Formulary Management: Prior Authorization Process

C. Bernie Good Jeanne Tuttle Pharmacy Benefits Management Services VA Central Office

March 2014, Informatics Call

Background

• At the recommendation of the Health Delivery Committee (HDC), an interdisciplinary Pharmaceutical Cost Proposal(s) Taskforce was formed to examine options to prospectively address how VA can continue to provide access to costly drugs while ensuring the pharmacy benefit is sustainable well into the future. • • HDC, NLC approval, signed EDM.

Evolve the National Formulary to include “Prior Authorization” VETERANS HEALTH ADMINISTRATION 1

Formulary Evolution

• • • • • Formulary decisions will still be made by the MAP/VPEs Prior Authorization is new formulary designation – formalizes process for criteria for use Prior authorization reviews may take place at National, VISN or Facility Level Designations on the posted formulary will be PA-N, PA-V and PA-F Implementation will be staged VETERANS HEALTH ADMINISTRATION 2

Current Process New drug – MAP/VPE Discuss Evidence and Vote Formulary Non-Formulary Formulary With Criteria Field Implementation Non-Formulary with Criteria 3

Future Process New drug – MAP/VPE Discuss Evidence and Vote Formulary Formulary With Criteria Formulary – National Prior Auth Formulary – VISN Prior Auth Non-Formulary Non-Formulary with Criteria Field Implementation 4

Prior Authorization Considerations

• • • • • • Cost Volume Marginal clinical benefit Narrow spectrum of safety Special significance to the mission of the VA (to ensure access to all veterans) Subject matter experts VETERANS HEALTH ADMINISTRATION 5

Benefits of Centralized Approach

• Supported by field clinicians – These can be very difficult and sometimes emotional decisions and there is support to have them made centrally • Decisions will be made objectively and will be evidence based • Less chance for inappropriate denials due to cost • Promotes positive relationships between local prescribers and formulary managers (reduced policing/gate keeping tensions) • Decreases the administrative burdens that would be necessary to replicate these processes across all 21 VISNs VETERANS HEALTH ADMINISTRATION 6

Benefits of Centralized Approach

• • Leverages the practices a small number of VISNs have been able to implement and extends them to the entire enterprise Improves ability to gather cost and patient outcome data at a national level which will can be used to determine value based decisions going forward – Specifically, can better accommodate a “coverage with evidence-development” scheme for particular drugs of interest VETERANS HEALTH ADMINISTRATION 7

**DRAFT** National Prior Authorization Process

•

Inter-facility consults

– Existing technology, provider and informatics staff familiarity – Located under a CPRS screen that ensures high visibility for providers – e.g. IFC section of CPRS and/or drug consults menus. – Keeps documentation within the EMR VETERANS HEALTH ADMINISTRATION 8

Inter-facility Consults

• • • • Consult template developed nationally based on MAP/VPE criteria determinations and sent out as TXML file Facility level consult set-up and drug file management Hines VA is the receiving facility Expectation for turn around is 96 hours in alignment with requirements for non-formulary reviews (VHA Handbook 1108.08) VETERANS HEALTH ADMINISTRATION 9

Inter-facility Consult Set-up

• • • Pharmacy ADPAC and CAC will need to work together on local set-up Simultaneous notification to local pharmacy, Chief of staff and National Reviewers when consult placed Creation of any associated drug quick orders or “hiding” drug in CPRS alpha list Placement on menus (e.g. IFC menu, drug consult menu, etc.) – Menu structure different across facilities VETERANS HEALTH ADMINISTRATION 10

Menu Placement

• In deciding consider…  Menu intuitive to providers – engage providers in decision  Facility Culture  Teaching vs Non-Teaching Facility  Additional provider training/education needed VETERANS HEALTH ADMINISTRATION 11

Example Consult Menus

All drug consults on same menu separated by inpatient and outpatient VETERANS HEALTH ADMINISTRATION 12

Example 2: Prior Authorization Requests: Placement choices: Use existing drug classification scheme OR Create a new menu “Prior Authorization Medications”

Meds Prior Authorization Example 3: Using the “Alpha list” LMNOP 311 < LMNOP> PA This is a “Prior Authorization medication!

Please complete the Prior Authorization request before ordering or contact pharmacy.

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

Drug File Management

• • Drug File Management for Non-Formulary and Criteria For Use medications varies widely across facilities, therefore a standardized process for handling PA medications will not be mandated Chief should ensure strong processes are in place that ensures prescriptions will not be processed until the prior authorization request is approved VETERANS HEALTH ADMINISTRATION 15

Drug File Management Considerations

• • Populate the message field of national prior authorization medications with “National Prior Auth Consult required” Create a place holder entry (in addition to the actual drug) in the drug file that is not matched to the NDF of an orderable item and contains information to direct the provider to the consult location. See additional presentations –

Thank-you to George Knight, VISN 2 VPE and Jennifer Yahnian, Pharmacy Information Manager/ADPAC VA Central California HCS (Fresno)

VETERANS HEALTH ADMINISTRATION 16

Drug File Management Considerations

• • Mark the actual drug entry so that it does not appear in the alpha list for providers to order and use a quick order associated with the consult or have the pharmacist enter the prescription through the appropriate Pharmacy VistA package once the consult is approved Develop a standardized process and educate staff on how to manage prescription orders in the pending file for national prior authorization medications prior to approval VETERANS HEALTH ADMINISTRATION 17

Communication

• • Mailgroup established to facilitate communication: VHAPBH Prior Authorization National POC in PBM phone directory - Recommend populate with Outlook Mailgroup – Heads up on drugs requiring special ordering – Help with requests for additional information if provider not responding – – Notification of adjudication results Request for facilities to populate sent to VPEs 2/13 VETERANS HEALTH ADMINISTRATION 18

Assessment of Outcomes

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

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

Patient Outcomes. In collaboration with local facility, will track patient response and adverse events to drug therapy and report quarterly to MAP and VPEs . VETERANS HEALTH ADMINISTRATION 19

20