TennCare Drug Utilization Review (DUR) Board Minutes - Magellan ...

March 6, 2012
State of Tennessee
Department of Finance and Administration
Bureau of TennCare
310 Great Circle Road
Nashville, TN 37228
TennCare Drug Utilization Review (DUR) Board Minutes
In attendance:
DUR Committee: Roland Gray, MD, Randall Ellis, MD, Alexander Koumtchev, MD,
Rebecca Brewer Mills, PharmD
Bureau of TennCare: David Collier, MD, Ray McIntire, DPh, Nicole Woods, PharmD
SXC Health Solutions: Toie Alston, PharmD, Bill Hudson, PharmD
Introduction:
The meeting was called to order by Dr. Alston, who welcomed everyone to the TennCare
Drug Utilization Review (DUR) Board meeting. DUR Board Appointees, Bureau of
TennCare Representatives, and SXC Health Solutions, Inc. Representatives introduced
themselves.
Review of minutes:
• The Board was asked to review minutes from December 6, 2011 meeting.
• A motion was made by Dr. Collier, seconded by Dr. Gray to approve the minutes
as presented. Minutes approved with no changes.
Dr. Collier gave the following TennCare Medical update:
• FY 2013 TennCare Budget: The governor presented his proposal to the
legislature which included modification to the proposal presented by TennCare.
These modifications were for the better.
o Provider rate reduction was amended by the governor. Legislation was
submitted to restore 1.75% of the rate reduction that went into effective in
January 1, 2012. That rate will be retroactive from January 1, 2012. Once
that legislation passes, it will cause rate reduction for FY 12 to be reduced
from 9.5% to 7.75%. Providers affected include nursing homes, ICFs/MR
(Intermediate care facilities for persons with mental retardation), MCO
administrative rates, Transportation providers (NEMT $2 co-pay removed),
and lab/ x-ray providers. Next year the rate will be refunded at that level
with recurring funds.
o
o
o
The governor restored the Perinatal grant (Regional Perinatal Centers).
TennCare proposed OB reimbursement at a flat rate of vaginal delivery
+5%. The governor recommended vaginal rate +17% and for next year,
FY 2013, vaginal delivery + 10% with recurring funds. These rates are
greater than what TennCare proposed.
The governor approved Emergency Dept physician reimbursement for
nonemergency visits at contract rate or $50, whichever is less, instead of
1

o
o
o
o
the level 1 (approximately $27) reimbursement TennCare proposed. Next
year reimbursement will be between $27 and $50 using non-recurring
funds. In FY 2014 the reimbursement rate will be re-evaluated.
Supplemental grants to the Med/ Metro/ Jellico were restored.
TNAAP contract was restored for FY2013 with $100,000 nonrecurring
funds.
Proposed reductions not in the Governor’s budget that will not be
implemented include:
• Eliminate hospice support services for adults
• 1.25% provider rate reduction
• Eliminate adult allergy medication coverage
• Mental health provider rate reduction
• Co-pay for non-pregnant adults for some services
Other changes that are forms of reductions
• Currently TennCare has low requirements to be eligible for long
term care requiring only 1 Activities of Daily Living (ADL)
deficiency. This is more generous than most states in the country.
• Tennessee is proposing to change that to 3 groups. The change
requirements for nursing facility care include:
• Deficiencies in 3-4 ADLs to qualify for nursing home
‣ Choices Group 1 - Nursing Home Care Recipients
‣ Choices Group 2 – Home care recipients (HCBS)
Adults 65 years of age and older
OR adults 21 years of age and older who
have physical disabilities
‣ New Group: Choices Group 3
Deficiency in 1-3 ADLs
Not eligible for residential care but will
be eligible for HCBS program
• This will allow TennCare to provide services to those in
need without being too liberal regarding nursing home
services.
• HBCS providers are going to see some reduction in their
rates. It’s a blended rate of homemaker and personal
assistant.
• Limit Retroactive Eligibility payments to MCO: Currently if a
member is approved for retroactive eligibility TennCare will pay 2
years full capitation rate to the MCO. It’s proposed that TennCare
pay the full capitation rate for no more than 12 months of
retroactive eligibility and pay only for claims received for services
rendered prior to the 12 months.
• TennCare is going to follow CMS policy to not pay for hospital
acquired conditions that could be preventable.
• TennCare Standard Spend Down
o The new enrollment opened February 21, 2012.
o There were approximately 2,500 calls in just over an hour.
• EHR Provider Incentive Program
o As of February 17, 2012, $37,242,756.58 has been paid out to 1,011
eligible professionals and 19 eligible hospitals.
• John B Lawsuit
2

o
John B lawsuit addresses the adequacy of EPSDT services provided by
TennCare for children under the age of 21. On 2/14/2012, Judge Wiseman
issued a ruling stating that the State is in substantial compliance with all
the binding provisions of the consent decree. He vacated the consent
decree, dissolved all injunctive relief and dismissed the case. The plaintiffs
have said they intend to appeal to the 6 th circuit court.
• ICD -10 Implementation
o
ICD – 10 was scheduled for October 1, 2013. However, CMS has
indicated it’s considering a delay due to concerns from the AMA
(American Medical Association) regarding the burden on physicians to
meet the deadline. There is no information on whether the delay will be
granted at this time. Until further notice, TennCare continues to work
toward the deadline requirements for the ICD- 10 implementation that was
previously set.
Dr. Woods gave an update on the TennCare Pharmacy Program:
• New NCPDP D.0 Claim Standard format
o
o
o
January 1 st , 2012 the new NCPDP D.0 format went into effect replacing the
previously accepted 5.1 claim format. The transition to the new format
went smoothly.
Pharmacies were allowed a transition period during the month of
December in which both the 5.1 and D.0 formats were accepted, so
pharmacies could properly convert to the new format. During that time
they were encouraged pharmacies to contact SXC to work out any
problems. Pharmacies that wanted to test submission of claims in the new
format were advised to contact SXC to arrange a testing time.
There will be future guidance going out to the pharmacies regarding a
couple new fields required to properly identify 340B claims. The federal
government has put forth some guidance stating that states must have a
way of documenting methodology, how 340B claims are identified and
ensure providers that are identified as 340B providers are submitting their
claims with 340B pricing. Any provider who qualifies as a 340B provider
gets the discount up front so those claims are not eligible for federal
rebates. There will be some future guidance going out as to specifically
what fields will be required and what values need to be put in those fields
to properly identify 340B claims.
• Pharmacy Budget Reductions
o
In FY2013 the proposed budget item regarding implementing a more
aggressive MAC (maximum allowable cost) on certain generic drugs was
postponed due to non-recurring funds. If no additional funds are available
this will go in after FY 2013.
• Proposed Budget Reductions for FY 2013
o
Enhanced Third Party Liability (TPL) - In July 2011, a POS (point of sale)
coordination of benefits (COB) edit was implemented. This COB edit
identified members who were known to have primary insurance and
required that the pharmacy submit the claim to the primary insurance first,
with TennCare being the payor of last resort. It’s anticipated that this edit
will continue into the next budget year and will continue to provide savings
for the State. This is a great edit to make sure we are the payor of last
resort.
3

o The Enhanced Specialty Pharmacy Contract Strategy didn’t make it into
the governor’s final proposal.
o The elimination of prescription allergy medication for adults was also
proposed but didn’t make it into the final proposal.
• Suboxone®/ Subutex® Tapering
o Last year a quantity limit on buprenorphine products was proposed which
would allow up to 16 mg/day for up to 6 months. Following this 6 month
time period, the member would need to be tapered down to a quantity limit
of 8mg/day. This quantity limit was implement Sept 1, 2011 so the first 6
month period came up March 1, 2012.
o To assist providers with this taper, multiple provider notices were faxed to
targeted prescribers informing them of the new quantity limit including a
list of patients receiving greater than 8mg/day. Providers were encouraged
to taper their patients down to the new quantity limit. All Suboxone®
providers have been informed of their patients that need to be tapered down
to 8mg/day.
o The average daily dose has decreased from 20mg/day to approximately
13mg/day.
o Dr. Mills asked if the State is able to see if any of these patients are paying
cash.
o Dr. Woods stated there are some patients paying cash. There is nothing
prohibiting them from paying cash however as a Medicaid patient a
physician can’t require them to do so. The downward trend is just a
reflection of TennCare claims it doesn’t include claims from controlled
substance database.
o Dr. McIntire mentioned there’s a fraud investigation line at DHS that
pharmacist can call 800-241-2629. Some Medicaid enrollees are eligible
due to a lack of financial ability to pay for expensive medication. If
enrollees are paying cash they may have undeclared income.
• Lastly, the Pharmacy Program will experience a change in leadership effective
March 14, 2012. Dr. Woods informed the DUR Board that she would be leaving
TennCare to explore a new job opportunity and thanked the committee for their
hard work. She stated that at this time a new Pharmacy Director has yet to be
named. However, interviews are currently being conducted and she expressed
confidence that a highly capable person will be selected to fill the position.
Dr. McIntire presented ADURS update:
Every year in February all the states Medicaid DUR directors meet in Scottsdale, AZ.
Some of the topics presented are very relevant to what we are discussing. Those programs
have included Dr. Ted Parran’s presentation on Suboxone® two years ago which basically
started our Suboxone® initiative. This year he discussed the new tamper resistant opioids.
Also highlighted, was Montana’s new pharmacy case management program, Arkansas’s
presentation on products we probably aren’t supposed to cover because they’re not drugs,
and important updates from CMS and state DUR initiatives.
• Newer “Less Abusable” Opioids
o Dr. Parran presentation centered on dopamine surge in the brain. Basically
all the euphoria producing drugs work differently with different effects but
all cause dopamine surge in the brain. His point for the presentation was
there are a lot of new products coming out to prevent drug abuse but don’t
prevent drug abuse because they don’t stop the dopamine surge. A drug
4

that will stop the dopamine surge is what’s needed out in the industry. The
more the dopamine surge the higher the street value. Dopamine surge
mediates addictive disease and affects the street value of the drug.
• Combination of opiates and benzos- There are more accidental
deaths in patients with sleep apnea than without sleep apnea. We
should consider a DUR activity around patients with sleep apnea.
• There are only 2 ways to give an opiate to an addict needing pain
treatment, Suboxone® or Methadone. TennCare doesn’t cover
Suboxone® for pain therefore if an addict needs pain treatment
there’s nothing TennCare should be giving them for pain
treatment.
• Montana’s New Pharmacy Case Management Program: This is a different way
of running their DUR program
o They involve face to face meetings with providers and pharmacists. They
actually pay providers for their office time.
o Letters are sent to providers, and then an appointment is set between
providers and a clinical pharmacist to discuss letter content.
o Scheduled office time is reimbursed by Medicaid using CPT code which
pays $33.04.
o With this program they did Suboxone® academic detailing which provided
best practice guidelines and appropriate medication management. They
saw a shift in claims from 24-32mg /day dose to 8-16mg/day. They didn’t
present outcomes data.
o There is expense to this program, including the cost of 2 full time
pharmacists plus provider charges.
• Medicaid Dilemma- Is it a drug
o
o
There are a number of products that look like drugs, are marketed like
drugs, require a prescription, and have a NDC number but they are not
drugs- they are devices. For Medicaid to cover these products they have to
be drugs.
The manufacturers are a “Covered Labeler” according to CMS and are
rebate eligible but rebates are not available for these products because they
are not drugs. “Cover Labeler” may not have a rebate agreement on file
with CMS for that NDC. All manufacturers must have rebate agreements
with CMS and the State to be able to have the drugs covered by state
Medicaid programs. Basically Arkansas went through a process to help
define whether these drugs are devices or medical foods:
• Examples include: Deplin® and other l-methylfolate products.
TennCare does cover these products in certain patients as a less
costly alternative to other treatments.
• Other products include, Freshkote® Eye Drops which is an eye
lubricant that’s not FDA approved.
• Hyaluronate sodium is a non-FDA approved product which
requires a prescription but it’s not a drug.
• Urea is another product which can be covered in combination with
products such as hydrocortisone cream; however urea by itself is
an emollient, and is not a drug.
• Medicaid can cover non-drug under home health, or medical or
thru pharmacy as a less costly alternative.
• CMS General Updates
5

o
o
o
o
The General Accountability Office conducted a study on atypical use in
foster children which revealed that foster children comprise approximately
3% of children enrolled in Medicaid, but they are prescribed atypical
antipsychotics at 9 times the rate of non-foster children. A letter was sent
to state Medicaid directors in November challenging the states to take
action. In the letter it was pointed out that states may use DUR programs
to monitor dispensing at the point of service and influence prescriber
behavior. DUR programs may use system edits to limit inappropriate
dosage utilization and poly-pharmacy. States can also use their RetroDUR
programs to reach out to providers whose prescribing habits vary
significantly from the recommended standard of care for children. A while
back, TennCare worked on utilization of atypicals in children and foster
children.
Dr. McIntire asked if anyone remember the outcomes.
Dr. Collier stated that atypical use in children was reviewed for DHS.
Tennessee data was compared to 14 other states and was in the middle.
Dr. Woods mentioned that TennCare sent out educational material to
providers which included some guidance that came from one of the
journals regarding safety and efficacy in children and algorithms to use as
they work through diagnosis in children. The drill down on kids receiving
high doses showed they had tried and failed a variety of things in the past
and they were some of the most difficult cases. These patients were being
appropriately monitored by psychiatrists and not general practitioners.
Overall it was felt that the utilization was appropriate.
• Individual State Updates: Here are some interesting things other states are doing.
Tennessee is really out front when it comes to our clinical criteria and edits. Some
states can’t management certain categories and some don’t have a PDL. Alabama
and Missouri may be a little more advance in some program aspects.
o
o
o
o
o
o
Alabama has a new atypical PA program. Children’s PAs are approved
only if written by a child psychiatrist. For adults, atypical PA requests
must be written by psychiatrist, otherwise, if written by provider other than
a psychiatrist a diagnosis is required.
Arizona implemented new pricing rules for 340B providers, reimbursing
the lower AAC or the 340B ceiling price.
Delaware implemented a new adult ADHD coverage. They will only
approve long acting simulants for adults. On 3/1/12, new opiate guidelines
went into effect which include:
• oxycodone IR 30mg max quantity of 60 tablets per year
• oxycodone IR 15mg max quantity of 240 tablets per year.
• All further claims require prior authorization, and require use of a
long acting opiate (LAO) before oxy IR 15mg or 30mg will be
approved. Total daily oxy IR dose will only be approved to equal
not greater than 20% of the total daily LAO dose
Iowa changed their reimbursement formula to AAC plus an increased
dispensing fee. Only one dispensing fee will be paid per month for
maintenance drugs.
Maine instituted a 2 year limit on Suboxone®, and a 45-day limit on
narcotic use, excluding HIV and cancer patients. A prior authorization is
then required for those patients being treated for chronic pain.
Maryland requires peer reviews to be conducted by U of M School of
Medicine for all prescribed mental health drugs.
6

o Montana implemented a “Provider” PA program. Providers can put a stop
on drugs that they have prescribed.
o North Dakota required a PA for all opioid combinations containing greater
than 325mg of APAP.
o Oklahoma stopped paying for prescriptions for all non-participating
providers. Notices were sent only to enrollees, not the providers.
o In April 2012, Oregon will be implementing a quantity limit of 120mg/day
MS equivalent of all opioids, with the exception of cancer patients. A
urine drug screen will be required for prior authorization.
o Virginia implemented an edit on atypicals for children under age 6. All
requests are subject to a peer to peer review with a State psychiatrist.
o Washington requires a second opinion by a pain specialist for narcotic
reviews for doses > 1000mg MS equivalents per day, with the exception of
cancer patients.
o West Virginia requires a prior authorization for atypicals in children under
age 6.
• They also implemented a “Provider Report Card” for narcotic
prescribers. They separate out physicians and mid-levels, and then
compared the mid-levels to their supervising physicians.
o Wisconsin will be implementing an ER Lock-In. They also require a PA
for atypicals in children under age 6, and the prescription must be written
by a child psychiatrist.
Old Business from December 6, 2012 meeting:
• Atypical Antipsychotic DUR Activity Letter: The Atypical Antipsychotic
Activity Letter was tabled at last meeting to allow Dr. Koumtchev to give his input
on the letter.
o
o
o
o
o
o
o
Dr. Koumtchev stated he understands the barriers to this letter. As it’s
difficult to describe what’s evidence based and standard practice. He will
draft a letter and send for review.
Dr. Woods mentioned they have received legal guidance on what can and
can’t be voted on via email. The actual letter would have to be voted on at
a meeting however the letter may be distributed via email to receive
feedback and comments.
Dr. McIntire stated it’s very difficult for the State to write this letter
strongly so we are really looking to the Board to help set the tone for this
letter.
Dr. Alston informed the Board the letter will be brought back in June
for a vote.
Physician Referral Letter: In your packet you have a copy of the
physician referral letter that the State developed for referring blocked nonparticipating
prescribers to the Board of Medical Examiners.
Dr. Hudson mentioned that Oklahoma has a process like this but it wasn’t a
peer review process. They have a more statutory process where if you’re
not in the managed care organization then you are an outlier.
Dr. Woods stated the Bureau is having discussions with legal regarding this
process, and down the road our process may look similar to Oklahoma,
where anyone not contracted with the MCOs will not be able to have
prescriptions reimbursed by TennCare. Within the Bureau there is
difference in opinion on the guidance that was issued by CMS; therefore
discussion is still taking place.
7

o
A motion was made by Dr. Gray, seconded by Dr. Mills to accept
referral letter without changes. Committee approved.
Standing Business:
• Blocking Non-Participating providers- Dr. McIntire provided the Board with a
summary of the reasons why each of the thirteen providers was being reviewed,
and blinded copies of their prescribing histories.
o Dr. McIntire presented prescriber #1: This prescriber is an APRN with
approximately 78% of total paid claims for controlled substances and 68%
of total paid claims for oxycodone products. An article from a Tennessee
newspaper about the prescriber and the prescriber’s pain clinic practice was
also presented. There are no prior authorizations from this provider and
there is only one TennCare enrollee who is subject to the Lock-In program
found with claims from this provider within the last 12 months.
• Dr. Gray mentioned there are rules and regulations for pain clinics.
Prescribers doing this kind of business have to be registered. You
should be able to go on line and see if they are registered. If they
are not registered both the clinic and physician can be fined. Also
with the new pain clinic regulations the Board has a right to go and
investigate without a complaint.
• A motion was made by Dr. Gray, seconded by Dr. Mills to
block prescriber number #1.
o Prescribers #3-5 and 7-13: These are all out of state Suboxone®
prescribers. Most of these prescribers are in cash Suboxone® clinics over
150 miles from Tennessee border. The Medicaid pharmacy director in that
state gave me the name of a P&T member who was a pharmacy owner in
the city from where we were seeing the most claims. The pharmacist told
me that he will not fill prescriptions from this clinic, and the owner hires
residents and retired practitioners to see patients. There are 7 different
locations throughout the state with the same name for counseling at each
location. We are still awaiting MCO approval on blocking these providers.
• Dr. Koumtchev mentioned DEA has been visiting everyone with X
DEA number. The website registration is confusing; the addressee
requested isn’t specific to home or office.
• Dr. Collier indicated this company has an office in Tennessee.
• Dr. Koumtchev stated there are many providers with X DEA
number. The V.A asked all physicians that participate in rounds to
have an X DEA.
• Dr. Gray asked if these physicians are licensed in state of
Tennessee.
• Dr. McIntire responded that 1 of the providers was registered in
Tennessee.
• Dr. Woods asked if the patients are counting toward these
prescribers’ 100 patient limit, and if patients are being seen in the
Tennessee clinic.
• Dr. McIntire stated there is no reason for enrollees to drive 150
miles into another state to see an out-of-state physician for
addiction treatment.
• Dr. Woods asked if there are different prescribers in the out-ofstate
clinics that are not practicing in Tennessee.
8

• Dr. McIntire informed these are not the same providers.
• Dr. Woods stated that it’s agreed that traveling 150 miles to a
Suboxone® clinic is not what we want patients to do so we decided
to block these providers, and the MCOs must have alternative
providers to treat these enrollees.
• Dr. McIntire stated if the MCOs come back and say these
providers are needed they will not be blocked. This action is
contingent on the MCOs saying they don’t need these providers.
• Dr. Alston stated since they are not getting the prescription filled in
Kentucky, maybe they are not actually going to the Kentucky
clinic.
• Dr. McIntire mentioned there is one city in Kentucky that’s the hot
spot for this.
• A motion was made by Dr. Gray, seconded by Dr. Koumtchev
to block provider 3-5 and 7-13 subject to approval by the
MCOs.
o Dr. McIntire asked that provider #2 be postponed and provider 6 be
dismissed.
o Prescriber #14: A TennCare enrollee locked into a pharmacy in Kingsport
could not get his prescription filled as the pharmacist will not fill
prescriptions from this provider. The pharmacist believes this is a newly
opened pain clinic that doesn’t accept insurance and the prescriber
commutes from out of state. This provider is not prescribing narcotic pain
relievers according to current standard of care. The enrollees’ utilization
has been reviewed for February along with PMP claims from the
prescriber’s PMPM profile and cash purchases. Cash purchases for this
provider are alarming.
• A motion was made by Dr. Gray, seconded by Dr. Ellis to
block provider #14.
• Dr. Gary recommended carbon copy to DEA
• Dr. McIntire reminded the board the approval to block will be
contingent upon MCO approval.
• Committee approved motion with additions.
• Dr. Alston Presented TennCare Drug Utilization Data
o TennCare population remains constant at approximately 1.2 million
enrollees. In regards to utilization, the number of utilizing members as
well as the prescription count decreased slightly from 4q10 to 4q11;
however during the same time frame the overall payment amount increased
11% and the average payment per claim increased 11.55%. Between 1-2%
of the increase can be attributed to the new protease inhibitor drugs used to
treat Hepatitis C (Incivek®, Victrelis®), and the rest is due to increases in
various drug classes, especially those listed in the Top 10 Therapeutic
Classes by Payment Amount.
o Looking at the average prescription payment, overall generic utilization
continues to increase keeping payment amount down.
o The brand originator category shows a significant increase in payment
amount. This is due to release of generic olanzapine. For a short time,
brand Zyprexa® claims were paying however they had not yet been added
to the Brand as Generic list. Therefore, they processed as a brand
originator verses a generic. The high cost of Zyprexa® claims affected the
brand originator category much more than the generic category, as the
9

generic category comprises 84% of TennCare pharmacy claims verses the
brand originator at only 0.34%.
o There are 5 classes of drugs in both the top 10 claim volume and top 10
payment amount. Those drugs classes consist of Narcotic Analgesics,
Anticonvulsants, ADHD Agents, Sympathomimetics, and Atypical
Antipsychotics.
o Generic olanzapine (Zyprexa®) became available in Oct 2011. Generic
quetiapine (Seroquel®) will be available in March. Perhaps in the next year
and half we will see a decline in atypical antipsychotic payment amount.
o Antihemophilic agents’ payment amount increased 38% due to increased
utilization. There have been 5 additional hemophilic enrollees since 4q10.
There has been an increase in the utilization of NovoSeven®.
o Simvastatin claims decreased approximately 10%. This is primarily due to
the recommendation from the FDA to limit the use of simvastatin 80mg. A
DUR activity went out in June 2011 to notify prescribers of the FDA
recommendation which included dosage restrictions, a limitation on the use
of the 80mg dose, and the addition of new contraindications to
simvastatin’s label.
o Synagis® payment amount increased 20% PMPM. This increase is
secondary to increased utilization this RSV season.
o The top ranking ProDUR edits in various categories are similar to their
ranking in 4q10. One exception is that the drug causing the highest
number of “Geriatric Precaution” alerts was amlodipine besylate, with
2,579 edits. Geriatric patients are more likely to experience a delayed
clearance of amlodipine and can be at greater risk for toxicity. This could
possibly be a good topic for a DUR activity.
• Dr. Alston presented 4 th Quarter RetroDUR and Provider Analysis Activities
o Strattera® Cardiovascular Safety--The October activity focused on safety
concerns surrounding use of atomoxetine (Strattera®), specifically
regarding the potential increase in blood pressure and heart rate. 569
profiles were reviewed, and 89 letters addressing 86 enrollees were sent to
prescribers, when the enrollee’s profile contained a paid prescription
claim(s) for atomoxetine and a cardiovascular medication.
o Antiretroviral Non-compliance-- The December activity concentrated on
non-compliance with antiretroviral therapy, and 504 enrollee profiles were
reviewed. A letter to the prescriber was generated when the enrollee did
not obtain a refill of their antiretroviral medication within 7 days after the
medication supply was expected to run out. We tried to avoid sending the
letter in situations where it appeared the enrollee was ill or hospitalized or
situations where there had been change in therapy. Twenty six providers
were lettered addressing 43 patients.
o Top Narcotic Prescribers-- Out of the top 200 narcotic prescribers the top
125 was lettered.
o Short Acting Narcotic Initiative-- A total of 1,636 prescribers were found
to meet the criteria during the Short Acting Narcotic initiative analysis,
from that total, 800 prescribers were lettered.
o Smoking Cessation-- A communication about smoking cessation was
requested by PAC (Pharmacy Advisory Committee) and the resulting
notice provided additional information on the quantity limits and
10

exceptions under which smoking cessation products would be covered for
all TennCare enrollees. This communication was sent to 764 prescribers.
o Buprenorphine Benefit Limit-- A letter was sent to remind providers that
beginning March 1, 2012; any adult TennCare recipient who has received 6
months of therapy on Suboxone®, Subutex®, or generic buprenorphine
will be limited to a maximum daily dose of 8 mg/day. There were 13,936
providers with patients receiving greater than 8mg per day. These
prescribers are being lettered based on the date the patient will reach 6
month mark. 194 letters went out to providers whose patients will reach 6
months of therapy sometime in March. The next round will be sent out this
week to physicians with patients will reach the 6 month mark in April.
• Dr. Alston presented RetroDUR and Provider Analysis Activity Outcomes
o ADHD Stimulants with CNS Depressants-- This activity’s focus was to
draw attention to counteractive prescribing with TennCare enrollees taking
ADHD products concomitantly with CNS depressants. There was a 19%
provider response rate, and 77.9% of the responders found the activity
useful. 38.98% of the responders stated that the patients had diagnoses
which required both medications (CNS stimulants and depressants).
o Use of Topamax® During Pregnancy-- This activity reviewed the risk of
orofacial birth defects in children born to mothers taking topiramate
(Topamax®). 13.9% of the prescribers who received the letter responded,
69.8% found this activity useful.
o Simvastatin Dose Restriction-- This activity reviewed the action that the
FDA took on simvastatin, which included dosage restrictions, limitation on
the use of the 80mg dose, and the addition of new contraindications to
simvastatin’s label. 10.5% of the prescribers who received the letter
responded, 76.3% found the activity useful. 30% of the responders
planned to adjust treatment based on the information we provided.
o Poly-Pharmacy-- Activity focused on patients with > = 14 prescriptions,
written by > = 4 different providers, and filled at > = 3 different
pharmacies over a 90 day period. 14.4% of the providers responded, of
which 75.8% thought the activity was useful.
o Strattera Adverse Reaction-- The Strattera® activity focused on safety
concerns surrounding the use of Strattera® particularly the increase in
blood pressure and heart rate. There was a 19.7% provider response rate,
and 64.7% of the responders found the activity useful.
o Top Narcotic Prescribers-- Top Narcotic Prescribers had 27.4% response
rate of that 64.7% thought this activity was useful. Most of these responses
are generally negative. Pain clinics states it’s their job to write pain
medication. Suboxone® prescribers don’t understand why they are included
since they are running a rehabilitation clinic and not prescribing medication
for pain.
• Dr. Woods recommended breaking the specialty down further to
include a Suboxone® category.
• Dr. Gary recommended including a copy of the letter from Center
of Substance Research to educate the prescribers that this
medication can be abused.
o Smoking Cessation in Pregnancy-- Smoking cessation in pregnancy, this
activity reviewed TennCare criteria for coverage of smoking cessation
products for pregnant women prior to these agents becoming a covered
11

enefit for everyone. There was a 6.0% provider response rate of that
79.4% thought the activity was useful.
o Short Acting Narcotic Initiative-- There was a 17.3% provider response
rate, and 74.2% of the responders found the activity useful. From 3Q09 to
4Q11 there’s been a 10% decrease in number of narcotic claims per
utilizing member. Since this activity is now going out quarterly there’s
been some discussion regarding modifying the letter to be more aggressive.
• Dr. McIntire informed the board that the subcommittee on narcotic
use will be reconvening in the upcoming months to focus on trends
we are seeing today and specifically oxycodone IR 30mg.
o Promethazine Safety in Children-- Promethazine safety in children
reviewed the “black box” warning added to promethazine’s label in 2004
involving contraindications for use in children less than 2 years of age and
advising against the use of promethazine with codeine cough syrups in
children less than 6 years of age. This activity had a 12.6% provider
response rate and of that 66.1% found this activity useful.
o Buprenorphine Benefit Limit-- This provider analysis activity focused on
Suboxone® new quantity limits that went into effect last quarter. There
was a 19.7% response rate and of that 67.6% found this activity useful.
Approximately 35% of the responders was aware of the quantity limit
changes and had already adjusted patients’ therapy where appropriate.
o Smoking Cessation-- The general smoking cessation letter addressed the
quantity limits and criteria under which these products would be covered
for TennCare recipients. There was a 4.0% provider response rate of that
88.8% found this activity useful.
• Dr. Alston proposed new RetroDUR and Provider Analysis Activities
o Non-compliance with Immunosuppressants Agents-- Noncompliance with
antirejection medications is the leading cause of acute rejection.
o Statin Use in Females of Child Bearing Age-- During another review it was
noticed that there were a number of females of child-bearing age receiving
statins and no methods of contraception.
o Statin Medication and Increased Risk for Diabetes Mellitus-- This activity
will review the article published by Archives of Internal Medicine, which
concluded that statin medication use in postmenopausal women is
associated with an increased risk for DM.
o Topical Antifungal verse fluconazole-- This activity will inform providers
that it’s cheaper to use oral fluconazole than a topical antifungal such as
miconazole.
• Dr. McIntire presented Pharmacy Lock In Program:
o The policy has been finalized.
o Targeted pharmacies and targeted physicians have been redefined. A target
physician is now defined as the top 100 non-participating narcotic
providers. Targeted pharmacies have been changed to out of state
pharmacies and those pharmacies with known violations.
o Suboxone® users are getting locked in as they come. Currently the 4,000
user have not been locked-in. This is a very manual process; some changes
may have to be made. In fourth quarter there was 151 re-reviews.
o We had a 100 pharmacy lock-in change request. 59 requests were granted
approval. There are times after reviewing an enrollee lock-in change
request it’s determine that the enrollee needs to go to re-review.
12

o
o
o
o
o
o
o
o
There will be a letter sent to the lock-in pharmacy notifying the pharmacy
that the patient is locked-in, why the patient is locked-in, and some
common things to do and what not to do. The letter also communicates
how to get the person unlocked.
Another letter will go to the pharmacy that the person was using that’s not
the lock-in pharmacy. The letter will tell the pharmacies they should no
longer fill TennCare prescriptions for this enrollee. Once the non-lock-in
pharmacy is notified and continues to fill TennCare covered prescriptions it
will probably become a targeted pharmacy because at that point they know
what is expected.
The policy has provisions for special circumstances such as when a drug is
unavailable.
Dr. Woods mentioned if the request for lock-in change is due to relocation
the enrollee would have to register the new address with DHS.
Dr. Collier asked how would other pharmacists at the non-lock- in
pharmacy, for example a floater, know not to fill prescription for the lockin
patient.
Dr. Mills mentioned without running a claim the only way would be to flag
that patient profile maybe with a note.
Dr. Alston stated there have been legal cases regarding note placing on
patient profiles.
Dr. McIntire reiterated these letters are being sent to ask pharmacists to be
part of the solution.
• Dr. Alston announced the December meeting was moved to November 27
due to schedule conflicts. A new schedule will be sent out to include the
revised September and November meetings dates.
Meeting was adjourned at 11:50pm
Next DUR Board Meeting scheduled for June 5, 2012
13