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2 TWO PRIMARY ACCESS POINTS Pharmacy Benefit Dispensed by a Pharmacy Billed via the PBM Process (NCPCP) Oversight by Drug Utilization Review (DUR) Board Prior Authorization Required Medical Benefit Administered in outpatient / inpatient setting Billed via medical claim form (1500) Prior Authorization Required
3 EXAMPLES: A claim for an individual receiving inpatient detoxification for multiple days would be submitted and paid through HP as a medical benefit. If the provider chose to prescribe a monthly injection of Vivitrol (obtained and administered by the physician), this service would also be paid as a medical benefit as buy and bill. If a provider wrote a prescription and sent a patient to a pharmacy for VIVITROL, it would be billed through Catamaran POS PBM system and would not require PA. If a provider chose to prescribe oral SUBOXONE, the medication would require PA to ensure it was NOT being used for pain management, and then be dispensed at a pharmacy and paid under the pharmacy benefit. If a prescriber writes a methadone prescription for pain and sends a patient to a pharmacy, it s billed as a Catamaran POS PBM claim and would NOT require PA. OPIATES HAVE A RETROSPECTIVE DUR REVIEW
4 PRODUCT INFO: Medication FDA Indications Covered Benefit Characterization Cost* buprenorphine sublingual tablet (SUBUTEX) buprenorphine/ nalaxone (SUBOXONE, BUNAVAIL, ZUBZOLV) methadone (pill form) methadone (liquid form, daily oral) naltrexone [REVIA (daily oral), VIVITROL (monthly injection)] Opiate dependence Generic version on market Pharmacy Addictive $90/month Opiate dependence YES Pharmacy Addictive $210/month Pain management YES Pharmacy Addictive $18/Rx Opiate dependence NO Medical Addictive Approx. $0.50 a dose at wholesale price Alcohol dependence; Opiate dependence YES Medical Non-Addictive $1,280/ month *Important: The costs outlined in the chart above solely represent the cost of the medications. They do not include Medicaid reimbursement for medical services rendered, transportation or counseling.
5 LEGAL AUTHORITY: 405 IAC (a) Medicaid reimbursement is available for inpatient detoxification, rehabilitation, and aftercare for chemical dependency when such services are prior authorized subject to this section.
6 SPECIFIC METHADONE COVERAGE In what form do individuals receive the medication? Where can a member receive the medication? Is it currently reimbursed by Indiana Medicaid Does it require prior authorization Methadone (for pain management) Oral Tablet Dispensed from any pharmacy with an appropriate prescription Yes No (But post utilization review is ongoing) Methadone Maintenance (for opiate dependence) Oral Liquid Administered only at certified Opioid Treatment Programs (OTPs) No (current rule under review) N/A
7 KEY TAKEAWAY POINTS: Indiana Medicaid DOES reimburse for inpatient detoxification services (aka opiate withdrawal) Indiana Medicaid DOES reimburse for outpatient substance abuse treatment. Indiana Medicaid DOES NOT reimburse for methadone for opiate dependence beyond detox (otherwise known as methadone maintenance therapy) but DOES cover methadone for pain management. Prior authorization is NOT CURRENTLY REQUIRED for methadone for pain management Indiana Medicaid DOES reimburse for other addictive (e.g. SUBOXONE ) and non-addictive (i.e. VIVITROL ) medications for the treatment of substance abuse Prior authorization is CURRENTLY REQUIRED for SUBOXONE Prior authorization is NOT CURRENTLY REQUIRED for VIVITROL
8 BY THE NUMBERS: methadone In CY2014, we processed and paid 933,091 opioid claims. 15,146 of those were for methadone for pain management. That represents 1.6% of all opioid claims paid in CY2014. Facility daily methadone costs < $1 per day Consider multiple transportation costs/office visits, counseling sessions Outpatient pharmacy methadone is $18 average per Rx (~30-days) VIVITROL CY2014 RX expenditure was $419,610 on 361 claims (avg $1,162) One office visit per month CY2014 MED expenditure was $184,620 on 112 claims (avg $1,648) HCPCS J2315 Service Code SUBOXONE CY 2013 RX was $7,438,057 on 27,952 claims (avg $266) CY 2014 RX was $7,848,053 on 30,247 claims (avg $259) buprenorphine sublingual (f.k.a. SUBUTEX ) $212,819 on 2,375 claims (avg $90)
9 BY THE NUMBERS: Opiate Treatment Centers Claims are primarily professional service CMS 1500 claims with some outpatient claims Medicaid Methadone Claims 7/1/2012 to 6/30/2014 Recipients Expenditures Units SFY 13 FFS Claims 5,551 $223,564 12,513 Encounter Claims 5,290 $91,629 9,612 Unduplicated Totals 10,616 $315,193 22,125 SFY14 FFS Claims 8,773 $509,537 23,385 Encounter Claims 8,158 $470,380 18,950 Unduplicated Totals 16,610 $979,917 42,335
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