Transcript June 18, 2003: Roles of DMAS, Pharmacy Therapeutics Committee, and PDL Contractor, Patrick W. Finnerty

Roles of DMAS, Pharmacy &
Therapeutics Committee, and
Preferred Drug List
Contractor
Presentation to:
The Medicaid Pharmacy & Therapeutics Committee
Patrick W. Finnerty
Department of Medical Assistance Services
June 18, 2003
Richmond, Virginia
Key DMAS Staff Contacts

Pat Finnerty, DMAS Director (786-8099)

Cindi Jones, Chief Deputy Director, (786-8099)

Cheryl Roberts,Deputy Director, Programs and Operations
(786-6147)

Bryan Tomlinson, Director, Division of Health Care
Programs (371-7398)

Adrienne Fegans, Program Administration Specialist (7864112)
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DMAS’ Role

Ensure PDL program conforms to all statutory/regulatory
requirements

Support P&T Committee Members and activities

Procure services of a PDL Contractor
– monitor Contractor and ensure performance meets
required quality and service standards

Review and approve all Contractor-written communications to
clients, providers, and others prior to release

Provide Contractor with all necessary and current client
eligibility and utilization data
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DMAS’ Role (cont’d)

Coordinate Contractor’s support of P&T Committee
– ensure Contractor is responsive to P&T Committee

Interpret policies and make final decisions regarding all
aspects of program
– Appropriations Act requires that DMAS establish a
process for acting on the recommendations of the P&T
Committee and documenting any decisions that deviate
from recommendations of the Committee

Review and approve all supplemental rebate agreements

Handle all media inquiries
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Members of P&T Committee
Member












Randy Axelrod (MD) (Chairman)
Roy Beveridge (MD)
Avtar Dhillon (MD)
James Reinhard (MD)
Arthur Garson, Jr (MD)
Mariann Johnson (MD)
Eleanor (Sue) Cantrell (MD)
Christine Tully (MD)
Mark Szalwinski (Pharmacist)
(Vice Chairman)
Gill Abernathy (Pharmacist)
Mark Oley (Pharmacist)
Renita Warren (Pharmacist)
Background
Anthem Chief Medical Officer
Oncologist
Psychiatrist (CSB)
Psychiatrist (DMHMRSAS)
Dean, UVA Med. School
Family Practice
Local Health District Director
Geriatrician, VCU/MCV
Sentara Health Care
INOVA Health System
Westwood Pharmacy
Edloe’s Pharmacies
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2003 Appropriations Act: P&T
Committee Responsibilities

The P&T Committee shall recommend to the Department:
– therapeutic classes of drugs to be subject to the PDL and
prior authorization requirements
– specific drugs within each class to be included on the
PDL
– appropriate exclusions for medications, including
atypical anti-psychotics, used for the treatment of serious
mental illnesses such as bi-polar disorders,
schizophrenia, and depression
– appropriate exclusions for medications used for the
treatment of brain disorders, cancer, and HIV-related
conditions
– other appropriate exclusions and “grandfather” clauses
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Role of P&T Committee (cont’d)

Conduct clinical reviews of preferred and non-preferred
drugs as needed to maintain the PDL

Conduct clinical reviews of new drugs

Provide advice to DMAS and Contractor on clinical issues
regarding all aspects of the PDL program, including the
prior authorization process for non-preferred drugs

Provide clinical advice/input to DMAS and Contractor on
prior authorization of “more than 9 unique prescriptions”
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Role of PDL Contractor

Provide information and staff support to the P&T Committee

Establish and maintain the PDL based on clinical
recommendations of the P&T Committee
– cost effectiveness is to be considered only after drug is
determined to be safe and clinically effective
– exclude from the PDL and prior authorization program for
non-preferred drugs those classes of drugs previously
excluded by DMAS

Manage the reference pricing process

Ensure all program components required by the
Appropriations Act are implemented
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Role of PDL Contractor (cont’d)

Negotiate and administer state supplemental rebates

Administer the PDL prior authorization program for nonpreferred drugs and the prior authorization program for
“more than nine unique prescriptions”
– administer a reconsideration and appeals process

Provide and maintain Call Center 24 hours/day; 7 days/week

Provide PDL and prior authorization program education
services for clients and providers

Ensure confidentiality of client/provider information
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PDL Development Process
All Therapeutic Classes of Drugs
P&T Committee Recommends Drug
Classes To Be Subject to PDL & P.A.
P&T Committee Recommends Drugs Within Each
Class That Are Clinically Effective and Safe
Preferred Drugs
Non-Preferred Drugs
Drugs at or below cost of
most cost-effective drug
Drugs above cost of most
cost-effective drug require
P.A.
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Overview of PDL With Reference
Pricing and Supplemental Rebates
$80
$70
$60
$50
$40
$30
$20
$10
$0
Original Price
$70
Non-Participating Manuf.
Drug Available through P.A.
$56
$38
Most Cost Effective Drug
$29
$11
$27
$27
$27
$22
Drug A
Drug B
Drug C
Final Price
Source: DMAS Staff Illustration
Drug D
Drug E
Supp. Rebate
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