69,706,601 $1,872,843,547 $26.87

N b 22 1996 D b 31 2003 Th l f ith th AWP i 10% l $3 50 di i f th U&C th bt ti $6 00

July 1, 1985 - June 1991: The lesser of either the AWP plus a $2.75 dispensing fee or the U&C, then subtracting a $4.00 cardholder payment.

July 1, 1991 - November 21, 1996: Same as above with copayment increased to $6.00.

STATE SHARE

32nd YEAR-TO-DATE TOTAL


AVERAGE

EXPENDITURES CLAIM **PROCESSED

AVERAGENUMBER STATE SHARE NUMBER OF

* The State Share is the amount paid by the PACE Program for each claim. The State Share per processed claim does not reflect rebates from manufacturers, recoupments from insurance carriers, or audit disallowances received from providers and enrollees. The number of claims includes all original, debit, credit and void claims. Some claims, therefore, do not have a payment associated with them. The State Share per original, paid claim would be higher than the values shown on this table.

CLAIMS

TABLE 3.1PACE AND PACENET CLAIMS AND EXPENDITURES PAID BY FISCAL YEAR

PER PROCESSED

Reimbursement formulas for PACE:

July 1, 1984 - June 1985: The lesser of either the Average Wholesale Price (AWP) plus a $2.50 dispensing fee or the Usual and Customary Charge (U&C), then subtracting a $4.00 cardholder payment.

WEEKS CLAIM *PER PROCESSED

31st YEAR TOTAL

OF

SOURCE: PDA/MRW200-01 & MRM730-01

November 22, 1996 - December 31, 2003: The lesser of either the AWP minus 10% plus a $3.50 dispensing fee, or the U&C, then subtracting a $6.00 copayment.

January 1, 2004 - July 9, 2006: The lesser of either AWP minus 10% plus a $4.00 dispensing fee, or the U&C, or the FUL for a generic product plus a $4.00 dispensing fee, then subtracting a copayment of $8.00 for generics and $15.00 for brand products. The copayment can be adjusted annually.

July 10, 2006 - Present: The lesser of either AWP minus 12% plus a $4.00 dispensing fee, or the U&C, or the FUL for a generic product plus a $4.00 dispensing fee, then subtracting a copayment of $8.00 for generics and $15.00 for brand products. The copayment can be adjusted annually.

September 2006 - Present: Program providers are required to accept the Medicare Part D Plan reimbursements for those claims in the coverage phase received by cardholders who are enrolled in both Medicare Part D and the PACE/PACENET Program. These Part D Plan reimbursements are comparable to the average commercial rate of AWP minus 17% plus a $2.00 dispensing fee. The Program reimburses at AWP minus 12% plus a $4.00 dispensing fee for claims not covered by an enrollee’s Part D Plan.

June 2004 - Present: Average state share per claim reflects savings from Medicare Part D.

June 2004 - December 2005: Average PACE state share per claim reflects additional savings from the Transitional Assistance benefit for Medicare Discount Program cardholders.

September 2006 - Present: Program providers are required to accept the Medicare Part D Plan reimbursements for those claims in the coverage phase received by cardholders who are enrolled in both Medicare Part D and the PACE/PACENET Program. These Part D Plan reimbursements are comparable to the average commercial rate of AWP minus 17% plus a $2.00 dispensing fee. The Program reimburses at AWP minus 12% plus a $4.00 dispensing fee for claims not covered by an enrollee’s Part D Plan.

June 2004 - Present: Average state share per claim reflects savings from Medicare Part D.

** The State Share is the amount paid by the PACENET Program when the cost of the claim(s) exceeds the monthly deductible premium amount plus the copayment. The number of processed claims includes all original, debit, credit and void claims and claims without a State Share payment in the premium deductible phases and all other claims with a State Share payment. Therefore, the State Share per claim on this table is lower than the State Share for claims beyond the premium deductible phase. The State Share per processed claim does not reflect rebates from manufacturers, recoupments from insurance carriers, or audit disallowances received from providers.

Reimbursement formulas for PACENET:

November 22, 1996 - December 31, 2003: The lesser of either AWP minus 10% plus a $3.50 dispensing fee, or the U&C, then subtracting a copayment of $8.00 for generics and $15 for brand products.

January 1, 2004 - July 9, 2006: The lesser of either AWP minus 10% plus a $4.00 dispensing fee, or the U&C, or the Federal Upper Limit (FUL) for a generic product plus a $4.00 dispensing fee, then subtracting a copayment of $6.00 for generics and $9.00 for brand products. The copayment can be adjusted annually.

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46

SECTION 4

CARDHOLDER UTILIZATION

DATA

47

48

PAGE 1

NEWLYQUARTER ENROLLED *

1st JUL-SEP 1984 273,001 100.0 273,001PROGRAM OCT-DEC 1984 23,561 7.9 296,562YEAR JAN-MAR 1985 20,941 6.6 317,503

APR-JUN 1985 69,436 17.9 386,939

2nd JUL-SEP 1985 38,750 10.0 389,177PROGRAM OCT-DEC 1985 20,522 5.0 409,699YEAR JAN-MAR 1986 18,770 4.4 428,469

APR-JUN 1986 17,367 3.9 445,836

3rd JUL-SEP 1986 23,595 5.6 420,776PROGRAM OCT-DEC 1986 14,982 3.4 435,758YEAR JAN-MAR 1987 18,130 4.0 453,888

APR-JUN 1987 18,853 4.0 472,741

4th JUL-SEP 1987 26,133 5.9 439,967PROGRAM OCT-DEC 1987 10,432 2.3 450,399YEAR JAN-MAR 1988 13,429 2.9 463,828

APR-JUN 1988 13,944 2.9 477,772

ENROLLMENT NEWLY AT END

QUARTER OF QUARTER**


APR-JUN 1989 57,406 12.7 451,547


APR-JUN 1990 40,169 9.8 408,493


APR-JUN 1991 46,020 12.4 371,592


APR-JUN 1992 44,986 12.2 369,919


APR-JUN 1993 41,397 12.1 341,361


APR-JUN 1994 33,967 10.4 325,090


APR-JUN 1995 31,995 10.5 304,153


APR-JUN 1996 22,518 8.1 279,397

NEWLYENROLLED ENROLLED

ENROLLED ENROLLMENTS

PACE

JULY 1988 - JUNE 1996CUMULATIVE % OF

TABLE 4.1PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER

PACE

JULY 1984 - JUNE 1988% OF NEWLY CUMULATIVE

49

PAGE 2

ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END

QUARTER OF QUARTER** ENROLLED ENROLLED OF QUARTER

13th JUL-SEP 1996 4,127 1.5 267,049

PROGRAM OCT-DEC 1996 9,332 3.6 260,678 1,523 100.0 1,523

YEAR JAN-MAR 1997 23,797 8.6 275,607 5,771 100.0 5,771

APR-JUN 1997 30,602 11.6 264,414 9,088 100.0 9,088

14th JUL-SEP 1997 4,536 1.8 257,291 1,949 17.7 11,037

PROGRAM OCT-DEC 1997 8,694 3.5 250,671 3,801 29.5 12,889

YEAR JAN-MAR 1998 16,693 6.6 251,915 5,710 48.5 11,771

APR-JUN 1998 22,838 9.3 245,553 7,419 53.8 13,802

15th JUL-SEP 1998 4,375 1.8 237,753 879 5.8 15,213

PROGRAM OCT-DEC 1998 8,042 3.5 230,722 1,504 9.4 15,964

YEAR JAN-MAR 1999 14,744 6.4 231,049 3,216 19.9 16,164

APR-JUN 1999 20,672 9.1 227,041 4,722 27.2 17,372

16th JUL-SEP 1999 4,086 1.8 221,535 761 4.2 18,195

PROGRAM OCT-DEC 1999 7,981 3.7 217,103 1,510 8.1 18,655

YEAR JAN-MAR 2000 18,146 8.2 220,896 4,169 21.6 19,298

APR-JUN 2000 25,583 11.8 217,140 6,125 30.1 20,375

17th JUL-SEP 2000 5,061 2.4 213,041 1,032 4.9 21,223

PROGRAM OCT-DEC 2000 10,283 4.9 208,227 2,034 9.3 21,781

YEAR JAN-MAR 2001 19,041 9.1 208,299 4,610 20.8 22,167

APR-JUN 2001 24,932 12.0 207,193 6,603 28.9 22,875

18th JUL-SEP 2001 3,877 1.9 204,839 1,710 6.9 24,929

PROGRAM OCT-DEC 2001 7,907 4.0 199,898 3,132 12.1 25,873

YEAR JAN-MAR 2002 16,319 8.2 199,719 6,931 23.3 29,692

APR-JUN 2002 22,742 11.4 198,629 9,938 32.7 30,346

19th JUL-SEP 2002 3,490 1.8 191,935 1,378 4.6 29,980

PROGRAM OCT-DEC 2002 6,925 3.7 188,566 2,476 8.2 30,356

YEAR JAN-MAR 2003 13,384 7.0 190,697 5,516 17.5 31,464

APR-JUN 2003 21,287 10.9 194,961 9,654 29.7 32,520

20th JUL-SEP 2003 4,467 2.4 187,914 2,299 6.8 33,855

PROGRAM OCT-DEC 2003 8,106 4.4 185,143 3,737 10.9 34,314

YEAR JAN-MAR 2004 21,568 10.8 200,130 37,246 51.4 72,474

APR-JUN 2004 28,312 14.3 197,600 43,224 49.7 87,007

21st JUL-SEP 2004 4,222 2.2 194,488 7,598 8.1 94,002

PROGRAM OCT-DEC 2004 6,717 3.5 191,669 15,186 15.3 99,572

YEAR JAN-MAR 2005 13,536 7.0 193,946 25,934 28.2 92,035

APR-JUN 2005 19,467 10.2 190,273 35,063 34.2 102,622

22nd JUL-SEP 2005 3,935 2.1 187,696 6,301 5.9 107,240

PROGRAM OCT-DEC 2005 9,001 4.8 188,495 15,579 13.3 116,755

YEAR JAN-MAR 2006 14,476 7.6 190,654 25,774 20.8 123,687

APR-JUN 2006 23,477 12.5 187,311 42,841 33.4 128,212

23rd JUL-SEP 2006 2,084 1.1 184,106 3,182 2.5 127,978

PROGRAM OCT-DEC 2006 5,269 2.9 179,240 11,330 8.5 132,764

YEAR JAN-MAR 2007 8,687 4.8 182,332 19,571 14.6 134,018

APR-JUN 2007 11,621 6.5 178,746 26,974 19.7 136,805

24th JUL-SEP 2007 2,143 1.2 174,824 3,940 2.8 138,701

PROGRAM OCT-DEC 2007 4,477 2.8 158,560 8,642 5.5 157,874

YEAR JAN-MAR 2008 6,956 4.5 155,547 19,078 11.9 160,227

APR-JUN 2008 9,712 6.3 155,026 29,033 17.2 169,043

ENROLLED ENROLLED NEWLY

CUMULATIVE % OF

PACE PACENET


TABLE 4.1 PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER

50

PAGE 3

ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END

QUARTER OF QUARTER** ENROLLED ENROLLED OF QUARTER

25th JUL-SEP 2008 2,321 1.5 150,074 6,087 3.6 170,931

PROGRAM OCT-DEC 2008 4,873 3.4 141,712 11,833 6.8 173,460

YEAR JAN-MAR 2009 6,838 6.7 101,470 17,435 10.5 165,925

APR-JUN 2009 8,521 6.3 134,590 23,075 13.8 167,488

26th JUL-SEP 2009 1,848 1.4 133,248 6,469 3.8 170,994

PROGRAM OCT-DEC 2009 2,654 2.0 131,002 13,898 8.2 169,270

YEAR JAN-MAR 2010 5,109 3.9 129,892 21,782 12.5 174,306

APR-JUN 2010 7,344 5.7 128,651 29,944 16.8 178,574

27th JUL-SEP 2010 1,203 1.0 126,424 4,636 2.6 178,869

PROGRAM OCT-DEC 2010 2,800 2.3 121,369 9,292 5.2 177,774

YEAR JAN-MAR 2011 4,553 3.8 120,244 15,376 8.6 179,606

APR-JUN 2011 6,438 5.4 118,605 20,912 11.6 181,016

28th JUL-SEP 2011 1,349 1.2 117,121 3,376 1.9 180,624

PROGRAM OCT-DEC 2011 3,291 2.9 112,850 7,820 4.4 176,771

YEAR JAN-MAR 2012 5,129 4.6 112,319 11,037 6.2 178,059

APR-JUN 2012 7,259 6.5 110,863 13,971 7.8 178,290

29th JUL-SEP 2012 1,382 1.3 110,133 2,571 1.4 177,702

PROGRAM OCT-DEC 2012 3,200 2.9 109,395 5,196 3.0 175,524

YEAR JAN-MAR 2013 4,756 4.5 106,109 8,428 4.9 173,206

APR-JUN 2013 5,971 5.7 104,853 11,836 6.8 173,220

30th JUL-SEP 2013 966 0.9 102,787 2,555 1.5 170,876

PROGRAM OCT-DEC 2013 2,273 2.2 101,375 6,018 3.5 173,456

YEAR JAN-MAR 2014 3,917 3.5 112,062 10,068 6.4 156,997 ***

APR-JUN 2014 5,651 5.1 110,606 13,673 8.7 157,043

31st JUL-SEP 2014 1,476 1.3 109,951 3,305 2.1 157,043

PROGRAM OCT-DEC 2014 3,547 3.3 106,796 7,754 5.0 154,936

YEAR JAN-MAR 2015 5,286 5.0 105,769 11,599 7.5 155,082

APR-JUN 2015 6,680 6.4 104,325 15,074 9.7 154,768

32nd JUL-SEP 2015 1,059 1.0 102,361 2,762 1.8 153,897

PROGRAM OCT-DEC 2015 2,649 2.7 97,995 6,502 4.3 151,429

YEAR

* THE NEWLY ENROLLED NUMBER IS CALCULATED AS A TOTAL FOR THE QUARTER.

** ENROLLMENT AT END OF QUARTER REPRESENTS THE ENROLLMENT REPORTED ON THE LAST DAY OF THE QUARTER (I.E., 97,995 PACE CARDHOLDERS AND 151,429 PACENET CARDHOLDERS ON THE FILE ON DECEMBER 31, 2015).

*** MOVED 13,280 PACENET CARDHOLDERS TO PACE AND ADDED 3,327 NEW PACENET CARDHOLDERS.

SOURCE: PDA/MR-0-01A/CARDHOLDER FILE

ENROLLED ENROLLED NEWLY

CUMULATIVE % OF

PACE PACENET


TABLE 4.1 PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER

51

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58

TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES


PAGE 1

PACE PACENET TOTAL

Part D, Auto-Enrolled 41,004 46,337 86,559Part D, Not Auto-Enrolled 63,166 105,318 165,474Not Enrolled in Part D 14,599 24,783 38,817Total PACE/PACENET Enrolled 118,769 176,438 290,850

Part D, Auto-Enrolled 35,127 41,751 76,223Part D, Not Auto-Enrolled 46,689 84,489 129,224Not Enrolled in Part D 9,455 13,658 22,809Total Participating Cardholders 91,271 139,898 228,256

Part D, Auto-Enrolled 1,348,170 1,664,882 3,013,052Part D, Not Auto-Enrolled 1,489,047 2,709,154 4,198,201Not Enrolled in Part D 389,908 479,752 869,660Total Claims 3,227,125 4,853,788 8,080,913

Part D, Auto-Enrolled 32.88 35.93 34.81Part D, Not Auto-Enrolled 23.57 25.72 25.37Not Enrolled in Part D 26.71 19.36 22.40All PACE/PACENET Enrolled 27.17 27.51 27.78

Part D, Auto-Enrolled $25,316,963 $31,083,254 $56,400,217Part D, Not Auto-Enrolled $25,007,805 $56,234,263 $81,242,068Not Enrolled in Part D $29,277,651 $33,311,562 $62,589,213All PACE/PACENET Enrolled $79,602,418 $120,629,079 $200,231,498

Part D, Auto-Enrolled $18.78 $18.67 $18.72Part D, Not Auto-Enrolled $16.79 $20.76 $19.35Not Enrolled in Part D $75.09 $69.43 $71.97All PACE/PACENET Enrolled $24.67 $24.85 $24.78




Total Cardholder Expenditures

Cardholder Share Per Claim

TPL Share

State Share Expenditures

State Share Per Claim

Enrolled Cardholders

Participating Cardholders

Claims

Claims Per Enrollee

59

TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES


PAGE 2

PACE PACENET TOTAL



Full LIS 17,674 3,762 21,337Partial LIS 2,656 2,730 5,336No LIS 20,674 39,845 59,886Total Auto-Enrolled Cardholders 41,004 46,337 86,559

Part D LIS Status Among Other Part D EnrolledFull LIS 30,682 9,972 40,056Partial LIS 4,233 7,421 11,380No LIS 28,251 87,925 114,038Total Other Part D Enrolled Cardholders 63,166 105,318 165,474

claim adjudication system. There may be additional prescription expenditures that were not submitted to PACE/PACENET.

Total Expenditures (State, Cardholder, TPL)

Part D LIS Status Among Auto-Enrolled

TPL Share Per Claim

Notes: Auto-enrolled cardholders include individuals who were enrolled or re-enrolled by PACE/PACENET into Part D partner plans within the two years prior to January 2015, and who had active coverage in a PACE/PACENET Part D partnerplan during 2015. The expenditure totals shown are based only on claims that were recorded in the PACE/PACENET

60

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TIM

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NO

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: D

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23.9

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68

FIG

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CE

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IN

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12.6

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0.00

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CE

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UR

BA

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99

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00%

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CO

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TIE

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ITH

HIG

HE

ST

PE

RC

EN

T E

NR

OLL

ED

: SC

HU

YLK

ILL

(23.

2%),

SO

ME

RS

ET

(22

.9%

), A

ND

CO

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BIA

(22

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CO

UN

TIE

S W

ITH

LO

WE

ST

PE

RC

EN

T E

NR

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: CH

ES

TE

R (

7.0%

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ON

TG

OM

ER

Y (

7.6%

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ND

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CK

S (

7.7%

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SO

UR

CE

S:

CA

RD

HO

LDE

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HIS

TO

RY

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D 2

014

INT

ER

CE

NS

AL

ES

TIM

AT

ES

69

70

SECTION 6

PROVIDER DATA

71

72

PR

OV

IDE

RT

YP

EN

O.

%N

O.

%N

O.

%N

O.

%N

O.

%

IND

EP

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DE

NT

943

31.3

123,

937

12.5

33,8

313.

483

5,33

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75

TABLE 6.4

PACENET CLAIMS VOLUME BY PHASE OF COVERAGE1, PRODUCT TYPE, AND PROVIDER TYPEJANUARY - DECEMBER 2015

PROVIDER TYPE NO. % NO. % NO. % NO. %

INDEPENDENT PHARMACIES 3,890 1.7 1,446 0.6 219,146 97.6 224,482 100.0

DISPENSING PHYSICIANS 0 0.0 0 0.0 5 100.0 5 100.0

INSTITUTIONAL PHARMACIES 50 3.7 43 3.2 1,264 93.1 1,357 100.0

CHAIN PHARMACIES 8,250 1.7 3,934 0.8 477,006 97.5 489,190 100.0

NURSING HOME PHARMACIES 1,429 2.6 426 0.8 52,977 96.6 54,832 100.0

MAIL ORDER PHARMACIES 95 2.1 33 0.7 4,313 97.1 4,441 100.0

HOME INFUSION PHARMACIES 1 25.0 1 25.0 2 50.0 4 100.0

TOTAL (ALL PROVIDERS) 13,715 1.8 5,883 0.8 754,713 97.5 774,311 100.0

PROVIDER TYPE NO. % NO. % NO. % NO. %

INDEPENDENT PHARMACIES 179,337 15.5 42,497 3.7 938,728 80.9 1,160,562 100.0

DISPENSING PHYSICIANS 445 68.5 70 10.8 135 20.8 650 100.0

INSTITUTIONAL PHARMACIES 932 11.3 356 4.3 6,992 84.4 8,280 100.0

CHAIN PHARMACIES 397,621 16.0 89,338 3.6 1,996,719 80.4 2,483,678 100.0

NURSING HOME PHARMACIES 41,247 12.3 10,451 3.1 282,790 84.5 334,488 100.0

MAIL ORDER PHARMACIES 10,362 11.8 3,555 4.1 73,731 84.1 87,648 100.0

HOME INFUSION PHARMACIES 26 40.0 0 0.0 39 60.0 65 100.0

TOTAL (ALL PROVIDERS) 629,970 15.5 146,267 3.6 3,299,134 81.0 4,075,371 100.0

DEDUCTIBLE PHASE CLAIMS

COPAYMENT PHASE CLAIMS

SINGLE-SOURCE MULTI-SOURCE GENERICBRAND BRAND

1IN 2015, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $33.91 TO COINCIDE WITH THE REGIONALMEDICARE PART D PREMIUM BENCHMARK. PACENET CARDHOLDERS WHO ARE NOT ENROLLED IN PART D ARE REQUIRED TO PAY THE BENCHMARK AMOUNT PRIOR TO ANY PACENET CLAIM COVERAGE. THE DEDUCT-IBLE AND COPAYMENT PHASES DIFFER IN THE TYPES OF CLAIMS SUBMITTED. LOW-PRICED PRESCRIPTIONS

TOTAL(ALL PRODUCTS)

SINGLE-SOURCE MULTI-SOURCE GENERIC (ALL PRODUCTS)BRAND BRAND TOTAL

SOURCE: PDA/CLAIMS HISTORYNOTE: DATA INCLUDE ORIGINAL, PAID CLAIMS BY DATE OF PAYMENT.

THE DEDUCTIBLE. GENERIC UTILIZATION RATES MAY THEREFORE BE HIGHER IN THE DEDUCTIBLE PHASE

FOR WHICH THE TOTAL PRICE IS LESS THAN THE $8 OR $15 COPAY ARE NOT NECESSARILY SUBMITTED DURING THE COPAYMENT PHASE, BUT MAY BE SUBMITTED DURING THE DEDUCTIBLE PHASE TO SATISFY

DUE TO THE OVER-REPRESENTATION OF LOW-PRICED GENERIC CLAIMS.

76

TABLE 6.5PACENET EXPENDITURES BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPE


PAGE 1

A. DEDUCTIBLE PHASE CLAIMS1

PROVIDER TYPE AMOUNT % AMOUNT % AMOUNT % AMOUNT %

INDEPENDENT PHARMACIES

CARDHOLDER EXPENDITURES $83,780 5.2 $28,185 1.8 $1,498,630 93.1 $1,610,595 100.0

OTHER PAYER EXPENDITURES $823,304 40.4 $164,898 8.1 $1,049,972 51.5 $2,038,175 100.0

STATE SHARE EXPENDITURES $1,433 72.3 $48 2.4 $502 25.3 $1,983 100.0

TOTAL EXPENDITURES $908,517 24.9 $193,130 5.3 $2,549,104 69.8 $3,650,752 100.0

DISPENSING PHYSICIANS

CARDHOLDER EXPENDITURES $0 0.0 $0 0.0 $21 100.0 $21 100.0

OTHER PAYER EXPENDITURES $0 0.0 $0 0.0 $173 100.0 $173 100.0

STATE SHARE EXPENDITURES $0 – $0 – $0 – $0 –

TOTAL EXPENDITURES $0 0.0 $0 0.0 $194 100.0 $194 100.0

INSTITUTIONAL PHARMACIES

CARDHOLDER EXPENDITURES $378 4.0 $311 3.3 $8,779 92.7 $9,468 100.0

OTHER PAYER EXPENDITURES $2,063 30.4 $511 7.5 $4,225 62.1 $6,800 100.0


TOTAL EXPENDITURES $2,441 15.0 $822 5.1 $13,004 79.9 $16,268 100.0

CHAIN PHARMACIES


OTHER PAYER EXPENDITURES $1,842,639 40.7 $356,065 7.9 $2,323,903 51.4 $4,522,607 100.0

STATE SHARE EXPENDITURES $2,011 37.1 $1,321 24.4 $2,090 38.5 $5,422 100.0

TOTAL EXPENDITURES $2,046,877 25.7 $433,899 5.5 $5,485,377 68.9 $7,966,153 100.0

NURSING HOME PHARMACIES

CARDHOLDER EXPENDITURES $24,753 6.8 $6,360 1.7 $335,664 91.5 $366,777 100.0

OTHER PAYER EXPENDITURES $257,093 41.8 $49,879 8.1 $307,492 50.0 $614,464 100.0


TOTAL EXPENDITURES $284,113 28.8 $57,414 5.8 $644,197 65.4 $985,725 100.0

MAIL ORDER PHARMACIES


OTHER PAYER EXPENDITURES $168,816 77.1 $7,527 3.4 $42,701 19.5 $219,044 100.0

STATE SHARE EXPENDITURES $1,209 99.1 $12 0.9 $0 0.0 $1,221 100.0

TOTAL EXPENDITURES $173,675 66.0 $8,745 3.3 $80,827 30.7 $263,247 100.0

HOME INFUSION PHARMACIES

CARDHOLDER EXPENDITURES $7 10.5 $11 17.9 $45 71.6 $63 100.0

OTHER PAYER EXPENDITURES $1,499 94.2 $0 0.0 $93 5.8 $1,592 100.0


TOTAL EXPENDITURES $1,505 91.0 $11 0.7 $138 8.3 $1,655 100.0

TOTAL (ALL PROVIDERS)




TOTAL EXPENDITURES $3,417,130 26.5 $694,022 5.4 $8,772,841 68.1 $12,883,993 100.0


THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF

1IN 2015, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $33.91 TO COINCIDE WITH THE REGIONAL MEDICARE PART D

BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION

CLAIMS WHICH COMPLETE THE $33.91 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS

THE PRESCRIPTION.

BRAND BRAND

SINGLE-SOURCE MULTI-SOURCE GENERIC ALL PRODUCTS

77

TABLE 6.5PACENET EXPENDITURES BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPE


PAGE 2

B. COPAYMENT PHASE CLAIMS

PROVIDER TYPE AMOUNT % AMOUNT % AMOUNT % AMOUNT %

INDEPENDENT PHARMACIES

CARDHOLDER EXPENDITURES $3,521,843 32.1 $815,866 7.4 $6,621,211 60.4 $10,958,920 100.0

OTHER PAYER EXPENDITURES $47,494,902 71.6 $5,811,585 8.8 $13,038,895 19.7 $66,345,382 100.0

STATE SHARE EXPENDITURES $20,391,375 56.8 $3,792,962 10.6 $11,723,280 32.7 $35,907,616 100.0

TOTAL EXPENDITURES $71,408,120 63.1 $10,420,413 9.2 $31,383,385 27.7 $113,211,918 100.0

DISPENSING PHYSICIANS


OTHER PAYER EXPENDITURES $1,885,104 96.5 $40,174 2.1 $28,605 1.5 $1,953,883 100.0

STATE SHARE EXPENDITURES1 $358,758 90.4 $10,785 2.7 $27,271 6.9 $396,814 100.0

TOTAL EXPENDITURES $2,252,344 95.4 $52,001 2.2 $57,071 2.4 $2,361,416 100.0

INSTITUTIONAL PHARMACIES


OTHER PAYER EXPENDITURES $1,037,572 84.1 $66,615 5.4 $130,000 10.5 $1,234,187 100.0


TOTAL EXPENDITURES $1,309,622 78.7 $94,881 5.7 $260,585 15.7 $1,665,089 100.0

CHAIN PHARMACIES

CARDHOLDER EXPENDITURES $8,296,730 33.6 $1,759,249 7.1 $14,625,832 59.3 $24,681,812 100.0




NURSING HOME PHARMACIES



STATE SHARE EXPENDITURES $3,243,869 49.7 $824,369 12.6 $2,458,664 37.7 $6,526,903 100.0


MAIL ORDER PHARMACIES

CARDHOLDER EXPENDITURES $351,354 28.5 $100,348 8.2 $779,737 63.3 $1,231,439 100.0


STATE SHARE EXPENDITURES $3,883,615 84.3 $285,181 6.2 $437,905 9.5 $4,606,701 100.0


HOME INFUSION PHARMACIES

CARDHOLDER EXPENDITURES $404 38.8 $0 0.0 $636 61.2 $1,040 100.0

OTHER PAYER EXPENDITURES $100,857 97.6 $0 0.0 $2,462 2.4 $103,318 100.0

STATE SHARE EXPENDITURES $13,309 67.6 $0 0.0 $6,378 32.4 $19,687 100.0

TOTAL EXPENDITURES $114,569 92.4 $0 0.0 $9,476 7.6 $124,045 100.0

TOTAL (ALL PROVIDERS)

CARDHOLDER EXPENDITURES $12,892,983 32.6 $2,855,649 7.2 $23,809,710 60.2 $39,558,342 100.0





THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF

THE PRESCRIPTION.

1IN 2015, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $33.91 TO COINCIDE WITH THE REGIONAL MEDICARE PART D

BRAND BRAND

SINGLE-SOURCE MULTI-SOURCE GENERIC ALL PRODUCTS

BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION

CLAIMS WHICH COMPLETE THE $33.91 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS

78

TABLE 6.6AVERAGE CARDHOLDER AND STATE SHARE COST PER PACENET CLAIM

BY PHASE OF COVERAGE, PRODUCT TYPE, AND PROVIDER TYPEJANUARY - DECEMBER 2015

BRAND BRAND BRAND BRANDSINGLE- MULTI- SINGLE- MULTI-SOURCE SOURCE GENERIC TOTAL SOURCE SOURCE GENERIC TOTAL

INDEPENDENT PHARMACIESAVERAGE CARDHOLDER SHARE2 $21.54 $19.49 $6.84 $7.17 $19.64 $19.20 $7.05 $9.44AVERAGE OTHER PAYER SHARE $211.65 $114.04 $4.79 $9.08 $264.84 $136.75 $13.89 $57.17AVERAGE STATE SHARE $0.37 $0.03 $0.00 $0.01 $113.70 $89.25 $12.49 $30.94AVERAGE TOTAL RX COST $233.55 $133.56 $11.63 $16.26 $398.18 $245.20 $33.43 $97.55

DISPENSING PHYSICIANSAVERAGE CARDHOLDER SHARE2 – – $4.28 $4.28 $19.06 $14.88 $8.86 $16.49AVERAGE OTHER PAYER SHARE – – $34.56 $34.56 $4,236.19 $573.92 $211.89 $3,005.97AVERAGE STATE SHARE – – $0.00 $0.00 $806.20 $154.07 $202.01 $610.48AVERAGE TOTAL RX COST – – $38.84 $38.84 $5,061.45 $742.87 $422.75 $3,632.95

INSTITUTIONAL PHARMACIESAVERAGE CARDHOLDER SHARE2 $7.56 $7.24 $6.95 $6.98 $17.01 $12.53 $6.31 $7.78AVERAGE OTHER PAYER SHARE $41.27 $11.88 $3.34 $5.01 $1,113.27 $187.12 $18.59 $149.06AVERAGE STATE SHARE $0.00 $0.00 $0.00 $0.00 $274.89 $66.87 $12.36 $44.26AVERAGE TOTAL RX COST $48.82 $19.12 $10.29 $11.99 $1,405.17 $266.52 $37.27 $201.10

CHAIN PHARMACIESAVERAGE CARDHOLDER SHARE2 $24.51 $19.45 $6.62 $7.03 $20.87 $19.69 $7.32 $9.94AVERAGE OTHER PAYER SHARE $223.35 $90.51 $4.87 $9.25 $259.99 $136.00 $15.41 $58.91AVERAGE STATE SHARE $0.24 $0.34 $0.00 $0.01 $110.99 $79.34 $10.53 $29.09AVERAGE TOTAL RX COST $248.11 $110.29 $11.50 $16.28 $391.85 $235.03 $33.27 $97.94

NURSING HOME PHARMACIESAVERAGE CARDHOLDER SHARE2 $17.32 $14.93 $6.34 $6.69 $16.93 $16.71 $6.14 $7.80AVERAGE OTHER PAYER SHARE $179.91 $117.09 $5.80 $11.21 $180.35 $155.54 $11.77 $37.05AVERAGE STATE SHARE $1.59 $2.76 $0.02 $0.08 $78.64 $78.88 $8.69 $19.51AVERAGE TOTAL RX COST $198.82 $134.78 $12.16 $17.98 $275.92 $251.14 $26.60 $64.36

MAIL ORDER PHARMACIESAVERAGE CARDHOLDER SHARE2 $38.43 $36.56 $8.84 $9.68 $33.91 $28.23 $10.58 $14.05AVERAGE OTHER PAYER SHARE $1,777.01 $228.10 $9.90 $49.32 $1,242.89 $265.90 $33.68 $186.06AVERAGE STATE SHARE $12.73 $0.35 $0.00 $0.27 $374.79 $80.22 $5.94 $52.56AVERAGE TOTAL RX COST $1,828.16 $265.00 $18.74 $59.28 $1,651.59 $374.35 $50.20 $252.67

HOME INFUSION PHARMACIESAVERAGE CARDHOLDER SHARE2 $6.60 $11.28 $22.52 $15.73 $15.52 – $16.31 $16.00AVERAGE OTHER PAYER SHARE $1,498.67 $0.00 $46.48 $397.91 $3,879.10 – $63.12 $1,589.51AVERAGE STATE SHARE $0.00 $0.00 $0.00 $0.00 $511.89 – $163.54 $302.88AVERAGE TOTAL RX COST $1,505.27 $11.28 $68.99 $413.63 $4,406.51 – $242.98 $1,908.39

TOTAL (ALL PROVIDERS)AVERAGE CARDHOLDER SHARE2 $22.95 $19.14 $6.68 $7.06 $20.47 $19.52 $7.22 $9.71AVERAGE OTHER PAYER SHARE $225.70 $98.40 $4.94 $9.56 $276.54 $141.11 $15.09 $60.03AVERAGE STATE SHARE $0.50 $0.43 $0.00 $0.02 $114.73 $82.21 $10.84 $29.46AVERAGE TOTAL RX COST $249.15 $117.97 $11.62 $16.64 $411.74 $242.84 $33.15 $99.20


PAYMENTS IF BRAND IS CHOSEN OVER GENERIC. THE CARDHOLDER SHARE DURING THE COPAYMENT PHASE MAYTHEREFORE EXCEED THE $8 OR $15 COPAYMENT.

DEDUCTIBLE PHASE1 COPAYMENT PHASE

PROVIDER TYPE

2THE CARDHOLDER SHARE INCLUDES THE DEDUCTIBLE PAYMENTS, COPAYMENTS, AND GENERIC DIFFERENTIAL

1IN 2015, THE MONTHLY PACENET DEDUCTIBLE WAS CHANGED TO $33.91 TO COINCIDE WITH THE REGIONAL MEDICARE PART D BENCHMARK PREMIUM. STATE SHARE EXPENDITURES FOR DEDUCTIBLE CLAIMS ARE ONLY INCURRED FOR TRANSITION CLAIMS WHICH COMPLETE THE $33.91 MONTHLY DEDUCTIBLE ACCUMULATION. FOR THESE CLAIMS, THE CARDHOLDER PAYS THE OUTSTANDING DEDUCTIBLE AMOUNT AND A COPAYMENT, WHILE PACENET COVERS THE REMAINING COST, IF ANY, OF THE PRESCRIPTION.

79

80

SECTION 7

THERAPEUTIC CLASS DATA

AND DRUG UTILIZATION

REVIEW DATA

81

82

PA

GE

1

% O

FT

OT

AL

% O

F%

OF

WIT

H A

NY

PA

RT

ICIP

AT

ING

TH

ER

AP

EU

TIC

CLA

SS

1C

LAIM

ST

OT

AL

TO

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LC

LAIM

SC

AR

DH

OLD

ER

S

AN

TI-

INF

EC

TIV

E A

GE

NT

S

106,

791

3.3

$2,5

72,3

64.4

73.

241

,290

45.2

$62.

30$2

1.66

QU

INO

LON

ES

20,9

700.

6$1

74,5

86.5

10.

213

,939

15.3

$12.

53$1

.47

CE

PH

ALO

SP

OR

INS

14,5

050.

4$6

5,36

8.77

0.1

9,98

810

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TIN

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PLA

ST

IC A

GE

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16,4

540.

5$2

,708

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3.4

3,08

73.

4$8

77.2

4$2

2.80

AU

TO

NO

MIC

DR

UG

S

129,

848

4.0

$5,7

40,6

99.2

77.

225

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27.4

$229

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33A

NT

ICH

OLI

NE

RG

ICS

39,7

911.

2$3

,147

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4.0

8,48

29.

3$3

71.0

3$2

6.50

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RE

NE

RG

IC A

GE

NT

S32

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1.0

$735

,686

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0.9

11,0

7212

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6.45

$6.1

9

BLO

OD

FO

RM

AT

ION

& C

OA

GU

LAT

ION

AG

EN

TS

133,

593

4.1

$4,9

21,2

16.5

56.

220

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22.5

$240

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$41.

44

CA

RD

IOV

AS

CU

LAR

DR

UG

S

1,04

8,21

332

.5$1

6,52

6,01

7.61

20.8

74,1

8281

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8$1

39.1

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AR

DIA

C D

RU

GS

684,

016

21.2

$7,4

98,7

87.3

69.

466

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$113

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$63.

14A

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EN

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RE

CE

PT

OR

BLO

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ER

S10

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53.

3$3

,511

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4.4

17,3

5819

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3$2

9.57

CA

RD

-H

OLD

ER

SA

NN

UA

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CE

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OR

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9$1

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30.

222

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$7.7

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RD

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GLY

CO

SID

ES

20,7

180.

6$9

3,59

7.30

0.1

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43.

7$2

7.91

$0.7

9A

NT

IAR

RH

YT

HM

IC A

GE

NT

S11

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0.4

$455

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0.6

2,22

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4$2

04.4

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TA

BLO

CK

ER

S24

3,31

37.

5$1

,424

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1.8

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0142

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$11.

99C

ALC

IUM

CH

AN

NE

L B

LOC

KE

RS

171,

231

5.3

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50.5

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027

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30.4

$56.

23$1

3.14

LIP

ID-L

OW

ER

ING

AG

EN

TS

287,

955

8.9

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06,8

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49.

145

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49.5

$159

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$60.

68H

YP

OT

EN

SIV

E A

GE

NT

S31

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1.0

$287

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0.4

5,05

95.

5$5

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$2.4

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AS

OD

ILA

TIN

G A

GE

NT

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1.4

$1,4

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11.

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$175

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41

AN

ALG

ES

ICS

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TIP

YR

ET

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16

1,64

85.

0$3

,543

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4.5

33,1

7036

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06.8

3$2

9.84

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AID

S47

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1.5

$1,4

44,5

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51.

813

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14.7

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OR

S13

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0.4

$868

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1.1

2,80

73.

1$3

09.3

2$7

.31

OP

IAT

E A

GO

NIS

TS

111,

229

3.4

$1,8

88,3

71.0

82.

425

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28.2

$73.

33$1

5.90

PS

YC

HO

TH

ER

AP

EU

TIC

AG

EN

TS

17

4,48

45.

4$2

,908

,142

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3.7

23,9

5826

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21.3

9$2

4.49

AN

TID

EP

RE

SS

AN

TS

151,

482

4.7

$1,6

34,4

08.3

42.

122

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24.9

$72.

03$1

3.76

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RI

AN

TID

EP

RE

SS

AN

TS

86,3

082.

7$4

00,2

74.9

40.

514

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16.4

$26.

73$3

.37

AN

TIP

SY

CH

OT

ICS

23,0

020.

7$1

,273

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1.6

3,49

73.

8$3

64.2

4$1

0.72

AN

XIO

LYT

ICS

/SE

DA

TIV

ES

/HY

PN

OT

ICS

99

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3.1

$618

,683

.91

0.8

18,2

2620

.0$3

3.95

$5.2

1B

EN

ZO

DIA

ZE

PIN

ES

75,3

072.

3$2

87,2

31.4

60.

414

,694

16.1

$19.

55$2

.42

MIS

CE

LLA

NE

OU

S A

NX

/SE

D/H

YP

NO

TIC

S22

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0.7

$308

,536

.53

0.4

4,78

15.

2$6

4.53

$2.6

0

83

PA

GE

2

% O

FT

OT

AL

% O

F%

OF

WIT

H A

NY

PA

RT

ICIP

AT

ING

TH

ER

AP

EU

TIC

CLA

SS

1C

LAIM

ST

OT

AL

TO

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LC

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SC

AR

DH

OLD

ER

S

CA

RD

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OLD

ER

SA

NN

UA

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OS

T(P

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(A

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EX

PE

ND

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OF

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RS

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BY

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ER

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AS

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DE

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5

RE

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CE

ME

NT

PR

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52,0

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6$3

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924

10.9

$39.

73$3

.32

DIU

RE

TIC

S

183,

294

5.7

$800

,399

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1.0

31,7

7734

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5.19

$6.7

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OP

DIU

RE

TIC

S10

2,58

33.

2$2

04,4

13.4

20.

319

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21.8

$10.

29$1

.72

PO

TA

SS

IUM

-SP

AR

ING

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S23

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0.7

$64,

841.

650.

14,

546

5.0

$14.

26$0

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TH

IAZ

IDE

DIU

RE

TIC

S46

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1.4

$43,

857.

800.

19,

533

10.4

$4.6

0$0

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RE

SP

IRA

TO

RY

TR

AC

T A

GE

NT

S69

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2.1

$4,3

14,9

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45.

415

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17.3

$273

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$36.

33

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E,

EA

R,

NO

SE

AN

D T

HR

OA

T P

RE

PA

RA

TIO

NS

109,

726

3.4

$3,8

63,6

50.1

54.

923

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26.0

$162

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$32.

53

GA

ST

RO

INT

ES

TIN

AL

AG

EN

TS

22

8,17

47.

1$7

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9.1

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3$6

0.77

H2-

RE

CE

PT

OR

AN

TA

GO

NIS

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24,7

910.

8$4

7,23

5.81

0.1

5,43

86.

0$8

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UM

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3,18

15.

1$5

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28,2

4030

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0.09

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R M

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NT

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RE

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ND

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1.0

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$1.5

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ST

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721

1.9

$212

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$3.0

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NT

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AG

EN

TS

181,

526

5.6

$9,6

96,1

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212

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3$3

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0,65

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0$1

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1.5

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9$1

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ALL

OT

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RU

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278,

599

8.6

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88,1

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48.1

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1 T

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24.5

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48

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1,52

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SECTION 8

PENNSYLVANIA PATIENT

ASSISTANCE CLEARINGHOUSE

91

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PENNSYLVANIA PATIENT ASSISTANCE PROGRAM CLEARINGHOUSE (PA PAP) In January 2001, the PACE Program began a referral program to assist Pennsylvanians ages 60 through 64 that facilitated contact between the Area Agency on Aging offices and the patient assistance programs offered by pharmaceutical manufacturers. That Program has evolved in recent years, and, as a result, the Program now accepts applications from individual patients, physician offices, social workers and other agencies throughout the Commonwealth. In late 2004, the name of the Program changed to reflect the Program’s current objectives; it became the Pennsylvania Patient Assistance Program Clearinghouse (PA PAP). Eighty of the largest pharmaceutical manufacturers offer limited prescription drug assistance to persons who are not eligible for other forms of pharmaceutical coverage and who cannot afford the cost of one or more of their medications. The PA PAP coordinator provides the expertise necessary to determine the likelihood of eligibility for persons seeking assistance from manufacturers’ medication programs, gathers the patient information required to complete the pharmacy assistance applications, offers guidance and assistance to the patient throughout the application and, if successful, reapplication processes. In 2006, the Clearinghouse extended assistance to all adult Pennsylvania residents who appear to meet the selected guidelines, without regard to age. Pharmaceutical manufacturers which offer pharmacy assistance programs set their income and eligibility guidelines as individual companies; they limit the products and the length of time for assistance. Typically, the gross household income should be at or below 200% of federal poverty level guidelines, but many manufacturers will consider circumstances of hardship that fall outside their usual guidelines. Household income is one factor of many criteria used by the manufacturers to determine eligibility for medication. Manufacturers require a wide range of information on company-specific forms which further complicates the application and review process. A substantial amount of coordination needs to occur between the PA PAP coordinator, the patient, and the patient’s physician. Since the inception of Medicare Part D, some manufacturers have instituted programs to assist cardholders while they are in the Part D coverage gap. The requirements for the Medicare Part D coverage gap programs differ from the base programs offered by the manufacturers. As a result of different settlements from the Pennsylvania Attorney General’s office, the Pennsylvania Patient Assistance Program Clearinghouse has been able to offer assistance for specific medications to patients who are not eligible for the manufacturer’s assistance programs. Eligible patients can receive a 30-day supply of medication for which they are charged varying copayments based on the program they are enrolled in. At the end of 2015, the Clearinghouse successfully enrolled 86 additional patients into these settlement programs. Despite the inherent difficulties of application, the lengthy wait for approval from the manufacturer, and the strictly limited amount of medication granted with each approval, the collaborative efforts of the local and central coordinators responded to inquiries from 29,837 patients after fourteen years of operation. At the end of 2015, 49% (14,515 persons) were receiving medication assistance through the PA PAP Clearinghouse. The Program successfully enrolled persons to the PACE Program (1,295), PACENET Program (3,810), VA benefits (69), or other insurance (249). Among the remaining inactive patients, 65 were over the income limits set by the manufacturers and were not eligible for PACE or PACENET benefits. Among the 14,515 persons receiving assistance through the PA PAP Clearinghouse, a total of 46,298 medications were obtained. Current initiatives are to continue processing manufacturers’ pharmacy assistance applications for cardholders who are uninsured, to assist cardholders with Medicare Part D, to assist Part D-enrolled cardholders in applying for the Low Income Subsidy (LIS) benefit, and to initiate any new Programs that are the result of Attorney General lawsuit settlements.

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In October 2014, The Clearinghouse expanded its scope to assisting Pennsylvania residents who were paroled from a Pennsylvania State Correctional Institution. This project is a combined effort between the Department of Aging’s Clearinghouse and the Department of Probation and Parole. This effort extended the Clearinghouse beyond its previous scope of assistance. The effort has been able to provide assistance to willing individuals with their medications, transportation services, Supplemental Nutrition Assistance Program (SNAP), Low-Income Home Energy Assistance Program (LIHEAP), Medical Assistance, enrollment into other state and federally funded programs and other life sustaining benefits. At the end of 2014, the Clearinghouse contacted 3,378 parolees. Of these parolees, 28 were enrolled in one of the Attorney General pharmaceutical settlement programs, 17 in PACE, 28 in SNAP benefits, and 46 in LIS. In addition to the initiatives listed above, Clearinghouse coordinators aided these individuals with finding furniture, physicians, and grants to assist with utility bills. The Clearinghouse plans to expand the current database of information, so that these Pennsylvanians and their family members may be better served with available benefits.

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APPENDIX A

The PACE Application Center 2015 Report

University of Pennsylvania and PACE/PACENET Behavioral Health Lab Program 2015 Report

The PACE Academic Detailing Program Impact Analysis January 2013 - December 2015

95

The PACE Application Center 2015 Report

Overview Since 2006, the PACE Application Center for the Pennsylvania Department of Aging has conducted data-driven outreach and application assistance to connect older Pennsylvanians with public benefit programs to help cover the cost of prescriptions, shelter and food. The PACE Application Center provides services:

to locate eligible persons and submit PACE applications on their behalf, to enroll persons in the Medicare Part D Extra Help Low-Income Subsidy (LIS), to assist older Pennsylvanians in accessing other benefit programs including the

Supplemental Nutrition Assistance Program (SNAP), Property Tax/Rent Rebate (PTRR), Low-Income Home Energy Assistance Program (LIHEAP), Medicare Savings Programs (MSP), and Medicaid coverage.

The PACE Application Center uses multiple sources of state, private and public data to conduct outreach. To date, the Center outreach efforts have resulted in over 204,500 applications for the PACE and PACENET programs, and 145,000 applications for LIS. In addition, the PACE Application Center has submitted over 125,500 additional benefit applications on behalf of Pennsylvania’s seniors. All told, the PACE Application Center has delivered approximately $840 million in benefits to help older Pennsylvanians afford their prescriptions, age in place, and live with dignity.

Outreach and Applications Submitted in 2015 Through mail, telephone and community-based outreach, the PACE Application Center assisted 27,768 senior households in applying for at least one benefit, delivering $99 million in benefits in one year.

2015 OUTREACH AND APPLICATION ASSISTANCE

TOTAL PACE/PACENET OUTREACH 606,527

UNIQUE PACE/PACENET OUTREACH 341,949

TOTAL LIS OUTREACH 113,104

UNIQUE LIS OUTREACH 48,521

PACE/PACENET APPLICATIONS SUBMITTED 11,687

RESPONSES TO PACE AND LIS OUTREACH 29,849

LIS APPLICATIONS SUBMITTED 8,837

SNAP APPLICATIONS SUBMITTED 14,102

PTRR APPLICATIONS SUBMITTED 3,781

LIHEAP APPLICATIONS SUBMITTED 1,572

MSP APPLICATIONS SUBMITTED 3,783

MEDICAID APPLICATIONS SUBMITTED 3,515

HOUSEHOLDS WITH AT LEAST ONE BENEFIT APPLICATION SUBMITTED 27,768

ESTIMATED ANNUAL BENEFIT VALUE $99,007,672

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Message Testing Results The PACE Application Center successfully reaches eligible seniors who were not yet enrolled in PACE, PACENET, or LIS by outreaching to them about other needs that they may have, such as access to food and to programs that assist with shelter costs. The PACE Application Center has tested outreach messages to previous non-responders which invited seniors to call for assistance to apply for the Supplemental Nutrition Assistance Program (SNAP) and the Property Tax/Rent Rebate (PTRR) Program. Overall, the Center found that using these messages on letters garnered higher response rates than using a prescription assistance message. The Center also found that the SNAP message letter was more effective than the LIS letter in identifying individuals who were eligible for Medicare Part D Extra Help (LIS).

2016 Initiatives For 2016, the Center anticipates conducting new outreach efforts and expanding its messaging about available services. The Center will:

receive 83,900 new, unique names for PACE/PACENET outreach. receive 11,500 new, unique names for LIS outreach. receive and conduct mail and telephone PACE outreach to refreshed lists

provided by PTRR, SNAP, MSP, LIHEAP, the Pennsylvania Department of Transportation, Medicaid for dual eligible re-deemed status, health insurance companies, commercial mailing list producers, and Pennsylvania Department of Aging.

receive and conduct mail and telephone outreach to refreshed PACE and PACENET enrollees for LIS and for SNAP.

seek additional lists for outreach from health insurance companies who provide Medicare Part D in conjunction with PACE and from valuable partnerships with community-based organizations.

AVAILABLE DATA SOURCES FOR OUTREACH

NEW NAMES AVAILABLE FOR PACE OUTREACH 83,867 NEW NAMES AVAILABLE FOR LIS OUTREACH 11,500 NON-RESPONDER NAMES AVAILABLE FOR PACE OUTREACH 647,000

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University of Pennsylvania and PACE/PACENET Behavioral Health Lab Program 2015 Report

Overview Depression, anxiety, and dementia are prevalent in later life and lead to significant morbidity and disability, thereby contributing to increased medical services utilization, nursing home utilization, and mortality. Despite advances in the assessment and treatment of behavioral health disorders among older adults, under-treatment of such disorders remains a major public health concern. Less than 20% of patients treated for major depression are seen monthly for the first three months, and they often do not achieve remission. To address these issues, there is a need to improve rates of treatment and to facilitate guideline adherent care for seniors in primary care settings. Much of the focus has been on the delivery of care management strategies either in person or by telephone. One such evidence based, algorithm driven program is SUSTAIN, SUpporting Seniors receiving Treatment And INtervention, conducted through the University of Pennsylvania Behavioral Health Lab (BHL) program. For several years, SUSTAIN has been shown to be effective in identifying community-dwelling older persons at risk of poor health outcomes, including nursing home admissions, and to support these individuals and their caregivers to manage their mental health care. The program is well suited to help reduce or delay the onset and progression of functional limitations, as well as to provide information about and access to community resources that enable independent living for longer periods of time. Assessments PACE enrollees receive evidenced-based care management that includes counseling, support, education and advice about pharmacological treatment as well as referral to available community resources based on needs. SUSTAIN delivers to prescribers written patient monitoring and feedback about medication response, tolerability and safety, and offers telephone consultation to them. Family caregivers may participate in evidenced-based support that focuses on amplifying their caregiving skills through focused problem solving and education offered at their convenience. In 2015, SUSTAIN completed:

634 initial assessments for cardholders and caregivers new to SUSTAIN

5 initial assessments were referrals from the prescribing provider or from the PACE Application Center

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o These individuals received follow-up care management services with BHL program providers and referrals to specialty mental health services

2,442 follow-up assessments o 240 cardholders received care management services with BHL providers o 289 cardholders received symptom and medication monitoring services o 29 cardholders worked with BHL program providers and received referrals

to specialty mental health services

Locations of SUSTAIN Service Recipients

Note: Smallest map dots are 1-9 persons. The dots increase in size by 10's with 10-19, 20-29, 30-39, 40-49, and the largest are 50+ persons. 2015 Caregiver Outreach Update In November 2014, CREST, the Caregiver Resources, Education, & SupporT Program, began to deliver caregiver outreach and telehealth education that specifically targets caregivers of cardholders with dementia or Alzheimer’s disease. Caregivers receive care management services in combination with education and support. In 2015, CREST completed:

139 initial assessments with PACE members and/or their caregivers (new to CREST)

o 83 initial assessments with cardholders 79 caregivers were eligible for services and received education and

resource materials 66 of these caregivers worked directly with a BHL provider

for care management and CREST education services

99

13 of these caregivers did not work with a provider but agreed to a 3-month follow-up assessment

4 caregivers were ineligible for follow-up services but received

resource information

o 25 cardholders failed the initial memory screening and did not identify a caregiver or the caregiver chose to not engage in follow-up services

o 31 cardholders completed an initial assessment (passed the memory screening) 9 enrollees were ineligible for services (absence of depression or

anxiety symptoms); they did receive resource materials 22 cardholders were eligible for follow-up services and participated

in either care management services with the BHL provider or medication monitoring, depending on severity of symptoms

100

Overall Outcomes The charts below highlight the differences between monitoring only (standard care) or monitoring with additional therapy and care management (enhanced care). In all cases, care management improves symptoms and function relative to monitoring alone. DEPRESSION SYMPTOMS ANXIETY SYMPTOMS (LOWER IS BETTER) (LOWER IS BETTER)

OVERALL FUNCTIONING (HIGHER IS BETTER)

Initiatives for 2016

CREST Program Starting in April 2015, project managers made minor changes to the sampling procedures to engage a higher percentage of the weekly referrals. Increased caregiver participation in care management and CREST services are expected throughout 2016.

Sampling procedures Starting in May 2016, project managers changed sampling procedures leading to an increase in cardholder referrals per week (up to 60) and made changes to the proportion of referrals from rural and urban counties.

0

5

10

0Month

3 6

PHQ‐9 Score

All Enrollees

Standard Care Enhanced Care

0

2

4

6

0Month

3 6

GAD‐7 Score

All Enrollees


40

45

50

55

0 3 6

SF12 M

CS Score

Month

All Enrollees


101

Enhanced partnership with the PACE Application Center The project welcomes referrals. It invites community providers to refer eligible participants to the programs to support their treatment plans through care management services with the Behavioral Health providers. Continued support for cardholders prescribed psychotropic medications The program will continue to enroll cardholders prescribed psychotropic medications into the care management and medication monitoring programs.

Award and Publications in 2015 Bronze Award, 2015 APA Achievement Awards: A Private-Public Partnership to Deliver Population-Level Integrated Care to Low-Income Seniors in Pennsylvania. Joel E. Streim, M.D., SUSTAIN medical director and professor of psychiatry, and David W. Oslin, M.D., SUSTAIN director and professor of psychiatry; SUSTAIN (SUpporting Seniors receiving Treatment And INtervention), Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, and the Department of Aging, Commonwealth of Pennsylvania, Harrisburg. Psychiatric Services 2015; 66:e12–e14; doi: 10.1176/appi.ps.661009. Mavandadi, S, Benson, A, DiFilippo, S, Streim, J, and Oslin, D. (2015). A telephone-based program to provide symptom monitoring alone vs. symptom monitoring plus care management for late-life depression and anxiety: A randomized clinical trial. JAMA Psychiatry, doi:10.1001/jamapsychiatry.2015.2157. Hearn, R, Rooney, D, Grecco, E. (2015). Integrating mental health specialty services via telehealth. Archives of Psychiatric Nursing, http://dx.doi.org/10.1016/j.apnu.2015.05.008. Maust, D, Chen, S, Benson, A, Mavandadi, S, Streim, J, DiFilippo, S, Snedden, T, and Oslin, D. (2015). Older adults recently started on psychotropic medication: Where are the symptoms? International Journal of Geriatric Psychiatry. 30: 580-6. PMID: 25116369. Presentations Mavandadi, S, Benson, A, Foust K, DiFilippo, S, Streim, J, Oslin, D, and Snedden, T. Evaluation of a telephone dementia care management program for caregivers of community-dwelling older adults. Presented at the Sylvan M. Cohen 2015 Annual Retreat, Philadelphia, PA, May 2015. Levine, K, Koenig, A, Leong, S, Benson, A, Streim, J, and Oslin, D. Benzodiazepine prescription patterns for older adults in Pennsylvania. Presented at the American Association for Geriatric Psychiatry 2015 Annual Meeting, New Orleans, LA, March 2015.

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The PACE Academic Detailing Program Impact Analysis January 2013 - December 2015

Overview The PACE Program provides funding and support to the Alosa Foundation for the delivery of an academic detailing service to primary care clinicians who care for PACE beneficiaries. Academic detailing is outreach education for health care professionals to improve clinical decision making. Rather than promote particular products, educators provide comprehensive summaries of the body of evidence for a particular topic to help clinicians prescribe the safest, most effective medications for their patients. The information is compiled from comparative effectiveness research that compares the effectiveness, benefits, and harms of different medical treatment options. This provides a convenient and efficient way for primary care providers to stay current on the latest medical findings about the health issues they most commonly treat. The model uses trained clinical educators who meet one-on-one with physicians, nurse practitioners, and physician assistants at their practice locations to discuss the most recent clinical data on a particular primary care topic. This report reflects activity over three calendar years, between January 2013 and December 2015. During this time, there were nine academic detailing modules covering a wide range of conditions managed by providers in primary care.

THERAPEUTIC AREA MODULE TITLE RELEASED

Heart Failure Managing Risk and Improving Patient Outcomes Nov. 2015

Atrial Fibrillation Anticoagulation: A Key Strategy—Slow(er), Even If Not Steady, Wins the Race Jul. 2015

Urinary Incontinence Evaluating and Managing Urinary Incontinence Mar. 2015

Pain Management Managing Pain in the Elderly Dec. 2014

Alzheimer’s Disease and Related Disorders

Evaluation and Management of Alzheimer's Disease and Related Disorders: Evidence-based Guidance for Primary Care Clinicians

Aug. 2014

Falls and Mobility Preventing Falls In The Elderly: What Primary Care Clinicians Can Do to Reduce Injury and Death Apr. 2014

Chronic Obstructive Lung Disease and Smoking Cessation

Helping Patients with COPD Breathe Easier: Integrating the Latest Evidence on Chronic Lung Disease into Primary Care Practice

Nov. 2013

Obesity Weighing the Evidence on Obesity and Its Management Aug. 2013

Type 2 Diabetes Just a Spoonful of Medicine Helps the Sugar Go Down: Improving the Management of Type 2 Diabetes

Apr. 2013

103

Evaluation Both qualitative and quantitative data are helpful to assess the impact of the program on prescribers and to improve the program’s design for the primary care setting.

Clinician participants complete post-visit surveys after each educational session to measure knowledge, as well as to assess how the program impacts prescribing for their older patients.

Alosa conducts drug utilization analyses using PACE claims information. Eight clinical educators record feedback from the participants after each

academic detailing visit, capturing the clinicians’ impressions on the relevance of the current module to their practice and their perceived utility of the module in helping to improve patient care.

Alosa reports the number of prescribers educated on each topic by provider type (physician, nurse practitioner, or physician assistant).

Post-Visit Surveys Participant surveys began with the obesity module in 2013 and have continued for subsequent topics. For each module, the providers rate topic-specific statements and broader statements on the benefit to their patients. Clinicians strongly agree when asked if they would like to see the program continue and if they receive useful resources to use in caring for their older patients. Below are ratings for two modules.

RATINGS* FOR ATRIAL FIBRILLATION MODULE (JULY 2015)

Please rate how strongly you agree or disagree with the following statements. 5 = Strongly Agree; 3 = Neutral; 1 = Strongly Disagree

The PACE academic detailer. . .

PERCENT OF

RESPONDENTS (N=311)

5 4 3 2 1

discussed the benefits of anticoagulation in reducing the risk of stroke, especially in elderly patients with atrial fibrillation.

98 2 0 0 0

explained the assessment tools and how I can use them to select therapy. 98 2 0 0 0

presented evidence on the efficacy and safety of the novel oral anticoagulants and how they compare to warfarin.

98 2 0 0 0

the PACE academic detailer provide current, non-commercial, evidence-based information that enables me to improve patient care.

97 3 0 0 0

the PACE academic detailing program has impacted the way I make clinical decisions in caring for my older patients.

90 9 1 0 0

information provided by the PACE academic detailing program benefits the well-being of my patients.

96 4 0 0 0

*Rating results are available for other modules.

Additional comments: Very helpful and concise; excellent presentation; clinical educator does an excellent job and is very clinically astute; useful charts; great information and handouts; great discussion; great representative.

104

RATINGS* FOR URINARY INCONTINENCE MODULE (MARCH 2015)

Please rate how strongly you agree or disagree with the following statements. 5 = Strongly Agree; 3 = Neutral; 1 = Strongly Disagree

The PACE academic detailer. . .

PERCENT OF

RESPONDENTS (N=336)

5 4 3 2 1

defined the impact of incontinence on patients’ risks for falls, depression and nursing home admission.

95 4 0 0 0

discussed reversible causes of incontinence, such as medications. 94 6 0 0 0

provided useful resources for patients that I can use in my practice. 96 4 0 0 0

the PACE academic detailer provide current, non-commercial, evidence-based information that enables me to improve patient care.

96 4 0 0 0

the PACE academic detailing program has impacted the way I make clinical decisions in caring for my older patients.

88 11 1 0 0

information provided by the PACE academic detailing program benefits the well-being of my patients.

94 5 0 0 0

*Rating results are available for other modules. Timely Education Heart failure: managing risk and improving patient outcomes launched in November 2015. This module updated clinicians on the American College of Cardiology Foundation and American Heart Association heart failure stages. The module was very timely, as a medication for reduced ejection fraction heart failure was recently approved. Given the focus on heart failure in quality metrics, namely readmissions, this topic was well received in the field. Clinicians appreciated the patient education, both the patient brochure and the lifestyle tear off.

Qualitative Feedback At the end of each educational session, the academic detailer records specifics on how the messages were received by the prescriber. This provides Alosa with valuable insight on the program, and helps the clinical educator reflect on how they presented the message so that they can engage in continuous quality improvement. Below are comments from clinicians participating in the program, noted by the clinical educators. Feedback on other modules is available from the PACE Program office. Heart Failure: Managing Risk and Improving Patient Outcomes She said that the evidence presented was very informative. She said she had never been exposed to his type of content other than at conferences and felt this is a great program, unlike pharmaceutical representatives. Practitioner liked the update on the new terminology and familiar with the staging as used in EMR; had not been detailed on the new medications and appreciated the detail on the studies and the algorithm for treatment line option of these new agents; has not had any cardiologist prescribe either medication and feels cost is a factor; liked the cost chart and amazed at the difference between brand and generic medications.

105

He does see heart failure patients in his office within seven days after discharge from the hospital. Practitioner will use the patient education tear-off pads; heard of the new drugs but had not used them. He was interested in the cost chart; he finds cost keeps so many patients from being compliant. He appreciates having PACE/PACENET applications and posters with the phone number to call to apply and had them in his office. He looks forward to next topic. Prescriber liked the detail on the new heart failure agents and was not aware there was a new class of agents. Liked the detail in the evidence document; commented the algorithm is helpful for treatment line of new agents; liked the new terminology and staging, as well as, the patient tear-off and weight log. She liked the algorithm and felt it was very easy to follow. She did not know about the two new medications; we talked about their category and where they fit into the algorithm. She liked the tear-offs and felt there is a lot of education when dealing with this disease. She feels compliance is an obstacle when dealing with this disease. Atrial Fibrillation--Anticoagulation: A Key Strategy—Slow(er), Even If Not Steady, Wins the Race She felt the screening tool was very good and was familiar with the CHADs2 scoring but had not heard of the CHADS-VASc scoring. She also admitted she was wary of bleeding and was very interested in the HASBLED screening tool. She felt this was a very helpful module and would consider anticoagulation sooner. Physician Assistant expressed how helpful she finds these visits and reports she used the heart failure materials but lost her packet. I provided her with another copy. We then reviewed the atrial fibrillation (AF) reference card on CHADS-VASc and HASBLED. She expressed again how timely and useful these modules are. She noted that she is more comfortable with prescribing. Prescriber liked topic information. She usually sends her patients to cardiology to have them direct the care, then she will follow them and prescribe as the cardiologist directs. Many of her patients are elderly with complex conditions, so many of them are already going to a specialist of some type. She agrees with the rate control, however, for the rhythm control she does send out. She doesn't want to prescribe these medications as they are too complex. She likes the patient education brochures and has many types on display in her office. She is knowledgeable about disease and management. Warfarin has been working out well for her patients although aware of NOACs, but prefers the warfarin. She said she will read thoroughly and looks forward to next topic/meeting. Visit Metrics The table and map below show the total number of educational visits by the provider types educated and by location. There were 79 practitioners who were new to the program in 2015. As the primary target for the program, physicians continue to represent the majority of prescribers taking part in the program. However, nurse practitioners and physician assistants are visited as well.

EDUCATIONAL VISITS

PRESCRIBER TYPE JUL 2015 -JUN 2016

Physician 1,842Physician Assistant 319Nurse Practitioner 387Total 2,548

106

NUMBER OF UNIQUE PRESCRIBERS VISITED IN 2014 AND 2015

107

APPENDIX B

THE PACE/PACENET MEDICAL EXCEPTION PROCESS BACKGROUND: Act 134-96, the State Lottery Law, requires publication and dissemination of the medical exception process used by the Department of Aging for the Pharmaceutical Assistance Contract for the Elderly (PACE) and for the Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET). Specifically, the legislation addresses the medical exception process with regard to generic substitution when an A-rated therapeutically equivalent medication is available. The law further requires that the Department of Aging distribute the medical exception process to providers and recipients in the Program. THE MEDICAL EXCEPTION PROCESS: Through the online claims processing system, the PACE/PACENET Program provides prospective therapeutic review of prescriptions before the pharmacist dispenses the medication to the cardholder. The review checks for potential drug interactions, duplicative therapies, over-utilization, under-utilization and other misutilization. The Department of Aging, of course, recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. A medical exception will be considered by the Program when the cardholder’s physician indicates the diagnosis, medical rationale, anticipated therapeutic outcomes, the expected length of exception therapy, and the last trial at alternative therapy. Act 134-96 requires a pharmacist to dispense the A-rated, therapeutically equivalent, generic drug to the cardholder if they have a prescription for a multi-source brand product. If a cardholder seeks an exception to this mandate, a pharmacist may request a short term medical exception at the time of dispensing by calling 1-800-835-4080. The PACE Program may grant a 30-day medical exception if requested. Immediately following approval of the exception, the Program sends a follow-up letter to the cardholder’s prescribing physician. This letter serves as notice that the Program granted a temporary medical exception to the mandatory substitution requirement. The letter seeks the therapeutic rationale for continuing the medical exception. The Program allows 30 days for the return of the written medical exception request from the prescriber. If the Program does not receive written documentation, the short term medical exception will expire. If the prescriber does respond to the letter and provides appropriate information, the Program may grant a longer medical exception period. The cardholder may continue to obtain the brand medication without paying the extra cost of a generic differential. The Program may refer a request to a physician consultant or to a therapeutics committee for special review and consideration. The cardholder will receive a short term medical exception until completion of the review process. If the Program denies a request for a medical exception to the mandatory generic requirement, the cardholder may opt to continue using the brand multi-source product and, then, pay the generic differential. If this occurs, the pharmacist must collect the copay for the brand name product plus 70 percent of the average wholesale price of the brand name product from the cardholder. Please direct questions regarding the implementation of the medical exception process to 1-800-835-4080 or in writing to: Mr. Thomas M. Snedden Director, Bureau of Pharmaceutical Assistance Pennsylvania Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919 Source: Pennsylvania Bulletin, Vol. 26, No. 52, December 28, 1996; address change December 8, 1997.

108

APPENDIX C AMERICAN HOSPITAL FORMULARY SERVICE (AHFS) CLASSIFICATIONS

FOR THERAPEUTIC CLASSES USED IN REPORT The American Hospital Formulary Service (AHFS) provides a universal standard of drug classification. Listed below are the AHFS classifications corresponding to the drug classes reported in the tables and figures of this report.

Name of Therapeutic Class AHFS Classification Anti-infective agents 08 Quinolones 08:12.18 Cephalosporins 08:12.06 Antineoplastic agents 10 Autonomic drugs 12 Anticholinergics 12:08 Adrenergic agents 12:12 Blood formation and coagulation agents 20 Cardiovascular drugs 24 Cardiac drugs 24:04 or any below Angiotensin receptor blockers 24:32.08 ACE inhibitors 24:32.04 Cardiac glycosides 24:04.08 Antiarrhythmic agents 24:04.04 Beta blockers 24:24 Calcium channel blockers 24:28 Lipid-lowering agents 24:06 Antihypertensive agents 24:08, 20 Vasodilating agents 24:12 Analgesics/antipyretics 28:08 NSAID's/COX-2 Inhibitors 28:08.04 Opiate agonists 28:08.08 Psychotropic drugs 28:12,16, 20, 24, 28 Anxiolytics, sedatives, hypnotics 28:24 Antidepressants 28:16.04 Antipsychotic agents 28:16.08 Replacement solutions 40:12 Diuretics 40:28, 24:32.20, 52:40.12 Loop diuretics 40:28.08 Thiazide diuretics 40:28.20, 24 Potassium-sparing diuretics 40:28.16, 24:32.20 Respiratory tract agents 48 Eye, ear, nose and throat preparations 52 Gastrointestinal agents 56 H2-receptor antagonists (H2RA's) 56:28.12 Proton pump inhibitors 56:28.36 Miscellaneous anti-ulcer agents 56:28.28, 56:28.32 Hormones and synthetic substances 68 Adrenals and comb. 68:04 Estrogens and comb. 68:16.04 and selected other products Antidiabetic agents (including insulin) 68:20 Thyroid and antithyroid agents 68:36 Drugs for osteoporosis multiple classes (68:16.12, 68:24, 92:24) Theophylline and related smooth muscle relaxants 86:16

SOURCE: AHFS Drug Information

109

APPENDIX D

PACE

PROSPECTIVE DRUG

UTILIZATION REVIEW

CRITERIA

Updated 9/2/2016

110

Therapeutic ClassStarting Page Therapeutic Class

Starting Page

Analgesics 112 Constipation Treatment Agents 133

Anaphylaxis Treatment 115 COX‐2 Inhibitors 133

Angiotensin Converting Enzyme Inhibitors 115 Erectile Dysfunction Agents 133

Angiotensin II Receptor Antagonists 116 Estrogen Agonist/Antagonist 134

Antibiotics 116 HCN Channel Blockers 134

Anticonvulsants 116 Histamine H2 Receptor Antagonists 134

Antidepressants 117 Inhaled Corticosteroids 135

Antihyperglycemic Agents 119 Irritable Bowel Agents 135

Antihistamines 121 Kinase Inhibitors 135

Antimetabolites 121 Laxatives 136

Antimigraine Agents 121 Lipid Lowering Agents 137

Anti‐Obesity Agents 122 Lipid Lowering Bile Acid Sequestrants 137

Antiplatelet Agents 123 Lipid Lowering Combinations 137

Antipsychotics 123 Non‐Steroidal Anti‐Inflammatory Agents 138

Arterial Hypertension Treatment Agents 125 Obsessive‐Compulsive Disorder Agent 140

Benign Prostatic Hyperplasia Treatment 125 Oncomycosis Treatment Agents 140

Benzodiazepines and Misc. Sedative/Hypnotics 126 Oral Anticoagulants 140

Beta Blockers 129 Parkinson's Disease Treatment Agents 140

Bisphosphonates 130 Proton Pump Inhibitors/Misc. GI Agents 141

Calcium Channel Blockers 130 Misc. Sedative/Hypnotics (Non‐Benzodiazepine) 142

Calcium Phosphate Binders 131 Skeletal Muscle Relaxants 142

Cardiac Glycosides 131 Smoking Cessation Agents 143

Cholinesterase Inhibitors 131 Vaccines 143

CNS Stimulants 132 Wakefulness Promoting Agents 143

Therapeutic Classes for Prospective Drug Utilization Review

111

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Qua

ntity

Date

Begun

Acetaminophen

/

Codeine

Combinations

No Criteria

‐‐‐

Less than

or eq

ual

to 4000 m

g/day

5/13/2002

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Buprenorphine

(Belbuca)

No Criteria

‐‐‐

Less than

or eq

ual

to 600 m

cg/day

7/5/2016

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Butalbital and

combinations

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Butorphanol

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Cocaine

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Codeine and

Chlorphen

iram

ine

(Tuzistra XR)

No Criteria

‐‐‐

Less than

or eq

ual

to 20 m

g/day

7/5/2016

No Criteria

‐‐‐

90 days

out of 120

7/5/2016

No Criteria

‐‐‐

‐‐‐

Codeine and

combinations

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Fentanyl buccal

(Fen

tora)

No Criteria

‐‐‐

No Criteria

‐‐‐

Tablets greater than

100/m

cg m

ust show

conversion from Actiq

6/3/2009

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Fentanyl Citrate

(Actiq)

6 Units

10/18/2004

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

48 Units in 30

days

10/18/2004

‐‐‐

Fentanyl

Sublingual

(Subsys)

100 m

cg5/6/2013

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

4 doses per day

5/6/2013

‐‐‐

Fentanyl

Transdermal

(Duragesic)

No Criteria

‐‐‐

No Criteria

‐‐‐

Patches greater than

50 m

cg m

ust show

prior conversion with

opiate.

10/27/2004

90 days

out of 120

3/8/2016

10 patches in

30 days. Dose

increase will

permit an

additional 10

patches.

10/18/2004

‐‐‐

Analgesics ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Dup

licate

Therap

y an

d Duration

Max Duration

Max Qua

ntity

Drug Nam

e Gen

eric (B

rand

)

Initial Qua

ntity

Maxim

um Daily Dose

Plan

Protocol

112

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Qua

ntity

Date

Begun

Nalbuphine

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Hydrocodone and

combinations

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Hydrocodone and

Ibuprofen

(Vicoprofen)

No Criteria

‐‐‐

Less than

or eq

ual

to 37.5 m

g/day

4/22/1998

No Criteria

‐‐‐

10 days

out of 30

4/22/1998

No Criteria

‐‐‐

‐‐‐

Hydrocodone

extended

release

(Hysingla ER

)

No Criteria

‐‐‐

No Criteria

‐‐‐

Must have used an

opiate within last 90

days. Also m

ust be

taking opiate 7 days

prior to taking

Hyslinga ER.

8/27/2015

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Hydromorphone

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Levorphanol

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Mep

eridine and

combinations

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Methadone

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Morphine Sulfate

(Kadian, V

arious)

No Criteria

‐‐‐

No Criteria

‐‐‐

Must show prior

conversion with

opiate before

reim

bursem

ent of 200

mg extended

release

tab.

10/18/2004

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Opium and

combinations

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐


ria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric (B

rand

)

Initial Qua

ntity

Maxim

um Daily Dose

Plan

Protocol

Max Duration

Max Qua

ntity

Dup

licate

Therap

y an

d Duration

113

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Qua

ntity

Date

Begun

Oxycodone/acet

(Xartemis XR)

No Criteria

‐‐‐

Less than

or eq

ual

to 4 tabs/day

5/29/2015

No Criteria

‐‐‐

30 days

out of 120

5/29/2015

No Criteria

‐‐‐

With other

long acting

opiates

Oxycodone

combinations

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Oxycontin

No Criteria

‐‐‐

Less than

or eq

ual

to 320 m

g/day

3/29/2004

No Criteria

‐‐‐

180 days

out of 210

10/18/2004

No Criteria

‐‐‐

With other

long acting

opiates

Oxymorphone

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

With other

long acting

opiates

Pen

tazocine

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Propoxyphen

e

HCl (Darvon)

No Criteria

‐‐‐

Less than

or eq

ual

to 390 m

g/day

5/13/2002

No Criteria

‐‐‐

90 days

out of 120

3/22/2016

No Criteria

‐‐‐

‐‐‐

Propoxyphen

e

napsylate

(Darvocet)

No Criteria

‐‐‐

Less than

or eq

ual

to 600 m

g/day

5/13/2002

No Criteria

‐‐‐

90 days

out of 120

3/22/2016

No Criteria

‐‐‐

‐‐‐

Tapen

tadol

(Nucynta)

No Criteria

‐‐‐

Less than

or eq

ual

to 600 m

g/day

12/14/2010

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

300 m

g daily

if over 75

years of age

12/4/1997

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

400 m

g daily

if under 75

years of age

12/4/1997

No Criteria

‐‐‐

No Criteria

‐‐‐

90 days

out of 120

3/8/2016

No Criteria

‐‐‐

‐‐‐

Tram

adol/

acetam

inophen

(Ultracet)

No Criteria

‐‐‐

Less than

or eq

ual

to 300 m

g/day

8/20/2003

No Criteria

‐‐‐

5 days out

of 30

8/20/2003

No Criteria

‐‐‐

‐‐‐

Max Qua

ntity

Dup

licate

Therap

y an

d Duration

Tram

adol

(Ultram)


ria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric (B

rand

)

Initial Qua

ntity

Maxim

um Daily Dose

Plan

Protocol

Max Duration

114

MG per day

Date Be

gun

MG per day

Date Be

gun

Date Be

gun

No Criteria

‐‐‐

No Criteria

‐‐‐

8/19/2003

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Ben

azep

ril

(Lotensin)

Less than

or eq

ual

to 20 m

g/day

8/1/2016

Less than

or eq

ual

to 80 m

g/day

5/15/1999

Concurren

t with other

ACE Inhibitors

5/15/1999

No Criteria

‐‐‐

Captopril

(Capoten)

Less than

or eq

ual

to 75 m

g/day

8/1/2016

Less than

or eq

ual

to 450 m

g/day

5/15/1999

Concurren

t with other

ACE Inhibitors

5/15/1999

No Criteria

‐‐‐

Enalapril

(Vasotec)

Less than

or eq

ual

to 5 m

g/day

8/1/2016

Less than

or eq

ual

to 40 m

g/day

10/18/1995

Concurren

t with other

ACE Inhibitors

10/22/1996

No Criteria

‐‐‐

Fosinopril

(Monopril)

Less than

or eq

ual

to 20 m

g/day

8/1/2016

Less than

or eq

ual

to 80 m

g/day

10/18/1995

Concurren

t with other

ACE Inhibitors

10/22/1996

No Criteria

‐‐‐

Lisinopril

(Prinivil)

Less than

or eq

ual

to 20 m

g/day

8/1/2016

Less than

or eq

ual

to 40 m

g/day

10/18/1995

Concurren

t with other

ACE Inhibitors

10/22/1996

No Criteria

‐‐‐

Moexipril

(Univasc)

Less than

or eq

ual

to 7.5 m

g/day

8/1/2016

Less than

or eq

ual

to 30 m

g/day

1/12/1998

Concurren

t with other

ACE Inhibitors

1/12/1998

No Criteria

‐‐‐

Perindopril

(Aceon)

Less than

or eq

ual

to 4 m

g/day

8/1/2016

Less than

or eq

ual

to 16 m

g/day

5/13/2002

Concurren

t with other

ACE Inhibitors

5/13/2002

No Criteria

‐‐‐

Quinapril

(Accupril)

Less than

or eq

ual

to 20 m

g/day

8/1/2016

Less than

or eq

ual

to 80 m

g/day

10/18/1995

Concurren

t with other

ACE Inhibitors

10/22/1996

No Criteria

‐‐‐

Ram

ipril

(Altace)

Less than

or eq

ual

to 5 m

g/day

8/1/2016

Less than

or eq

ual

to 20 m

g/day

10/18/1995

Concurren

t with other

ACE Inhibitors

10/22/1996

No Criteria

‐‐‐

Trandolopril

(Mavik)

Less than

or eq

ual

to 5 m

g/day

8/1/2016

Less than

or eq

ual

to 4 m

g/day

Future 2016

Concurren

t with other

ACE Inhibitors

Future 2016

No Criteria

‐‐‐

Maxim

um Daily Dose

Anap

hylaxis T

reatmen

t ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Step

The

rapy

Drug Nam

e Gen

eric (B

rand

)

Epinep

hrine Injection

(AUVI‐Q)

Maxim

um In

itial Dose

Duration of The

rapy

Perio

dReimbursem

ent requires

documen

tation of inability

to use standard Epi‐Pen

.

Drug Nam

e Gen

eric (B

rand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yAn

gioten

sin Co

nvertin

g En

zyme Inhibitors ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

115

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Candesartan

(Atacand)

Less than

or eq

ual

to 16 m

g/day

8/1/2016

Less than

or eq

ual to

32 m

g/day

5/19/1999

No Criteria

‐‐‐

No Criteria

‐‐‐

Eprosartan

(Teveten

)

Less than

or eq

ual

to 400 m

g/day

8/1/2016

Less than

or eq

ual to

800 m

g/day

10/8/2001

No Criteria

‐‐‐

No Criteria

‐‐‐

Irbesartan

(Avapro)

Less than

or eq

ual

to 150 m

g/day

8/1/2016

Less than

or eq

ual to

300 m

g/day

5/15/1999

No Criteria

‐‐‐

No Criteria

‐‐‐

Losartan

(Cozaar)

Less than

or eq

ual

to 50 m

g/day

8/1/2016

Less than

or eq

ual to

100 m

g/day

4/22/1998

No Criteria

‐‐‐

No Criteria

‐‐‐

Olm

esartan

(Ben

icar)

Less than

or eq

ual

to 20 m

g/day

8/1/2016

Less than

or eq

ual to

40 m

g/day

8/19/2003

No Criteria

‐‐‐

No Criteria

‐‐‐

Telm

isartan

(Micardis)

Less than

or eq

ual

to 40 m

g/day

8/1/2016

Less than

or eq

ual to

80 m

g/day

10/8/2001

No Criteria

‐‐‐

No Criteria

‐‐‐

Valsartan

(Diovan)

Less than

or eq

ual

to 160 m

g/day

8/1/2016

Less than

or eq

ual to

320 m

g/day

8/18/1997

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Doxycycline

(Periostat)

No Criteria

‐‐‐

Less than

or eq

ual to

40 m

g/day

5/13/2002

No Criteria

‐‐‐

9 m

onths out of

every 12

5/13/2002

Rifaxim

in

(Xifaxan)

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

3 days out of

every 180

6/3/2009

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Oxcarbazep

ine

extended

release

(Oxtellar XR)

3/22/2015

Peram

panel

(Fycompa)

Less than

or eq

ual

to 2 m

g/day

10/22/2014

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

Antib

iotics ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Angioten

sin II Re

ceptor Antagon

ists ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Previous therapy required

with im

med

iate release oxcarbazep

ine (Trileptal)

Anticon

vulsan

ts ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

116

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate Be

gun

Amitriptyline

(Elavil)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

250 m

g/day

1/16/1995

No Criteria

‐‐‐

Amoxapine

(Asendin)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

300 m

g/day

1/16/1995

No Criteria

‐‐‐

Bupropion

(Aplenzin)

No Criteria

‐‐‐

Less than

or eq

ual to

348 m

g/day

12/14/2010

Bupropion

(Wellbutrin)

Less than

or eq

ual to

200 m

g/day

1/16/1995

Less than

or eq

ual to

450 m

g/day

1/16/1995

No Criteria

‐‐‐

Bupropion

(Wellbutrin XL)

Less than

or eq

ual to

300 m

g/day

2/6/1997

Less than

or eq

ual to

400 m

g/day

1/16/1995

2/6/1997

‐‐‐

Citalopram

(Celexa)

Less than

or eq

ual to

20 m

g/day

5/15/1999

Less than

or eq

ual to

40 m

g/day

5/15/1999

No Criteria

‐‐‐

Clomipramine

(Anafranil)

Less than

or eq

ual to

50 m

g/day

1/16/1995

Less than

or eq

ual to

250 m

g/day

1/16/1995

No Criteria

‐‐‐

Desipramine

(Norpramin)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

250 m

g/day

1/16/1995

No Criteria

‐‐‐

Desvenlafaxine

(Pristiq)

No Criteria

‐‐‐

Less than

or eq

ual to

50 m

g/day

12/14/2010

No Criteria

‐‐‐

Doxepin

(Sineq

uan)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

250 m

g/day

1/16/1995

No Criteria

‐‐‐

Duloxetine

(Cym

balta)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

2/11/2008

No Criteria

‐‐‐

Escitalopram

(Lexapro)

Less than

or eq

ual to

10 m

g/day

8/19/2003

Less than

or eq

ual to

20 m

g/day

8/19/2003

No Criteria

‐‐‐

Fluoxetine

(Prozac)

Less than

or eq

ual to

20 m

g/day

1/16/1995

Less than

or eq

ual to

60 m

g/day

1/16/1995

No Criteria

‐‐‐

Fluoxetine

(Prozac weekly)

Imipramine

(Tofranil)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

250 m

g/day

1/16/1995

No Criteria

‐‐‐

Antid

epressan

ts (SSR

I and

SSN

RI) ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Prior to Prozac weekly being approved, 90 days of therapy with Prozac daily is req

uired

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

Step

Therapy Req

uires use of bupropion

tablets (not T12 or T24) prior to

reim

bursem

ent

117

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate Be

gun

Isocarboxazid

(Marplan)

Less than

or eq

ual to

30 m

g/day

1/16/1995

Less than

or eq

ual to

50 m

g/day

1/16/1995

No Criteria

‐‐‐

Maprotiline

(Ludiomil)

Less than

or eq

ual to

50 m

g/day

1/16/1995

Less than

or eq

ual to

200 m

g/day

1/16/1995

No Criteria

‐‐‐

Milnacipran

(Savella)

No Criteria

‐‐‐

Less than

or eq

ual to

200 m

g/day

12/14/2010

No Criteria

‐‐‐

Mirtazapine

(Rem

eron)

Less than

or eq

ual to

15 m

g/day

8/18/1997

Less than

or eq

ual to

45 m

g/day

8/18/1997

No Criteria

‐‐‐

Nefazodone

(Serzone)

No Criteria

‐‐‐

Less than

or eq

ual to

600 m

g/day

8/28/1995

No Criteria

‐‐‐

Nortriptyline

(Pam

elor)

Less than

or eq

ual to

50 m

g/day

1/16/1995

Less than

or eq

ual to

150 m

g/day

1/16/1995

No Criteria

‐‐‐

Paroxetine

(Paxil)

Less than

or eq

ual to

20 m

g/day

1/16/1995

Less than

or eq

ual to

40 m

g/day

1/16/1995

No Criteria

‐‐‐

Paroxetine

(Paxil CR)

Less than

or eq

ual to

12.5 m

g/day

8/19/2003

Less than

or eq

ual to

50 m

g/day

8/19/2003

No Criteria

‐‐‐

Phen

elzine

(Nardil)

Less than

or eq

ual to

45 m

g/day

1/16/1995

Less than

or eq

ual to

90 m

g/day

1/16/1995

No Criteria

‐‐‐

Protriptyline

(Vivactil)

Less than

or eq

ual to

15 m

g/day

1/16/1995

Less than

or eq

ual to

40 m

g/day

1/16/1995

No Criteria

‐‐‐

Sertraline

(Zoloft)

Less than

or eq

ual to

50 m

g/day

1/16/1995

Less than

or eq

ual to

200 m

g/day

1/16/1995

No Criteria

‐‐‐

Tranylcypromine

(Parnate)

Less than

or eq

ual to

30 m

g/day

1/16/1995

Less than

or eq

ual to

60 m

g/day

1/16/1995

No Criteria

‐‐‐

Trazodone

(Desyrel)

Less than

or eq

ual to

150 m

g/day

1/16/1995

Less than

or eq

ual to

400 m

g/day

1/16/1995

No Criteria

‐‐‐

Trim

ipramine

(Surm

ontil)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

250 m

g/day

1/16/1995

No Criteria

‐‐‐

Ven

lafaxine

(Effexor)

Less than

or eq

ual to

75 m

g/day

1/16/1995

Less than

or eq

ual to

225 m

g/day

1/16/1995

No Criteria

‐‐‐

Vortioxetine

(Brintellex)

No Criteria

‐‐‐

Less than

or eq

ual to

20 m

g/day

7/5/2016

No Criteria

‐‐‐

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

Antid

epressan

ts (SSR

I and

SSN

RI) ‐ Criteria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

118

MG per day

Date

Begun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate

Begun

All agen

ts excep

t insulin

Acarbose

(Precose)

Less than

or eq

ual

to 25 m

g/day

6/20/2016

Less than

or eq

ual to

300 m

g/day

4/10/2000

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Alogliptin

(Nesina)

No Criteria

‐‐‐

Less than

or eq

ual to

25 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Alogliptin/m

etform

in

(Kazano)

No Criteria

‐‐‐

Less than

or eq

ual to

25/2000 m

g/day

Future 2016

‐‐‐

‐‐‐

No Criteria

‐‐‐

Alogliptin/pioglitazone

(Oseni)

No Criteria

‐‐‐

Less than

or eq

ual to

25/45 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Dapagliflozen

(Farxiga)

Less than

or eq

ual

to 5 m

g/day

6/20/2016

Less than

or eq

ual to

10 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

dapaglifozen and m

etform

in

extended

release

(Xigduo‐XR)

No Criteria

‐‐‐

Less than

or eq

ual to

1 tablet/day

8/27/2015

Step

therapy with dapagliflozin

or metform

in1/4/2016

No Criteria

‐‐‐

Dulaglutide

(Trulicity)

No Criteria

‐‐‐

Less than

or eq

ual to

0.5ml/week

8/27/2015

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Empagliflozin and linagliptin

(Glyxambi)

No Criteria

‐‐‐

No Criteria

‐‐‐

Step

therapy with empagliflozin

or linagliptin

1/4/2016

No Criteria

‐‐‐

Exen

atide extended

release

(Bydureon)

No Criteria

‐‐‐

Less than

or eq

ual to

2 m

g/week

Future 2016

Previous trial w

ith Byetta

required

1/4/2016

No Criteria

‐‐‐

Glim

epiride

(Amaryl)

Less than

or eq

ual

to 2 m

g/day

6/20/2016

Less than

or eq

ual to

8 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Glipizide

(Glucotrol)

Less than

or eq

ual

to 5 m

g/day

6/20/2016

Less than

or eq

ual to

40 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Glyburide

(Diabeta)

Less than

or eq

ual

to 5 m

g/day

6/20/2016

Less than

or eq

ual to

20 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Glyburide/metform

in

(Glucovance)

No Criteria

‐‐‐

Less than

or eq

ual to

20 m

g/2000 m

g/day

10/8/2001

‐‐‐

1/4/2016

No Criteria

‐‐‐

Human

Insulin

(Afrezza)

No Criteria

‐‐‐

Less than

or eq

ual to

24 units/day

Overlap

in therapy when

taken

concurren

tly with a drug to treat

asthma/COPD/smoking cessation

Antih

yperglycem

ic Agents ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

For new

therapy starts: Trial with m

etform

in or a metform

in combination product req

uired

in the last 365 days.

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Step

The

rap y

Dup

licate Th

erap

y

119

MG per day

Date

Begun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate

Begun

Linagliptin

(Tradjenta)

No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Metform

in

(Glucophage)

Less than

or eq

ual

to 1000 m

g/day

6/20/2016

Less than

or eq

ual to

2550 m

g/day

4/10/2000

‐‐‐

1/4/2016

No Criteria

‐‐‐

Metform

in/canagliflozin

(Invokamet)

No Criteria

‐‐‐

No Criteria

‐‐‐

Step

therapy with m

etform

in

and canagliflozin

1/4/2016

No Criteria

‐‐‐

Metform

in/empagliflozin

(Synjardy)

No Criteria

‐‐‐

No Criteria

‐‐‐

‐‐‐

‐‐‐

No Criteria

‐‐‐

Miglitol

(Glyset)

Less than

or eq

ual

to 75 m

g/day

6/20/2016

Less than

or eq

ual to

300 m

g/day

4/10/2000

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Nateglinide

(Starlix)

No Criteria

‐‐‐

Less than

or eq

ual to

360 m

g/day

10/8/2001

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Pioglitazone

(Actos)

Less than

or eq

ual

to 30 m

g/day

6/20/2016

Less than

or eq

ual to

45 m

g/day

10/8/2001

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Pioglitazone/glim

epride

(Duetact)

Less than

or eq

ual

to 30/2 m

g/day

6/20/2016

Less than

or eq

ual to

30/4 m

g/day

6/2/2009

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Rep

aglinide

(Prandin)

Less than

or eq

ual

to 6 m

g/day

6/20/2016

Less than

or eq

ual to

16 m

g/day

4/10/2000

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Rosiglitazone

(Avandia)

Less than

or eq

ual

to 4 m

g/day

6/20/2016

Less than

or eq

ual to

8 m

g/day

4/10/2000

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

'No Criteria

‐‐‐

Rosiglitazone and combinations

(Avandia, A

vandam

et,

Ad

lL

i)

No Criteria

‐‐‐

No Criteria

‐‐‐

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Rosaglitazone/glim

epiride

(Avandaryl)

Less than

or eq

ual

to 4/1 m

g/day

6/20/2016

Less than

or eq

ual to

8/4 m

g/day

Future 2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Rosiglitazone/metform

in

(Avandam

et)

No Criteria

‐‐‐

Less than

or eq

ual to

8/2000 m

g/day

Future 2016

‐‐‐

‐‐‐

No Criteria

‐‐‐

Sagliptin

(Onglyza)

No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day

12/14/2010

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Sitagliptin

(Januvia)

No Criteria

‐‐‐

Less than

or eq

ual to

100 m

g/day

7/5/2016

Trial w

ith m

etform

in req

uired

in

the last 365 days

1/4/2016

No Criteria

‐‐‐

Antih

yperglycem

ic Agents ‐ Criteria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Step

The

rap y

Dup

licate Th

erap

y

120

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Cetirizine

(Zyrtec, Zyrtec‐D)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

8/19/2003

Concurren

t with other

antihistamines

8/19/2003

No Criteria

‐‐‐

Desloratadine

(Clarinex, Clarinex‐D)

No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day

8/19/2003

Concurren

t with other

antihistamines

8/19/2003

No Criteria

‐‐‐

Fexofenadine

(Allegra, Allegra‐D)

No Criteria

‐‐‐

Less than

or eq

ual to

120 m

g/day

8/19/2003

Concurren

t with other

antihistamines

8/19/2003

No Criteria

‐‐‐

Fexofenadine

(Allegra, 180 m

g

strength tablet)

No Criteria

‐‐‐

Less than

or eq

ual to

180 m

g/day

8/19/2003

Concurren

t with other

antihistamines

8/19/2003

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Date Be

gun

No Criteria

‐‐‐

No Criteria

‐‐‐

6/8/2015

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Alm

atriptan

(Axert)

No Criteria

‐‐‐

Less than

or eq

ual to

25 m

g/day

8/19/2003

Concurren

t with other

antimigraines

8/19/2003

4 days out of

every 30

3/13/2000

Dihydroergotamine

(Migranal)

No Criteria

‐‐‐

Less than

or eq

ual to

2 bottles daily

8/19/2003

Concurren

t with other

antimigraines

8/19/2003

4 days out of

every 30

3/13/2000

Eletriptan

(Relpax)

No Criteria

‐‐‐

Less than

or eq

ual to

40 m

g/day

3/29/2004

Concurren

t with other

antimigraines

8/19/2003

3 days out of

every 30

3/13/2000

Frovatriptan

(Frova)

No Criteria

‐‐‐

Less than

or eq

ual to

7.5 m

g/day

8/19/2003

Concurren

t with other

antimigraines

8/19/2003

4 days out of

every 30

3/13/2000

Methysergide maleate

(Sansert)

No Criteria

‐‐‐

Less than

or eq

ual to

8 m

g/daily

8/19/2003

Concurren

t with other

antimigraines

8/19/2003

150 days out of

every 180

3/13/2000

Naratriptan

(Amerge)

3/13/2000

Rizatriptan

(Maxalt, M

axalt MLT)

No Criteria

‐‐‐

Less than

or eq

ual to

30 m

g/day

8/19/2003

Concurren

t with other

antimigraines

8/19/2003

4 days out of

every 30

3/13/2000

Sumitriptan and naproxen

(Treximet)

3/13/2000

Zolm

itriptan

(Zomig, ZMT)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

8/19/2003

Concurren

t with other

antimigraines

8/19/2003

3 days out of

every 30

3/13/2000

Antim

etab

olite

s ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Antih

istamines ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Perio

dMust try oral m

ethotrexate

prior to reimbursem

ent of

Rasuvo

or Otrexup

Sub Q M

ethotrexate

(Rasuvo, O

trexup)

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Step

The

rapy

Not Recommen

ded

for the Elderly

Not indicated

in the elderly

Antim

igraine Ag

ents ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

121

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Class

Date Be

gun

Bupropion/N

altrexone

(Contrave)

No Criteria

‐‐‐

No Criteria

‐‐‐

Documen

t at least 5%

weight loss after

12 weeks

2/2/2015

Concurren

t with other

weight loss agents

Future 2016

Diethylpropion

(Ten

uate)

No Criteria

‐‐‐

Less than

or

equal to 100

mg/day

7/26/1999

60 days out of

every 120

8/9/1999

Concurren

t with other

weight loss agents

Future 2016

Lorcaserin HCL

(Belviq)

No Criteria

‐‐‐

No Criteria

‐‐‐

Documen

t at least 5%

weight loss after

12 weeks

‐‐‐

Concurren

t with other

weight loss agents

Future 2016

Orlistat

(Xen

ical)

No Criteria

‐‐‐

Less than

or

equal to 360

mg/day

7/26/1999

60 days out of

every 90

8/9/1999

Concurren

t with other

weight loss agents

Future 2016

Phen

dim

etrazine

(Bontril)

No Criteria

‐‐‐

Less than

or

equal to 105

mg/day

7/26/1999

60 days out of

every 120

8/9/1999

Concurren

t with other

weight loss agents

Future 2016

Phen

term

ine HCL

(Adipex‐P)

No Criteria

‐‐‐

Less than

or

equal to 37.5

mg/day

7/26/1999

60 days out of

every 120

8/9/1999

Concurren

t with other

weight loss agents

Future 2016

Phen

term

ine HCL

(Suprenza)

No Criteria

‐‐‐

No Criteria

‐‐‐

Documen

t at least 5%

weight loss after

12 weeks

‐‐‐

Concurren

t with other

weight loss agents

Future 2016

Phen

term

ine/To

piram

ate

(Qsymia)

No Criteria

‐‐‐

8/28/2013

Concurren

t with other

weight loss agents

Future 2016

Sibutram

ine

(Meridia)

No Criteria

‐‐‐

Less than

or

equal to 30

mg/day

7/26/1999

60 days out of

every 90

8/9/1999

Concurren

t with other

weight loss agents

Future 2016

Anti‐Obe

sity Agents ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um Daily Dose

Duration of The

rapy

Refer to m

anufacturer recommen

dations for dose

titration as well as weight loss related

to use at each

dose

Dup

licate Th

erap

yMaxim

um In

itial Dose

122

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Aspirin/dipyridam

ole

(Aggrenox)

No Criteria

‐‐‐

Less than

or eq

ual to

50 m

g/400 m

g/day

10/8/2001

No Criteria

‐‐‐

No Criteria

‐‐‐

Cilostazol

(Pletal)

No Criteria

‐‐‐

Less than

or eq

ual to

200 m

g/day

4/10/2000

No Criteria

‐‐‐

No Criteria

‐‐‐

Clopidogrel bisulfate

(Plavix)

No Criteria

‐‐‐

Less than

or eq

ual to

75 m

g/day

10/8/2001

No Criteria

‐‐‐

No Criteria

‐‐‐

Dipyridam

ole

(Persantine)

No Criteria

‐‐‐

Less than

or eq

ual to

400 m

g/day

concurren

t with

warfarin

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Prasugrel

(Effient)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Ticagrelor

(Brilinta)

No Criteria

‐‐‐

Less than

or eq

ual to

180 m

g/day for 1 year

then

120 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Ticlopidine

(Ticlid)

No Criteria

‐‐‐

Less than

or eq

ual to

500 m

g/day

5/15/1999

No Criteria

‐‐‐

No Criteria

‐‐‐

Vorapaxar

(Zontivity)

No Criteria

‐‐‐

Less than

or eq

ual to

2.08 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Aripiprazole

(Abilify)

No Criteria

‐‐‐

Less than

or eq

ual to

15 m

g/day

8/19/2003

No Criteria

‐‐‐

No Criteria

‐‐‐

Aripiprazole, Ext. Release

Injectible

(Abilify M

aintena)

5/13/2013

No Criteria

‐‐‐

Cariprazine

(Vraylar)

No Criteria

‐‐‐

Less than

or eq

ual to

6 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Chlorpromazine

(Thorazine)

Less than

or eq

ual

to 50 m

g/day

1/16/1995

Less than

or eq

ual to

200 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Clozapine

(Clozaril)

Less than

or eq

ual

to 25 m

g/day

1/16/1995

Less than

or eq

ual to

100 m

g/day

8/18/1997

No Criteria

‐‐‐

No Criteria

‐‐‐

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Reimbursem

ent required

documen

tation of inability to use Abilify.

Antip

sychotics ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Antip

latelet A

gents ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

123

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Fluphen

azine

(Prolixin)

Less than

or eq

ual

to 1 m

g/day

1/16/1995

Less than

or eq

ual to

10 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Haloperidol

(Haldol)

Less than

or eq

ual

to 1 m

g/day

1/16/1995

Less than

or eq

ual to

10 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Loxapine

(Loxitane)

Less than

or eq

ual

to 20 m

g/day

1/16/1995

Less than

or eq

ual to

100 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Mesoridazine

(Seren

til)

Less than

or eq

ual

to 30 m

g/day

1/16/1995

Less than

or eq

ual to

125 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Olanzapine

(Zyprexa)

Less than

or eq

ual

to 2.5 m

g/day

8/18/1997

Less than

or eq

ual to

10 m

g/day

8/18/1997

No Criteria

‐‐‐

No Criteria

‐‐‐

Paliperidone

(Invega)

No Criteria

‐‐‐

Less than

or eq

ual to

12 m

g/day

6/2/2009

No Criteria

‐‐‐

No Criteria

‐‐‐

Paliperidone palmitate

(Invega Trinza)

11/16/2015

No Criteria

‐‐‐

Perphen

azine

(Trilafon)

Less than

or eq

ual

to 8 m

g/day

1/16/1995

Less than

or eq

ual to

24 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Quetiapine

(Seroquel)

Less than

or eq

ual

to 50 m

g/day

4/22/1998

Less than

or eq

ual to

400 m

g/day

4/22/1998

No Criteria

‐‐‐

No Criteria

‐‐‐

Risperidone

(Risperdal & Risperdal‐M

)

Less than

or eq

ual

to 0.5 m

g/day

1/16/1995

Less than

or eq

ual to

6 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Thioridazine

(Mellaril)

Less than

or eq

ual

to 50 m

g/day

1/16/1995

Less than

or eq

ual to

200 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Thiothixen

e

(Navane)

Less than

or eq

ual

to 4 m

g/day

1/16/1995

Less than

or eq

ual to

20 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Trifluoperazine

(Stelazine)

Less than

or eq

ual

to 2 m

g/day

1/16/1995

Less than

or eq

ual to

10 m

g/day

1/16/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

Ziprasidone

(Geo

don)

No Criteria

‐‐‐

160 m

g per day Oral

40 m

g/day IM

8/19/2003

No Criteria

‐‐‐

No Criteria

‐‐‐

Duration of The

rapy

Antip

sychotics ‐ Criteria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

Must use Invega Susten

na for 4 m

onths prior to Invega Trinza being approved.

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

124

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Ambrisentan

(Letairis)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Bosentan

(Tracleer)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Epoprosten

ol

(Veletri/flolan)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Iloprost

(Ven

tavis)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Maciten

tan

(Opsumit)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Riociguat

(Adem

pas)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Selexipag

(Uptravi)

No Criteria

‐‐‐

Max dose is

3200 m

cg/day

7/5/2016

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

12/28/2015

No Criteria

‐‐‐

Silden

afil

(Revatio)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

Tadalafil

(Adcirca)

No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t with other

agen

ts used to treat

pulm

onary arterial

10/14/2014

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Male/Female

Date Be

gun

Alfuzosin

(Uroxatral)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

Future 2016

No Criteria

‐‐‐

Male

2/22/2007

Doxazosin

(Cardura)

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

Male

2/22/2007

Agen

ts to

Treat Arterial H

ypertension ‐ C

riteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Agen

ts to

Treat Ben

ign Prostatic

Hyperplasia ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yGen

der E

dit

125

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Male/Female

Date Be

gun

Dutasteride

(Avodart)

No Criteria

‐‐‐

Less than

or eq

ual to

0.5 m

g/day

Future 2016

No Criteria

‐‐‐

Male

2/22/2007

Finasteride

(Proscar)

No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day

Future 2016

No Criteria

‐‐‐

Male

2/22/2007

Silodosin

(Rapaflo)

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

Male

11/5/2009

Tamsulosin HCI

(Flomax)

No Criteria

‐‐‐

Less than

or eq

ual to

0.8 m

g/day

Future 2016

No Criteria

‐‐‐

Male

1/4/2007

Dutasteride/

Tamsulosin

(Jalyn)

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

Male

4/21/2012

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Perio

dDate Be

gun

Alprazolam

(Xanax)

Less than

or eq

ual to

0.75 m

g/day

1/16/1995

Less than

or eq

ual to

3 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Alprazolam

(Xanax XR)

Less than

or eq

ual to

0.5 m

g/day

3/29/2004

Less than

or eq

ual to

6 m

g/day

3/29/2004

No Criteria

Chlordiazepoxide

(Librium)

Less than

or eq

ual to

20 m

g/day

1/16/1995

Less than

or eq

ual to

100 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Clonazep

am

(Klonopin)

Less than

or eq

ual to

1 m

g/day

1/16/1995

Less than

or eq

ual to

4 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Only for Panic Disorder

Benzod

iazepine


ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Agen

ts to

Treat Ben

ign Prostatic

Hyperplasia ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yGen

der E

dit

126

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Perio

dDate Be

gun

Clorazepate

(Tranxene)

Less than

or eq

ual to

15 m

g/day

1/16/1995

Less than

or eq

ual to

60 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Diazepam

(Valium)

Less than

or eq

ual to

5 m

g/day

1/16/1995

Less than

or eq

ual to

40 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Halazep

am

(Paxipam

)

Less than

or eq

ual to

40 m

g/day

1/16/1995

Less than

or eq

ual to

40 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Lorazepam

(Ativan)

Less than

or eq

ual to

2 m

g/day

1/16/1995

Less than

or eq

ual to

6 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Oxazepam

(Serax)

Less than

or eq

ual to

30 m

g/day

1/16/1995

Less than

or eq

ual to

60 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate

Begun

Class

Date Be

gun

Estazolam

(Prosom)

Less than

or eq

ual to

1 m

g/day

1/16/1995

Less than

or eq

ual to

2 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Eszopiclone

(Lunesta)

No Criteria

‐‐‐

Less than

or eq

ual to

2 m

g/day

2/19/2007

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

10/25/2005

Flurazepam

(Dalmane)

Less than

or eq

ual to

15 m

g/day

1/16/1995

Less than

or eq

ual to

30 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Benzod

iazepine

s/Miscellane

ous S

edative/Hypno

tics ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Duration of The

rapy

Dup

licate Th

erap

y

Benzod

iazepine


ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

127

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate

Begun

Class

Date Be

gun

Quazep

am

(Doral)

Less than

or eq

ual to

15 m

g/day

1/16/1995

Less than

or eq

ual to

15 m

g/day

1/16/1995

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Ram

elteon

(Rozerem)

No Criteria

‐‐‐

Less than

or eq

ual to

8 m

g/day

2/19/2007

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

10/25/2005

Temazep

am

(Restoril)

Less than

or eq

ual to

7.5 m

g/day

3/1/1994

Less than

or eq

ual to

15 m

g/day

3/1/1994

240 m

g/6 m

os

3/1/1994

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Triazolam

(Halcion)

Less than

or eq

ual to

.125 m

g/day

1/31/1992

Less than

or eq

ual to

.25 m

g/day

1/31/1992

4 m

g/6 m

os

1/31/1992

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

3/13/2000

Zolpidem

(Ambien)

Less than

or eq

ual to

5 m

g/day

1/16/1995

Less than

or eq

ual to

5 m

g/day

7/5/2016

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

10/25/2005

Zolpidem

(Ambien CR)

No Criteria

‐‐‐

Less than

or eq

ual to

6.25 m

g/day

11/1/2005

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

10/25/2005

Zolpidem

(Edluar)

12/14/2010

Zolpidem

(Interm

ezzo)

No Criteria

‐‐‐

Less than

or eq

ual to

1.75 m

g/day

7/5/2016

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

10/25/2005

Zaleplon

(Sonata)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

2/19/2007

No Criteria

‐‐‐

Concurren

t

Ben

zodiazepines and

Misc Sed/Hypnotics

10/25/2005

Step

Therapy Documen

tation req

uired

as to need for sublingual dosage form

Benzod

iazepine

s/Miscellane

ous S

edative/Hypno


ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Duration of The

rapy

Dup

licate Th

erap

y

128

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Acebutolol

(Sectral)

Less than

or eq

ual to

100 m

g/day

8/8/2016

Less than

or eq

ual to

1200 m

g/day

5/15/1999

Concurren

t with other

Beta Blockers

12/9/1995

No Criteria

‐‐‐

Atenolol

(Ten

orm

in)

Less than

or eq

ual to

25 m

g/day

8/8/2016

Less than

or eq

ual to

200 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Betaxolol

(Kerlone)

Less than

or eq

ual to

5 m

g/day

8/8/2016

Less than

or eq

ual to

20 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Bisoprolol

(Zeb

eta)

Less than

or eq

ual to

5 m

g/day

8/8/2016

Less than

or eq

ual to

20 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Carteolol

(Cartrol)

Less than

or eq

ual to

2.5 m

g/day

8/8/2016

Less than

or eq

ual to

10 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Carvedilol

(Coreg)

Less than

or eq

ual to

12.5 m

g/day

8/8/2016

Less than

or eq

ual to

100 m

g/day

8/18/1997

Concurren

t with other

Beta Blockers

8/18/1997

No Criteria

‐‐‐

Carvedilol

(Coreg CR)

Less than

or eq

ual to

20 m

g/day

8/8/2016

Less than

or eq

ual to

80 m

g/day

7/5/2016

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Labetalol

(Norm

odyne)

Less than

or eq

ual to

200 m

g/day

8/8/2016

Less than

or eq

ual to

2400 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Metoprolol

(Lopressor)

Less than

or eq

ual to

50 m

g/day

8/8/2016

Less than

or eq

ual to

450 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Metoprolol

(Toprol XL)

Less than

or eq

ual to

50 m

g/day

8/8/2016

Less than

or eq

ual to

400 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Nadolol

(Corgard)

Less than

or eq

ual to

40 m

g/day

8/8/2016

Less than

or eq

ual to

320 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Pen

butolol

(Levatol)

Less than

or eq

ual to

20 m

g/day

8/8/2016

Less than

or eq

ual to

80 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Pindolol

(Visken)

Less than

or eq

ual to

10 m

g/day

8/8/2016

Less than

or eq

ual to

60 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Propranolol

(Inderal)

Less than

or eq

ual to

80 m

g/day

8/8/2016

Less than

or eq

ual to

640 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Propranolol

extended

release Le

ss than

or eq

ual to

80 m

g/day

8/8/2016

Less than

or eq

ual to

120 m

g/day

3/29/2004

Concurren

t with other

Beta Blockers

3/29/2004

No Criteria

‐‐‐

Propranolol LA

(Inderal LA)

Less than

or eq

ual to

80 m

g/day

8/8/2016

Less than

or eq

ual to

640 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Sotalol

(Betapace)

Less than

or eq

ual to

80 m

g/day

8/8/2016

Less than

or eq

ual to

320 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Timolol

(Blocadren)

Less than

or eq

ual to

20 m

g/day

8/8/2016

Less than

or eq

ual to

60 m

g/day

10/18/1995

Concurren

t with other

Beta Blockers

10/18/1995

No Criteria

‐‐‐

Beta Blockers ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

129

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Alendronate

(Fosamax)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

8/19/2003

No Criteria

‐‐‐

No Criteria

‐‐‐

Rised

ronate

(Actonel)

No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day

3/29/2004

No Criteria

‐‐‐

No Criteria

‐‐‐

Teriparatide

(Forteo

)No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day

3/29/2004

No Criteria

‐‐‐

24 M

onths

12/14/2010

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Amlodipine

(Norvasc)

Less than

or eq

ual to

2.5 m

g/day

8/8/2016

Less than

or eq

ual to

10 m

g/day

12/9/1995

Concurren

t with Other Calcium

Channel Blockers

12/9/1995

No Criteria

‐‐‐

Amlodipine & Atorvastatin

(Caduet)

Less than

or eq

ual to

10 m

g/day (based

on

Atorvastatin)

8/8/2016

Less than

or eq

ual to

80 m

g/day (based

on

Atorvastatin)

2/14/2005

Concurren


Channel Blockers

2/14/2005

No Criteria

‐‐‐

Bep

ridil

(Vascor)

Less than

or eq

ual to

200 m

g/day

8/8/2016

Less than

or eq

ual to

400 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Diltiazem

(Cardizem

)

Less than

or eq

ual to

180 m

g/day

8/8/2016

Less than

or eq

ual to

360 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Diltiazem CD

(Cardizem

CD)

Less than

or eq

ual to

180 m

g/day

8/8/2016

Less than

or eq

ual to

540 m

g/day

5/15/1999

Concurren


Channel Blockers

5/15/1999

No Criteria

‐‐‐

Felodipine

(Plendil)

Less than

or eq

ual to

2.5 m

g/day

8/8/2016

Less than

or eq

ual to

10 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Isradipine

(DynaCirc)

Less than

or eq

ual to

5 m

g/day

8/8/2016

Less than

or eq

ual to

20 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Nicardipine

(Carden

e)

Less than

or eq

ual to

60 m

g/day

8/8/2016

Less than

or eq

ual to

120 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Nifed

ipine

(Procardia)

Less than

or eq

ual to

30 m

g/day

8/8/2016

Less than

or eq

ual to

120 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Nisoldipine

(Sular)

Less than

or eq

ual to

17 m

g/day

8/8/2016

Less than

or eq

ual to

34 m

g/day

8/18/1997

Concurren


Channel Blockers

8/18/1997

No Criteria

‐‐‐

Verapam

il

(Calan, Isoptin)

Less than

or eq

ual to

240 m

g/day

8/8/2016

Less than

or eq

ual to

480 m

g/day

10/18/1995

Concurren


Channel Blockers

10/18/1995

No Criteria

‐‐‐

Bispho

spho

nates a

nd Recom

bina

nt Hum

an Parathyroid Hormon

e An

alog

‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Calcium Cha

nnel Blockers ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

130

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Sevelamer

Carbonate

(Ren

vela)

No Criteria

‐‐‐

Less than

or eq

ual to

7200 m

g/day

4/21/2008

No Criteria

‐‐‐

No Criteria

‐‐‐

Maxim

um In

itial

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Digoxin

(Lanoxin)

No Criteria

‐‐‐

Less than

or eq

ual to

0.125 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Donep

ezil

(Aricept)

Less than

or eq

ual to

5 m

g per day

5/15/1999

Less than

or eq

ual to

10 m

g/day

5/15/1999

No Criteria

‐‐‐

No Criteria

‐‐‐

Galantamine

(Rem

inyl)

Less than

or eq

ual to

8 m

g per day

5/13/2002

Less than

or eq

ual to

24 m

g/day

5/13/2002

No Criteria

‐‐‐

No Criteria

‐‐‐

Mem

antine

(Nam

enda)

Less than

or eq

ual to

5 m

g per day

2/14/2005

Less than

or eq

ual to

20 m

g/day

2/14/2005

No Criteria

‐‐‐

No Criteria

‐‐‐

Mem

antine

(Nam

enda XR)

Less than

or eq

ual to

7 m

g per day

3/2/2015

Less than

or eq

ual to

28 m

g/day

3/2/2015

No Criteria

‐‐‐

No Criteria

‐‐‐

Rivastigm

ine

(Exelon)

Less than

or eq

ual to

3 m

g per day

5/13/2002

Less than

or eq

ual to

12 m

g/day

5/13/2002

No Criteria

‐‐‐

No Criteria

‐‐‐‐

No Criteria

3/2/2015

Less than

or eq

ual to

4.6 m

g/24 hour for patch

3/2/2015

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

3/2/2015

Less than

or eq

ual to

9.5 m

g/24 hour for patch

3/2/2015

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

3/2/2015

Less than

or eq

ual to

13.3 m

g/24 hour for patch

3/2/2015

No Criteria

‐‐‐

No Criteria

‐‐‐

Duration of The

rapy

Drug Nam

e Gen

eric (B

rand

)

Rivastigm

ine

(Exelon Patch)

Dup

licate Th

erap

y

Calcium Pho

spha

te Binde

rs ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Cardiac Glycoside


ts and

Implem

entatio

n Dates

Cholinesterase In

hibitors ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Maxim

um Daily Dose

Duration of The

rapy

Drug Nam

e Gen

eric (B

rand

)Initial Qua

ntity

Maxim

um Daily Dose

Dup

licate The

rapy

131

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Amphetam

ine

dextroam

phetam

ine mixed

salts

(Adderall)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Amphetam

ine

dextroam

phetam

ine mixed

salts

(Adderall XR)

No Criteria

‐‐‐

Less than

or eq

ual to

20 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Amphetam

ine sulfate

(Evekeo)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Atomoxetine

(Strattera)

No Criteria

‐‐‐

Less than

or eq

ual to

100 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Dexmethylphen

idate hcl

(Focalin

XR)

No Criteria

‐‐‐

Less than

or eq

ual to

40 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐‐

Dextroam

phetam

ine

(Dexed

rine)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐‐

Dextroam

phetam

ine sulfate

(Zen

zedi)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Lisdexam

fetamine dim

esylate

(Vyvanse)

No Criteria

‐‐‐

Less than

or eq

ual to

70 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐‐

Metam

phetam

ine hcl

(Desoxyn)

No Criteria

‐‐‐

Less than

or eq

ual to

15 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Methylphen

idate hcl

(Methylin)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐‐

Methylphen

idate hcl

(Ritalin SR)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Methylphen

adate hcl exten

ded

release (M

etadate ER

)No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Methylphen

idate hcl exten

ded

release (M

ethylin ER)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Methylphen

idate hcl exten

ded

release (Quillichew

ER)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Methylphen

idate hcl exten

ded

release (Quillivant XR)

No Criteria

‐‐‐

Less than

or eq

ual to

60 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

CNS Stim

ulan

ts ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

132

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate

Begun

Perio

dDate Be

gun

Lubiprostone

(Amitiza)

No Criteria

‐‐‐

Less than

or eq

ual to

25 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Methylnaltrexone bromide

(Relistor)

No Criteria

‐‐‐

Less than

or eq

ual to

48 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Naloxegol

(Movantik)

No Criteria

‐‐‐

Less than

or eq

ual to

12 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

MG per day

Date

Begun

Perio

dDate Be

gun

Celecoxib

(Celeb

rex)

No Criteria

‐‐‐

Less than

or eq

ual to

400 m

g/day

4/10/2000

No Criteria

‐‐‐

Curren

t

NSA

IDS

4/10/2000

Valdecoxib

(Bextra)

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Male/

Female

Date Be

gun

Alprostadil

(Caverject)

No Criteria

‐‐‐

8 days out of

every 30

2/11/2008

Concurren

t with

other erectile

dysfunction agents

5/7/2004

Male

2/11/2008

Silden

afil Citrate

(Viagra)

Less than

or eq

ual

to 50 m

g/day

6/1/1998

8 days out of

every 30

10/18/2004

Concurren

t with

other erectile

dysfunction agents

5/7/2004

Male

10/18/2004

Tadalafil

(Cialis)

Less than

or eq

ual

to 20 m

g/day

3/15/2004

8 days out of

every 30

10/18/2004

Concurren

t with

other erectile

dysfunction agents

4/29/2008

Male

10/18/2004

Drug Nam

e Gen

eric

(Brand

)

Maxim

um Daily Dose

Maxim

um Duration

Agen

ts to

Treat Con

stipation (Both Ch

ronic an

d Opioid Indu

ced) ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um Daily Dose

Maxim

um Duration

Dup

licate Th

erap

yGen

der E

dit

Dup

licate Th

erap

y

Dup

licate Th

erap

yMaxim

um In

itial Dose

COX‐2 Inhibitors ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Erectile Dysfunctio

n Ag

ents ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Maxim

um Duration

Rem

oved from M

arket

133

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Perio

dDate

Begun

Ospem

ifen

e

(Osphen

a)No Criteria

‐‐‐

No Criteria

‐‐‐

Concurren

t use with

other estrogen products

or SERM class agents

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Perio

dDate

Begun

Ivabradine

(Colanor)

No Criteria

‐‐‐

Less than

or eq

ual

to 15 m

g/day

7/5/2016

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

Date Be

gun

MG per day

Perio

dDate

Begun

Perio

dDate

Begun

Cim

etidine

Maintenance Therapy

(Tagam

et)

No Criteria

‐‐‐

8/16/1992

Less than

or eq

ual to

1600 m

g/day

Unlim

ited

10/8/2004

Proton Pump

Inhibitors and

Concurren

t H2

8/16/1992

Famotidine

Maintenance Therapy

(Pep

cid)

No Criteria

‐‐‐

8/16/1992

Less than

or eq

ual to

40 m

g/day

Unlim

ited

10/8/2004

Proton Pump

Inhibitors and

Concurren

t H2

8/16/1992

Nizatidine

Maintenance Therapy

(Axid)

No Criteria

‐‐‐

8/16/1992

Less than

or eq

ual to

300 m

g/day

Unlim

ited

10/8/2004

Proton Pump

Inhibitors and

Concurren

t H2

8/16/1992

Ranitidine

Maintenance Therapy

(Zantac)

No Criteria

‐‐‐

8/16/1992

Less than

or eq

ual to

300 m

g/day

Unlim

ited

10/8/2004

Proton Pump

Inhibitors and

Concurren

t H2

8/16/1992

Histamine H2 R

ecep

tor A

ntagon

ists ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Estrogen

Agonist/A

ntagon

ist ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

eGen

eric (B

rand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

HCN

Cha

nnel Blockers ‐ C

riteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

eGen

eric (B

rand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Drug Nam

eGen

eric (B

rand

)

Maxim

um Daily Dose

Duration of The

rapy

Dup

licate Th

erap

yMaxim

um In

itial Dose

134

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Budesonide

(Pulm

icort‐Respules)

No Criteria

‐‐‐

Less than

or eq

ual to

1 m

g/day

6/3/2009

No Criteria

‐‐‐

MG per day

Date Be

gun

Perio

dDate Be

gun

Perio

dDate Be

gun

Alosetron

(Lotronex)

No Criteria

‐‐‐

Less than

or eq

ual to

2 m

g/day

Future 2016

Female Only

10/18/2004

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate Be

gun

Afatinib

(Gilotrif)

No Criteria

‐‐‐

Less than

or eq

ual to

40 m

g/day

Future 2016

No Criteria

‐‐‐

Axitinib

(Inlyta)

No Criteria

‐‐‐

Less than

or eq

ual to

20 m

g/day

Future 2016

No Criteria

‐‐‐

Bosutinib

(Bosulif)

No Criteria

‐‐‐

Less than

or eq

ual to

600 m

g/day

Future 2016

No Criteria

‐‐‐

Cabozantinib

(Cometriq)

No Criteria

‐‐‐

Less than

or eq

ual to

1800 m

g/day

10/14/2013

No Criteria

‐‐‐

Crizotinib

(Xalkori)

No Criteria

‐‐‐

Less than

or eq

ual to

500 m

g/day

Future 2016

No Criteria

‐‐‐

Dasatinib

(Sprycel)

No Criteria

‐‐‐

Less than

or eq

ual to

180 m

g/day

Future 2016

No Criteria

‐‐‐

Erlotinib

(Tarceva)

No Criteria

‐‐‐

Less than

or eq

ual to

150 m

g/day

Future 2016

No Criteria

‐‐‐

Gefitinib

(Iressa)

No Criteria

‐‐‐

Less than

or eq

ual to

250 m

g/day

Future 2016

No Criteria

‐‐‐

Imatinib

(Gleevec)

No Criteria

‐‐‐

Less than

or eq

ual to

800 m

g/day

Future 2016

No Criteria

‐‐‐

Lapatinib

(Tykerb)

No Criteria

‐‐‐

Less than

or eq

ual to

1500 m

g/day

Future 2016

No Criteria

‐‐‐

Inha

led Co

rticosteroids ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

Irrita

ble Bo

wel Agents ‐ C

riteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial dose

Maxim

um Daily Dose

Gen

der E

dit

Kina

se In

hibitors ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

135

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate Be

gun

Nilotinib

(Tasigna)

No Criteria

‐‐‐

Less than

or eq

ual to

800 m

g/day

Future 2016

No Criteria

‐‐‐

Nintedanib

(Ofev)

No Criteria

‐‐‐

Less than

or eq

ual to

30 m

g/day

8/29/2015

Concurren

t with

Esbriet

8/27/2015

Pazopanib

(Votrient)

No Criteria

‐‐‐

Less than

or eq

ual to

800 m

g/day

Future 2016

No Criteria

‐‐‐

Pirfenidone

(Esbriet)

No Criteria

‐‐‐

Less than

or eq

ual to

9 capsules per/day

8/29/2015

Concurren

t with

Ofev

8/27/2015

Ponatinib

(Iclusig)

No Criteria

‐‐‐

Less than

or eq

ual to

45 m

g/day

Future 2016

No Criteria

‐‐‐

Regrorafenib

(Stivarga)

No Criteria

‐‐‐

Less than

or eq

ual to

160 m

g/day

Future 2016

No Criteria

‐‐‐

Ruxolitinib

(Jakafi)

No Criteria

‐‐‐

Less than

or eq

ual to

50 m

g/day

Future 2016

No Criteria

‐‐‐

Sunitinib

(Sutent)

No Criteria

‐‐‐

Less than

or eq

ual to

50 m

g/day

Future 2016

No Criteria

‐‐‐

Tofacitinib

(Xeljanz)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

Future 2016

No Criteria

‐‐‐

Tofacitinib

(Xeljanz XR)

Less than

or eq

ual to

11 m

g/day

Future 2016

No Criteria

‐‐‐

Vandetanib

(Capresla)

No Criteria

‐‐‐

Less than

or eq

ual to

300 m

g/day

Future 2016

No Criteria

‐‐‐

Vem

urafenib

(Zelboraf)

No Criteria

‐‐‐

Less than

or eq

ual to

1920 m

g/day

Future 2016

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Sodium picosulfate,

magnesium oxide and

anhydrous citric acid

(Prepopik)

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

Xeljanz must be tried prior to using

Laxativ

es ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

Kina

se In

hibitors ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

Drug Nam

e Gen

eric (B

rand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

136

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Atorvastatin

(Lipitor)

No Criteria

‐‐‐

Less than

or eq

ual to

80 m

g/day

12/4/1997

Concurren

t HMG‐Co A

Red

uctase Inhibitors

12/4/1997

No Criteria

‐‐‐

Ezetim

ibe

(Zetia)

No Criteria

‐‐‐

Less than

or eq

ual to

10 m

g/day

3/29/2004

No Criteria

‐‐‐

No Criteria

‐‐‐

Fluvastatin

(Lescol)

No Criteria

‐‐‐

Less than

or eq

ual to

80 m

g/day

4/15/1997

Concurren

t HMG‐Co A

Red

uctase Inhibitors

4/15/1997

No Criteria

‐‐‐

Lovastatin

(Mevacor)

No Criteria

‐‐‐

Less than

or eq

ual to

80 m

g/day

4/15/1997

Concurren

t HMG‐Co A

Red

uctase Inhibitors

4/15/1997

No Criteria

‐‐‐

Pravastatin

(Pravachol)

No Criteria

‐‐‐

Less than

or eq

ual to

80 m

g/day

4/15/1997

Concurren

t HMG‐Co A

Red

uctase Inhibitors

4/15/1997

No Criteria

‐‐‐

Rosuvastatin

(Crestor)

Less than

or

equal to 5 m

g2/14/2005

Less than

or eq

ual to

40 m

g/day

2/14/2005

Concurren

t HMG‐Co A

Red

uctase Inhibitors

2/14/2005

No Criteria

‐‐‐

Simvastatin

(Zocor)

No Criteria

‐‐‐

Less than

or eq

ual to

80 m

g/day

5/15/1999

Concurren

t HMG‐Co A

Red

uctase Inhibitors

4/15/1997

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Cholestyram

ine

(Prevalite)

No Criteria

‐‐‐

Less than

or eq

ual to

4 packets/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Cholestyram

ine

(Questran

Lite)

No Criteria

‐‐‐

Less than

or eq

ual to

4 packets/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Colesevelam

(Welchol)

No Criteria

‐‐‐

Less than

or eq

ual to

6 tablets/day or

1 packet/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Colestipol

(Colestid)

No Criteria

‐‐‐

Less than

or eq

ual to

16 tablets/day or

6 scoops/day or

6 packets/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Ezetim

ibe/

atorvastatin

(Lipruzet)

No Criteria

‐‐‐

Less than

or eq

ual to

10/80 m

g/day

Future 2016

No Criteria

‐‐‐

No Criteria

‐‐‐

Lipid Lowering Ag

ents ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Lipid Lowering Bile Acid Sequ

estran

ts ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Lipid Lowering Co

mbina

tions ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

137

MG per day

Date Be

gun

Perio

dDate Be

gun

Perio

dDate Be

gun

Aspirin (Legend)

(Easprin, Zorprin)

Less than

or eq

ual to

4000 m

g/day

Future 2016

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Choline Magnesium Sulfate

(Trisalicylate)

Less than

or eq

ual to

3000 m

g/day

10/28/1994

No Criteria

‐‐‐

Concurren

t NSA

IDS

10/28/1994

Diclofenac

(Cataflam)

(Quick Release)

Less than

or eq

ual to

200 m

g/day

10/28/1994

No Criteria

‐‐‐

Concurren

t NSA

IDS

10/28/1994

Diclofenac

(Voltaren

)

(Norm

al Release)

Less than

or eq

ual to

225 m

g/day

3/29/1995

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Diclofenac Epolamine

(Flector Patch)

2 patches/day

Future 2016

No Criteria

‐‐‐

Concurren

t NSA

IDS

3/10/2009

Diclofenac Potassium

(Zipsor)

Less than

or eq

ual to

100 m

g/day

12/14/2010

No Criteria

‐‐‐

Concurren

t NSA

IDS

12/14/2010

Diflunisal

(Dolobid)

Less than

or eq

ual to

1500 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Etodolac

(Lodine)

Less than

or eq

ual to

1200 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Fenoprofen

(Nalfon)

Less than

or eq

ual to

3200 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Flurbiprofen

(Ansaid)

Less than

or eq

ual to

300 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Ibuprofen

(Motrin)

Less than

or eq

ual to

3200 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Indomethacin

(Indocin)

Less than

or eq

ual to

200 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Indomethacin SR

(Indocin SR)

Less than

or eq

ual to

200 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Non

‐Steroidal Anti‐Inflammatory Ag

ents (N

SAIDs) ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric (B

rand

)Maxim

um Daily Dose

Maxim

um Duration

Dup

licate Th

erap

y

138

MG per day

Date Be

gun

Perio

dDate Be

gun

Perio

dDate Be

gun

Ketoprofen

(Orudis, O

ruvail)

Less than

or eq

ual to

300 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Ketorolac

(Toradol) Less than

or eq

ual to

60 m

g/day

7/15/1993

5 days out of 30 days

5/15/1995

Concurren

t NSA

IDS

8/16/1992

Ketorolac

(Toradol) Less than

or eq

ual to

40 m

g/day

7/5/1993


5/15/1995

Concurren

t NSA

IDS

8/16/1992

Meclofenam

ate

(Meclomen

)

Less than

or eq

ual to

400 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Mefen

amic Acid

(Ponstel)

Less than

or eq

ual to

1000 m

g/day

Future 2016


Future 2016

Concurren

t NSA

IDS

8/16/1992

Meloxicam

(Mobic)

Less than

or eq

ual to

15 m

g/day

5/13/2002

No Criteria

‐‐‐

Concurren

t NSA

IDS

5/13/2002

Meloxicam

(Vivlodex)

Less than

or eq

ual to

10 m

g/day

7/5/2016

No Criteria

‐‐‐

Concurren

t NSA

IDS

7/5/2016

Nabumetone

(Relafen

)

Less than

or eq

ual to

2000 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Naproxen

(Naprosyn)

Less than

or eq

ual to

1500 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Naproxen Sodium

(Anaprox)

Less than

or eq

ual to

1650 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Oxaprozin

(Daypro)

Less than

or eq

ual to

1800 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Piroxicam

(Felden

e)

Less than

or eq

ual to

20 m

g/day

Future 2016

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Salsalate

(Disalcid)

Less than

or eq

ual to

3000 m

g/day

10/28/1994

No Criteria

‐‐‐

Concurren

t NSA

IDS

10/28/1994

Sulindac

(Clinoril)

Less than

or eq

ual to

400 m

g/day

7/5/1993

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Tolm

etin

(Tolectin)

Less than

or eq

ual to

1800 m

g/day

Future 2016

No Criteria

‐‐‐

Concurren

t NSA

IDS

8/16/1992

Drug Nam

e Gen

eric (B

rand

)Maxim

um Daily Dose

Maxim

um Duration

Dup

licate Th

erap

y

Non

‐Steroidal Anti‐Inflammatory Ag

ents (N

SAIDs) ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates (C

ontin

ued)

139

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date

Begun

Perio

dDate

Begun

Fluvoxamine

(Luvox)

Less than

or eq

ual to

50 m

g/day

8/28/1995

Less than

or eq

ual to

300 m

g/day

8/28/1995

No Criteria

‐‐‐

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate

Begun

Perio

dDate

Begun

Efinaconazole

(Jublia)

No Criteria

‐‐‐

4 m

l/16 days

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

Griseofulvin, m

icrosize

and ultramicrosize

No Criteria

‐‐‐

No Criteria

‐‐‐

60/90

6/12/2000

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate

Begun

Perio

dDate

Begun

Apixaban

(Eliquis)

No Criteria

‐‐‐

No Criteria

‐‐‐

Less than

or eq

ual to

5 m

g/day if over 80

years of age

7/5/2016

No Criteria

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Perio

dDate

Begun

Perio

dDate

Begun

Carbidopa/Levadopa

(Duopa)

No Criteria

‐‐‐

No Criteria

‐‐‐

Less than

or eq

ual to

100 m

l/day

7/5/2016

No Criteria

‐‐‐

Obsessive

‐Com

pulsive Disorde

r Agent ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Agen

ts to

Treat Onycomycosis ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Maxim

um Duration

Dup

licate Th

erap

y

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Oral A

nticoa

gulants ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Maxim

um Duration

Dup

licate Th

erap

y

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Agen

ts to

Treat Parkinson

's Disease ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Maxim

um Duration

Dup

licate Th

erap

y

140

MG per day

Date Be

gun

Perio

dDate Be

gun

Perio

dDate Be

gun

Dexlansoprazole

(Dexilant)

Less than

or eq

ual to 60

mg/day

12/14/2010

90 days out of 120

Future 2016

Proton Pump Inhibitors/

H2 Recep

tor Antagonists

12/14/2010

Esomep

razole

(Nexium)

Less than

or eq

ual to 40

mg/day

10/8/2001

90 days out of 120

Future 2016


H2 Recep

tor Antagonists

10/8/2001

Esomep

razole

strontium

Less than

or eq

ual to

49.3 m

g/day

Future 2016

90 days out of 120

Future 2016


H2 Recep

tor Antagonists

9/28/2015

Lansoprazole

(Prevacid)

Less than

or eq

ual to 30

mg/day

8/28/1995

90 days out of 120

Future 2016


H2 Recep

tor Antagonists

8/28/1995

Metoclopramide

(Reglan)

Less than

or eq

ual to 60

mg/day

10/28/1994

No Criteria

‐‐‐

No Criteria

‐‐‐

Misoprostol

(Cytotec)

Less than

or eq

ual to

800 m

g/day

7/5/1993

No Criteria

‐‐‐

No Criteria

‐‐‐

Naproxen and

Lansoprazole

(Prevacid NapraPAC)

Omep

razole

(Prilosec)

Less than

or eq

ual to 40

mg/day

7/5/1993

90 days out of 120

Future 2016


H2 Recep

tor Antagonists

8/28/1995

Pantoprazole

(Protonix)

Less than

or eq

ual to 40

mg/day

10/8/2001

90 days out of 120

Future 2016


H2 Recep

tor Antagonists

10/8/2001

Rabep

razole

(Aciphex)

Less than

or eq

ual to 20

mg/day

10/8/2001

90 days out of 120

Future 2016


H2 Recep

tor Antagonists

10/8/2001

Sucralfate

(Carafate)

Less than

or eq

ual to

4000 m

g/day

7/5/1993

No Criteria

‐‐‐

No Criteria

‐‐‐

Proton

Pum

p Inhibitors and

Other M

iscellane

ous G

astrointestin

al Agents ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Rem

oved from m

arket

Drug Nam

e Gen

eric

(Brand

)Maxim

um Daily Dose

Maxim

um Duration

Dup

licate Th

erap

y

141

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Amobarbital

(Amytal)

No Criteria

‐‐‐

Less than

or eq

ual

to 200 m

g/day

6/7/2000

14 days out of every 180

6/7/2000

No Criteria

‐‐‐

Amobarbital/Secobarbital

(Tuinal)

No Criteria

‐‐‐

Less than

or eq

ual

to 50 m

g/day

11/26/1997


4/20/1998

No Criteria

‐‐‐

Butabarbital

(Butisol)

No Criteria

‐‐‐

Less than

or eq

ual

to 90 m

g/day

11/26/1997


4/20/1998

No Criteria

‐‐‐

Chloral H

ydrate

(Somnote)

No Criteria

‐‐‐

Less than

or eq

ual

to 1 gm/day

11/26/1997


4/20/1998

No Criteria

‐‐‐

Ethchlorvynol

(Placidyl)

No Criteria

‐‐‐

Less than

or eq

ual

to 500 m

g/day

11/26/1997


6/1/1998

No Criteria

‐‐‐

Secobarbital

(Seconal)

No Criteria

‐‐‐

Less than

or eq

ual

to 100 m

g/day

11/26/1997


6/1/1998

No Criteria

‐‐‐

MG per day

Date

Begun

MG per day

Date

Begun

Class

Date

Begun

Perio

dDate

Begun

Baclofen

(Lioresal)

No Criteria

‐‐‐

Less than

or eq

ual

to 80 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Carisoprodol

(Soma)

No Criteria

‐‐‐

Less than

or eq

ual

to 1400 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Chlorzoxazone

(Parafon Forte)

No Criteria

‐‐‐

Less than

or eq

ual

to 3000 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Cycloben

zaprine

(Flexeril)

No Criteria

‐‐‐

Less than

or eq

ual

to 30 m

g/day

4/19/2006

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Dantrolene

(Dantrium)

No Criteria

‐‐‐

Less than

or eq

ual

to 400 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Metaxalone

(Skelaxin)

No Criteria

‐‐‐

Less than

or eq

ual

to 3200 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Methocarbam

ol

(Robaxin)

No Criteria

‐‐‐

Less than

or eq

ual

to 4500 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Orphen

adrine Citrate

(Norflex)

No Criteria

‐‐‐

Less than

or eq

ual

to 200 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Tizanidine

(Zanaflex)

No Criteria

‐‐‐

Less than

or eq

ual

to 36 m

g/day

6/5/2000

No Criteria

‐‐‐

21 days out

of 30

6/12/2000

Miscellane

ous S

edative/Hypno


ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Skeletal M

uscle Re

laxants ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

142

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Varen

icline

(Chantix)

No Criteria

‐‐‐

No Criteria

‐‐‐

No Criteria

‐‐‐

12 weeks followed

by another 12

weeks if smoking cessation has

been documen

ted

2/19/2007

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Zoster Vaccine Live

(Zostavax)

No Criteria

‐‐‐

No Criteria

‐‐‐

1 Injection per

lifetim

e12/8/2015

‐‐‐

‐‐‐

MG per day

Date Be

gun

MG per day

Date Be

gun

Class

Date Be

gun

Perio

dDate Be

gun

Arm

odafinil

(Nuvigil)

No Criteria

‐‐‐

Less than

or

equal to 250

mg/day

7/5/2016

No Criteria

‐‐‐

‐‐‐

‐‐‐

Modafinil

(Provigil)

No Criteria

‐‐‐

Less than

or

equal to 200

mg/day

7/5/2016

No Criteria

‐‐‐

‐‐‐

‐‐‐

Smok

ing Ce

ssation Ag

ent ‐ Criteria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Vaccines ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

yDuration of The

rapy

Duration of The

rapy

Wakefulne

ss Promoting Ag

ents ‐ Crite

ria Elemen

ts and

Implem

entatio

n Dates

Drug Nam

e Gen

eric

(Brand

)

Maxim

um In

itial Dose

Maxim

um Daily Dose

Dup

licate Th

erap

y

143

APPENDIX E

State Funded Pharmacy Programs

Utilizing the PACE Program Platform

Updated January 2016

144

STATE FUNDED PHARMACY PROGRAMS UTILIZING THE PACE PROGRAM PLATFORM

SECTION A: ENROLLMENT OUTREACH, ADJUDICATION, AND

CUSTOMER SUPPORT

PROGRAM NAME ACRONYM ENROLLEES MEMBER

APPLICATION PROCESSING

MEMBER ELIGIBILITY

DETERMINATION

MEMBER CUSTOMER SUPPORT

PART D PLAN COORDINATION1

PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY, PDA

PACE 118,769 YES YES YES YES

PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY NEEDS ENHANCEMENT TIER, PDA

PACENET 176,438 YES YES YES YES

ANCILLARY Rx BENEFIT PROGRAMS

CHRONIC RENAL DISEASE PROGRAM, DOH

CRDP 7,401 YES YES YES YES

SPECIAL PHARMACEUTICAL BENEFITS PROGRAM, HIV/AIDS, DOH

SPBP1 8,461 YES YES YES YES

SPECIAL PHARMACEUTICAL BENEFITS PROGRAM, MENTAL HEALTH, DHS

SPBP2 1,401 YES YES

CYSTIC FIBROSIS, DOH CF 18

SPINA BIFIDA, DOH SB 6

PHENYLKETONURIA DISEASE, DOH PKU 258

MAPLE SYRUP URINE DISEASE, DOH MSUD 0

AUTOMOTIVE CATASTROPHIC LOSS BNEEFITS CONTINUATION FUND, PDI

AUTO CAT FUND 439

WORKERS COMPENSATION SECURITY FUND, PDI

WCSF 1,279

PENNSYLVANIA PATIENT ASSISTANCE PROGRAM, PDA

PA PAP 12,627 YES YES YES

DEPARTMENT OF MILITARY AFFAIRS DMVA 525 YES YES YES YES

NON-BENEFIT SUPPORTED PROGRAMS

DEPARTMENT OF AGING PDA

DEPARTMENT OF CORRECTIONS DOC 51,121 YES YES

DEPARTMENT OF GENERAL SERVICES

DGS

DEPARTMENT OF HUMAN SERVICES, GENERAL ASSISTANCE PROGRAM

GA

BOARD OF PROBATION AND PAROLE (BENEFIT OUTREACH)

PBPP 343 YES YES YES YES

1 Includes exchange of enrollment and payment information with partner and non-partner plans; verification of premium invoices; and, management of cardholder drug coverage appeals and prior authorizations with Part D plans


145

SECTION B: CLAIMS ADJUDICATION AND PROVIDER SUPPORT

SECTION C: DUR INTERVENTIONS AND CLINICAL

SUPPORT

PHARMACY

CLAIMS

ANNUAL EXPENDITURES

CY 2014

PHARMACY CLAIMS

ADJUDICATION

PHARMACY NETWORK ENROLL-

MENT

PROVIDER CUSTOMER SUPPORT

PROVIDER AUDIT

SUPPORT

CLINICAL MANAGE-

MENT

FORMULARY MAINTEN-

ANCE

PACE 3,450,935 $76,239,100 YES YES YES YES YES YES

PACENET 4,795,176 $114,860,600 YES YES YES YES YES YES

CRDP 99,926 $4,468,100 YES YES YES YES YES YES

SPBP1 265,828 $90,789,400 YES YES YES YES YES

SPBP2 12,232 $1,218,000 YES YES YES YES YES

CF 138 $20,100 YES YES YES YES

SB 22178 $3,100 YES YES YES YES

PKU 1,970 $837,300 YES YES YES YES

MSUD - - YES YES YES YES

AUTO CAT

FUND 6,126 $942,400 YES YES YES YES YES YES

WCSF 11,129 $3,196,400 YES YES YES YES YES YES

PA PAP 8712 $258,400 YES YES YES YES YES

DMVA 4,604 $290,000 YES YES YES

PDA

DOC $47,500,000 YES YES YES

DGS

GA

PBPP

2 Includes online, real time claims adjudication; claim denials when claim exceeds drug utilization review criteria; and, seamless wrap-around of other pharmacy benefits.


146

SECTION D: CRITICAL OPERATIONS, FINANCE AND RESEARCH ACTIVITIES

FINANCIAL MGMT AND REPORTING

MANUFACTURER REBATE MGMT

QUALITY IMPROVEMENT

PROGRAM DATA MGMT

MGMT REPORTING

AD HOC REPORTING

RESEARCH AND

EVALUATION

WEBSITE SUPPORT

PACE YES YES YES YES YES YES YES YES

PACENET YES YES YES YES YES YES YES YES

CRDP YES YES YES YES YES YES YES 3

SPBP1 YES YES YES YES YES YES YES 3

SPBP2 YES YES YES YES YES YES YES 3

CF YES YES YES YES YES YES

SB YES YES YES YES YES YES

PKU YES YES YES YES YES YES

MSUD YES YES YES YES YES YES

AUTO CAT FUND YES YES YES YES YES YES

WCSF YES YES YES YES YES YES

PA PAP YES YES YES YES YES YES YES YES

DMVA YES YES YES YES YES

PDA YES YES YES YES YES

DOC YES YES YES YES YES YES YES

DGS YES YES YES YES YES

GA YES

PBPP YES

3 Although technical support for the website is not provided, documentation relevant to the program is provided for inclusion on the website.


147

Documents

PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE …...PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY ANNUAL REPORT TO THE PENNSYLVANIA GENERAL ASSEMBLY JANUARY 1 - DECEMBER 31, 2015