Executive Summary

The Texas Vendor drug Program (VDP) implements prospective and retrospective drug utilization review (DUR) to ensure appropriate and medically necessary drugs are prescribed to people enrolled in Medicaid. The Texas Medicaid Drug Utilization Review Board’s focus is to promote cost saving initiatives through prospective, point-of-sale (POS) interventions. This, along with educational intervention letters, creates opportunity to promote proper pharmaceutical care to people enrolled in Medicaid, as well as pharmacy claim reviews by HHSC field staff. The percentage net savings for FFY 2016 was 5% of the total expenditure.

DUR Board

  • The Texas Medicaid DUR Board conducted 4 meetings for federal fiscal year 2016.

The 2014 review of HHSC by the Texas Sunset Advisory Commission favored eliminating fragmentation of services by combining similar functions.  This decision lead to combining the activities of the Pharmaceutical and Therapeutics Committee into the DUR Board as of February 2016.  The Sunset review also recommended an increase in the number of the DUR Board members from nine to eighteen members and added a few new specialties such as OBGYN, patient advocacy, academia, child and adolescent psychiatry, two members from the managed care organizations (MCO) of which one is a medical director. Of all the members, the MCO representatives are non-voting members and they do not participate in the closed executive session of the meeting.

Prospective Drug Utilization Review

  • Texas FFS Medicaid implemented several updates to the existing clinical prior authorization criteria including: combining all the existing Fentanyl containing agents into one document, update on the Xifaxan clinical prior authorization criteria to include new indications for Xifaxan 550mg, update on the topical Immunomodulators to account for the correct age indications and length of prior authorization approval.  Other minor updates were on Ranexa, leukotrienes, Duplicate Therapy, etc.  Implementation of majority of the clinical prior authorizations are optional for the MCOs. 
  • The preferred drug list (PDL) prior authorizations are implement twice per calendar year.  In FFY 2016, Texas Medicaid FFS implemented non-preferred prior authorization criteria in November of 2015 and in July of 2016.  The MCOs are required to implement the same PDL criteria and on the same dates as the FFS Medicaid. 
  • In addition to the clinical and non-preferred prior authorization criteria, the Vendor Drug Program imposes quantity limits and internal claim override process to some drugs or therapeutic classes to help ensure medications are used at appropriate doses for approved indications.
  • FFY 2016 total savings from the pro-DUR prior authorization was reported as $35,427,072.00 of which $5,994,146.00 was reported as savings associated with the non-preferred prior authorizations, $16,159,680.00 associated with clinical prior authorizations, and $9,149,713.00 as claims that encountered both non-preferred and clinical prior authorizations.  The pro-DUR clinical prior authorization vendor, HID, Inc., also reported on an additional $12,120,981.00 in saving which were associated with prior authorization requests that were denied as a result of validation errors (i.e. prior authorization already in place, drug does not need prior authorization, patient was covered, etc.).  The reported total savings did not include validation error savings because the state did not consider this as a result of a true DUR process.

Retrospective Drug Utilization

  • Texas contracts with a non-fiscal agent vendor to review patient profiles for selected prescriber performance indicators. Prescribers who are identified as having prescribing practices outside of accepted parameters or clinical guidelines are sent educational letters approved by the DUR Board and include patient profiles and suggestions that include specific messages to assist prescribers with enhanced treatment management.
  • In 2016 HHSC implemented the following 10 disease or drug related retro-DUR interventions: Clozapine, Rheumatoid Arthritis, Bipolar, Antidepressant, Chronic non-Malignant Pain, Stroke, ADHD, Diabetes, Polypharmacy, and Atypical Antipsychotics.
  • The savings reported by the vendor is $15,558,578.38.  The details for each intervention is included within attachment 5.  The negative numbers reflect an increase in the claims (indicative compliance with prescription drugs needed for treatment) or an increase in the necessary laboratory testing or office visit for any necessary exams such as foot exams or eye exams for diabetic patients.
  • Automated-Refill Policy:
    • Refills may only be submitted when requested by the individual. Providers must not bill Medicaid unless the individual has requested the refill – this includes pharmacies that use automated refill systems/programs.

Conclusion

In FFY 2016 the DUR Board addressed many prospective and retrospective interventions, all to improve health and safety of the Medicaid eligible clients as well as ensuring that appropriate cost prevention parameters were in place to maximize limited health resources.