Microsoft word - 2007%20hc%20mco%20questionnaire[1].doc

Name of MCO
HEALTHCHOICE MCO DRUG USE MANAGEMENT PROGRAM ANNUAL ASSESSMENT
February 2007
The Maryland Medicaid Pharmacy Program, Division of Clinical Pharmacy Services is responsible for monitoring and approving each MCO's drug use management program. Approval of your MCO's drug use management program for FY 2008 will be determined by a review of your formulary and your responses to the information and documentation requested on this form. All Questions should be directed to Eva Carey-Brown, Maryland Medicaid Pharmacy Program,
via e-mail at Ecarey-Brown@dhmh.state.md.us
Name: Title:
Address:
State: Zip:
Pharmacy Website:

Pharmacy Benefit Manager

Company:
PBM Pharmacy Website:
Address:
State: Zip:

Please identify the individual completing this survey


Primary contact person for Drug Formulary & Prior Authorization inquiries:


(Revised 2/2007)


Name of MCO
Please answer all questions in the context of your MCO's current policies and procedures and
the services provided to HealthChoice enrollees.

1.0 P & T COMMITTEE

1. Has your MCO changed the P & T Committee structure, membership, policies and procedures, meeting schedule, or made any other changes since your last submission to the Department of Health & Mental Hygiene (DHMH) in 04/2006? Please summarize any changes to the P & T Committee and attach supporting documentation. 2. What is the total number of Maryland Medicaid HealthChoice enrollees in your MCO as of 12/2006? _____________ 2a. What is the percent of Maryland Medicaid HealthChoice enrollees within your entire membership as of 12/2006? __________%
2.0 FORMULARY

1. Has your MCO changed the formulary structure, policies and procedures, or made any other type
of changes to your formulary since your last submission to DHMH in 04/2006? 1a. Please summarize any other changes to the formulary and attach supporting documentation. 2. Does your MCO allow the use of non-formulary medications for HealthChoice enrollees?
3. What was the date of the last complete formulary review by the MCO management or P & T

4. In what format is the formulary available to: (check all boxes that apply)
Physician providers
enrollment materials/provider agreement wireless communication device (PDA) Epocrates
Pharmacy providers
enrollment materials/provider agreement HealthChoice enrollees
Name of MCO

5. In what format are updates available to: (check all boxes that apply)
Physician providers
Pharmacy providers

HealthChoice enrollees
6. When was the most recent MCO formulary update, based on P & T decisions, submitted to the 6a. Formulary updates to the PBM are distributed monthly quarterly other (specify)_____________________________________ 7. Provide documentation that your MCO includes the following medications as formulary products Medication
Page Location on Formulary
Payable Through
Benefits Summary Sheet
conditions Hypodermic needles and syringes years of age Nonlegend ergocalciferol liquid Vitamin D POS = point of sale - online pharmacy processing. Med. Ben. = medical benefits provided by the MCO. Name of MCO
These medications are required to be included on your formulary as stated in COMAR 10.09.67.04D4. If prior authorization is required supply total number of
requests approved, and total number of requests denied. P/A criteria for these drugs must be submitted.
Medication
Formulary Item
P/A Required
Total Number of
Emergency
Requests
Approved
Supplies
Available
During P/A
naloxone (Suboxone®)* carbamazepine (Tegretol®) *Coverage required per memo from Department dated December 10, 2003. 8. Send a complete list detailing the following drug plan benefits or indicate the formulary page where the list is located. 9. Please indicate below the current co-payments charged recipients for the following types of medications: Generic non-preferred or non-formulary drugs: $_________ co-payment Brand non-preferred or non-formulary drugs: Name of MCO

10. Complete attached list of new drugs approved by the Food & Drug Administration (FDA) for CY2006.
HEALTHCHOICE MANAGED CARE ORGANIZATIONS
REVIEW OF NEWLY FDA APPROVED MEDICATIONS
New Drugs Approved January 1, 2006 - December 31, 2006 New Molecular Entities
Drug Name/Description
P & T Committee evaluated/will evaluate on:
Added to the formulary
*Restrictions
arformoterol (Brovana®) - Long-acting Date:___/___/___ Aspergillus and Candida in severely Name of MCO
HEALTHCHOICE MANAGED CARE ORGANIZATIONS
REVIEW OF NEWLY FDA APPROVED MEDICATIONS
New Drugs Approved January 1, 2006 - December 31, 2006 New Molecular Entities (continued)
Drug Name/Description
P & T Committee evaluated/will evaluate on:
Added to the formulary
*Restrictions
Corticosteroid nasal spray for treatment Date:___/___/___ biskalcitrate/metronidazole/tetracycline treatment of H. pylori in combination *Please enclose copies of criteria and any prior authorization procedures that differ from your standard prior authorization procedures and are required to obtain these
medications.
Name of MCO
HEALTHCHOICE MANAGED CARE ORGANIZATIONS
REVIEW OF NEWLY FDA APPROVED MEDICATIONS
New Drug Products Approved January 1, 2006 - December 31, 2006 New Dosage Forms
Drug Name/Description
P & T Committee evaluated/will evaluate on:
Added to the formulary
*Restrictions
(Atripla®) - A new fixed-dose combination estradiol (Elestrin®) - Topical gel for formulation for breakthrough pain in opioid- fentanyl (Ionsys) - Transdermal system for norethindrone/ethinyl estradiol (Loestrin 24 oral formulations for management of pain. doxycycline (Oracea®) - New formulation Name of MCO
HEALTHCHOICE MANAGED CARE ORGANIZATIONS
REVIEW OF NEWLY FDA APPROVED MEDICATIONS
New Drugs Approved January 1, 2006 - December 31, 2006 New Dosage Forms (continued)
Drug Name/Description
P & T Committee evaluated/will evaluate on:
Added to the formulary
*Restrictions
(Seasonique®) - An extended-cycle (84-day) miconazole/zinc oxide/petrolatum (Vusion®) - New ointment for treatment of diaper rash drospirenone/ethinyl estradiol (Yaz®) - A disintegrating tablets for Parkinson's disease. *Please enclose copies of criteria and any prior authorization procedures that differ from your standard prior authorization procedures and are required to obtain these
medications.
Name of MCO
11. Does your MCO provide latex condoms without a written order?
12. Does your MCO provide coverage of Plan B without a written order for
3.0 GENERIC SUBSTITUTION
1. Does your MCO require generic substitution for HealthChoice enrollees? 2. Has your MCO made any changes to the generic substitution policy and procedures since your last submission Please summarize any changes to generic substitution policies and procedures and attach 3. Are all FDA approved generic drug products, including those which are not listed on the 4. Is a FDA MedWatch form required for authorization of a Brand Medically
4.0 THERAPEUTIC INTERCHANGE
1. Does your MCO have any therapeutic interchange programs for HealthChoice enrollees where by
pharmacists may make a therapeutic substitution without prior approval from the prescriber ? If yes, please submit detailed description of the program since these programs are not currently allowed, except under COMAR 10.34.10.01C (2).
5.0 PRIOR AUTHORIZATION
1. Has your MCO made any changes to the prior authorization criteria, policies or procedures since Please summarize any changes to prior authorization criteria, policies or procedures and attach supporting documentation.
2. What is the range of time from the initial receipt of a non-formulary, brand medically necessary or
prior authorization request until a decision is made to approve/deny the medication? Name of MCO

3. If the HealthChoice enrollee requires prior authorization to receive a medication, does your MCO
have an emergency supply policy and procedure to provide medication for the enrollee during the authorization process for the following? 4. Does your MCO allow overrides in the following situations? Is prior authorization required for HealthChoice enrollees? Override Allowed?
P/A Required?
Two prescriptions for the same medication 5. Does your MCO notify the Prescriber when a P/A is approved? 5a. Does your MCO provide written notification to the prescriber when a P/A is denied? 6. Does your MCO notify the pharmacy (when known) if the P/A is approved? 6a. Does your MCO notify the pharmacy (when known) if the P/A is denied? 7. Does your MCO require Step Therapy Protocols for the use of any medications? Yes 7a. If yes, please submit a listing of medications that require Step Therapy Protocols along with 8. Does your MCO use electronic edits when processing prescription claims at Point-Of-Service? Electronic edits are defined as verification programs utilized by the PBM at Point-Of- Service to identify prior drug therapy with preferred or first line agents before allowing second line or non-formulary Name of MCO
9. List the number of requests received for HealthChoice enrollees from January 1, 2006 -
December 31, 2006 for the following.
a. List the total number of requests for formulary medications that require P/A.

Total # of requests __________ Number approved _________ Number denied ___________
Number redirected to formulary drugs_________ b. List the total number of requests for non-formulary medications:
Total # of requests __________ Number approved __________ Number denied __________ Number redirected to formulary drugs_________ c. List the total number of requests for BMN overrides:
Total # of requests __________ Number approved __________ Number denied __________ d. List the total number of requests for early refill override:
Total # of requests __________ Number approved __________ Number denied __________ Name of MCO
10. List the total number of prior authorization/non-formulary requests for HealthChoice enrollees from January 1, 2006 - December 31,
2006 for the following medications. Include all strengths, dosage forms, and combination products (e.g., azithromycin tablets and
suspension) as well as brand or generic version of the drugs listed.
Medication
This Medication is
Number Redirected
Non-formulary or Requires
Number of
Approved
to Formulary Drug
Prior Authorization
Requests
(Botox®) -- for medical uses only celecoxib (Celebrex®) estradiol (NuvaRing®) exenatide (Byetta®) Name of MCO

6.0 DRUG USE EVALUATION

1. Does your MCO have the following programs?
(Check all types of criteria that apply) State of Maryland Coordinated ProDUR criteria Retrospective drug use review frequency monthly
2. Has your MCO made any changes to the policies and procedures of your drug use evaluation
program since your last submission to DHMH in 04/2006? Please summarize changes to the drug use evaluation policies and procedures and attach supporting documentation. 3. Does your P&T Committee or MCO have policies and procedures in place to provide oversight for the drug use evaluation process and maintain patient confidentiality? Name of MCO
4. List the types of prospective DUR alerts utilized by your MCO. Indicate which alerts result in a
claim denial, and whether MCO or PBM overrides the claim denial, if appropriate. Type of Prospective DUR Alert
Utilized by
Claim Denial
Claim Denial
Override
Name of MCO
5. Provide the following information for each retrospective drug use review activity performed during the year 2006, using HealthChoice enrollee 5a. Are retrospective studies completed by ____MCO ____ PBM 5b. Does the P & T Committee review the following: • Retrospective study design (including criteria and standards), Start date, range
Title and Purpose of Study
Expected Outcome
Results Received
Interventions
and completion
Performed
date (or indicate
if on-going)
Name of MCO
7.0 DISEASE MANAGEMENT

Disease Management is a continuous, coordinated, evolutionary process that seeks to manage and
improve the health status of a carefully defined patient population over the entire course of a disease.
A successful disease management program achieves this goal by identifying and delivering the most
effective and efficient combination of available resources.
1. Does your MCO have any disease management programs for HealthChoice enrollees that meet the
above definition and have a significant medication component? (A significant medication
component is defined as that which utilizes medication step-therapy guidelines or protocols,
medication algorithms or medication practice guidelines. For example, an asthma disease management
program that utilizes the Practical Guide for the Diagnosis and Management of Asthma, developed by
the National Institutes of Health or other treatment algorithms that include guidelines for drug
therapy.)
2. Has your MCO made any changes to the disease management program policies and procedures, the programs available to HealthChoice enrollees, or any other changes since your last submission to Please summarize changes to the disease management program policies and procedures and attach supporting documentation. 3. Does your P & T Committee or another committee review and approve all medication step-therapy protocol usage within practice guidelines, clinical algorithms, and protocols that are used within the disease management programs? If other committee, submit a list of the committee members indicating whether they are voting members and whether they have direct patient care responsibilities for HealthChoice enrollees. 4. Does your MCO have a policy to allow physician and pharmacy providers to make exceptions to Disease Management protocols if in the best interest of patient care. (Please submit policy if separate from Disease Management policy) 5. Does your MCO have an enrollee confidentiality policy that limits access of data to responsible personnel (such as providers, pharmacy benefit manager and MCO staff)? Name of MCO
6. Please list the disease management programs currently offered to HealthChoice enrollees, as well as any programs planned for 2007. Indicate if
these are active MCO programs and list the number of HealthChoice enrollees currently included in each program.
Disease Management
Source of
Date Medication
Is This Disease
Educational
Disease Management Program
Number of
External Funding
Usage Guidelines,
Management
Materials for
Performed By
HealthChoice
if Applicable
Clinical Algorithms
Providers/
Enrollees
& Protocols were
Currently
Enrollees
(If none, please
Approved by the
(List for all
indicate)
Appropriate
Committee
Programs)
7. Are performance audits conducted for each disease management program performed by the PBM or other contractor? Name of MCO
Please submit the following in addition to the required supporting documents:

BENEFIT SUMMARY
A summary of the pharmacy benefits provided by the PBM for the MCO's

POLICY AND PROCEDURES

Your
Policies and procedures to provide oversight for the drug use evaluation process Any policies and procedures revised during year 2006 or for year 2007.
P & T COMMITTEE

P & T Committee meeting minutes for all meetings held in the year 2006.
Name of MCO
Listing of P & T Committee voting members and whether they have clinical duties for HealthChoice enrollees. Please indicate which member serves as the chairperson of the P & T Committee. The chart on the following page may be used to ensure information submitted is complete. P & T COMMITTEE MEMBERSHIP
P & T Committee Members
Voting Member
Direct Patient Care
Provider for
Responsibilities
HealthChoice
enrollees
Name of MCO

FORMULARY
Copy of your 2007 Formulary (printed booklet) as stated in
COMAR
Specific URL for web based formulary (enter here) www.______________________ Included A
PRIOR AUTHORIZATION

Copy of P/A Non-Formulary forms including submission phone and fax number
Copies of Step Therapy Protocols & Algorithms for all included drug classes. Copies of P/A criteria for Mental Health Drugs cited in COMAR 10.09.67.04D4
DISEASE MANAGEMENT

For each Disease Management program active in 2006 and planned for 2007 with a significant
medication component, submit the following information.
Your MCO's rationale for all disease management programs
Your committee approved medication step-therapy protocol usage guidelines, clinical algorithms, and protocols for all disease management programs. • If the medication usage guidelines are national

guidelines,
reference.
• If the medication usage guidelines have been
modified or are unique to the MCO, they must be
submitted.
Educational materials sent to providers for each active disease management program.
Enrollee educational material does not need to be submitted at this time.

Source: http://www.emdhealthchoice.org/pdf/Questionnaire0207.pdf