Below is the HillCo client report from the January 30 Drug Utilization Review Board meeting.

The following report only includes selected agenda items.
2014 Clinical Edit Review Process
Andy Vasquez, Medicaid Vendor Drug Deputy Director, HHSC

  • There are many parties whose concerns must be taken into account during the drug review process including prescribers, patients, health plans and drug manufacturers
  • With the new process, important existing factors in the current process will be leveraged such as the public process of input and testimony and the Board’s great reputation and experience
  • Staff has developed a revised process that will build on these factors and at the same time implement new procedures
  • On the front end, MCOs will be allowed to submit clinical edits, they will go to HHSC staff for review and then be submitted to PA vendors who develop the clinical edit proposal to submit to the DUR Board
  • The criteria for review will depend on whether it is a drug specific proposal or class-wide, whether they are the same as clinical edits already in place, whether they are consistent with the package insert and their impact on the PDL
  • Proposals will be developed and consolidated for review in a way that makes sense
  • DUR Board will consider the potential impacts to providers, patients and payers; proposals will be approved, declined or pended
  • Intake and preparation will depend heavily on timeline; trying for a six month window from proposal intake to that class being heard by the P&T committee
  • Some proposals have already been accepted and the April DUR Board meeting will be a catch-up to hear the remaining proposals
  • Another difference in the process will be that implementation will vary by MCO who will be allowed to act on changes whether or not they have been implemented by HHSC
  • Board member Dr. Rolf Habersang asked if MCOs will have their own edits whether clinical edits will be able to be implemented if approved by the DUR Board
    • Correct, and all MCOs will have the same formulary and the same PDL as directed by the legislature through 2018
  • Board member Dr. Laura Ferguson asked why MCOs will be able to implement changes faster than HHSC
    • If changes are already in their commercial plans and ready to go, it will be relatively simple whereas HHSC would still have development work to put them in place

Report on Retrospective DUR Proposal for Chronic Non-Malignant Pain
Larry Dent, HHSC

  • The proposal mail date was December 30, 2013
  • 775 providers are potentially impacted
  • 487 patients are potentially impacted