Major Depression Medication Adherence Tool Kit

Transcription

1 Major Depression Medication Adherence Tool Kit

2 Major Depression Medication Adherence Tool Kit One of the keys to successfully managing major depression is medication adherence. VSHP has developed a new tool kit to give you additional insight into your patient population diagnosed with major depression. Providers may use code V Screening for depression as part of a regular office visit. Based on the time used for depression screening, the visit may need to be coded for a longer period of time which would increase the reimbursement rate. Not everyone will be majorly depressed. Use DSM IV guidelines for alternatives to coding. There may be one principal diagnosis of major depression or two secondary diagnoses. If you feel you have a member who may benefit from behavioral health services, you may call VSHP Referral Assistance at , Monday through Friday, 8 a.m. to 5 p.m. ET. Telephone consultation services are provided by Peer Advisors who are Board Certified Psychiatrists and available to discuss all aspects of mental health and substance abuse treatment including medications. Call , Monday through Friday, 9 a.m. to 5 p.m. ET. Identify yourself as a TennCare primary care provider seeking psychiatric consultation services. On page 4 of this toolkit is a depression screening tool you may use during your patient office visits. Please let VSHP know if you have any questions or recommendations on how we can partner with you to enhance the care to VSHP members.

3 VSHP Pharmacy Benefits for AGE 21 Years and Older 5 prescriptions each month only 2 brand name drugs $3 copay for each brand name drug No copay for generic drugs, birth control, and medications given in hospice care, for a medical emergency, or pregnancy problems Attached is a memo about script limits from the Bureau of TennCare For a current list of the drugs and supplies that do not count toward a TennCare enrollee s monthly drug limit, go to Preferred Anti-Depressants All Classes citalopram fluoxetine fluvoxamine paroxetine sertraline Effexor XR ST, QL venlafaxine ST, QL budeprion SR budeprion XL QL bupropion IR/SR bupropion XL QL maprotiline mirtazapine, mirtazapine rapdis trazodone amitriptyline clomipramine desipramine doxepin imipramine HCl nortriptyline Nardil Azilect selegiline Zelapar 1

4 Clinical Criteria, Step Therapy and Quantity Limits for TennCare PDL Central Nervous System Medication Class Medication PDL Step Therapy or Clinical Criteria Qty. Limits PA Form Antidepressants: SNRIs Effexor XR P Will only be authorized if recipient has tried and failed a therapeutic course of an SSRI at an appropriate dose (Defined as: 3 weeks at the maximum tolerated dose within the recommended therapeutic range). venlafaxine P See Effexor XR Step Therapy 2/day Cymbalta NP Cymbalta will be authorized for the following diagnoses: Depression/Major Depressive Disorder/Generalized Anxiety Disorder: Approval after trial and failure of one SSRI AND one preferred SNRI Diabetic peripheral neuropathic pain: Approved without trial and failure of an SSRI or any preferred agents within the SNRI class. Fibromyalgia: Approval will be granted after trial and failure, contraindication, or intolerance to: A tricyclic antidepressant or muscle relaxant, AND At least ONE of the following: an SSRI, preferred SNRI, pregabalin, or gabapentin 37.5, 75mg (1/ day); 150mg (2/day) Special Note: for 225mg dose: must use 150mg and 75mg tabs; for 375mg dose: must use 2-150mg tabs plus 75mg tab 2/day Effexor NP See Effexor XR Step Therapy 2/day Pristiq NP See Effexor XR Step Therapy 1/day Savella NP Will only be authorized for a diagnosis of fibromyalgia (see Cymbalta Clinical Criteria for fibromyalgia). 2/day venlafaxine XR NP See Effexor XR Step Therapy 1/day SNRI PA Form 2

5 Clinical Criteria, Step Therapy and Quantity Limits for TennCare PDL Central Nervous System Medication Class Medication PDL Step Therapy or Clinical Criteria Qty. Limits PA Form Antidepressants: SSRI (continued) Antidepressants: New Generation citalopram P 1.5/day General PA Form fluoxetine P 3/day fluvoxamine P 3/day paroxetine P 10, 20mg (1/day); 30, 40mg (2/ day) sertraline P 25mg, 50mg (1.5/day); 100mg (2/ day) Celexa NP 1.5/day fluoxetine weekly NP Lexapro NP 1.5/day Luvox NP 3/day May be approved if recipient has been stabilized at a dose of 20mg/ day of fluoxetine for > one month, with valid reason why recipient is unable to continue on fluoxetine 20mg daily. Luvox CR NP 100mg (3/day); 150mg (2/day) paroxetine CR NP 12.5, 25mg (1/day); 37.5mg (2/day) Paxil NP See paroxetine Paxil CR NP See paroxetine CR Pexeva NP 10, 20mg (1/day); 30, 40mg (2/ day) Prozac NP 3/day Prozac Weekly NP Sarafem NP 3/day Zoloft NP See sertraline See Clinical Criteria for fluoxetine weekly 4/month 4/month budeprion XL P 1/day General PA Form buproprion XL P 1/day Oleptro NP 150mg (1.5/day); 300mg (1/day) Wellbutrin XL NP 1/day The prevalence of depression within the United States (U.S.) adult population is 6.7 percent (Kessler, Chiu, Demier, & Walters, 2005). Although often undetected, about 20 percent of primary care patients suffer from significant symptoms of depression requiring further assessment and patient education (RAND Health Partners in Care). Depression is often difficult to identify and treat within the primary care setting as the 3

6 patient usually masks depressive symptomology with physical ailments; often, the patient is unaware that he/ she is depressed and/or in need of treatment (Kass-Bartelmes, 2004). Depression screening within the primary care setting is an evidence-based practice with data supporting a positive effect on patient outcomes (Pignone, 2002). Utilization of a formal, yet simple depression screening tool provides the primary care physician the opportunity to identify this often debilitating yet, very treatable condition (AHRQ, 2002). The Whooely Depression Screen, a simple two-question tool, is an easy and reliable way to identify a depressed patient within the primary care arena. Furthermore, when compared to longer traditional standardized tools, the Whooley produces similar test results with less administration time (Whooley, Avins, Miranda, & Browner, 1997). Whooley Screening Questions 1. During the past month, have you often been bothered by feeling down, depressed, or hopeless? 2. During the past months, have you been bothered by little interest or pleasure in doing things? If the patient answers Yes to one or both of these questions, further screening with a more detailed tool is recommended. Examples of additional standardized tools have been provided and can be located on the Internet. Patient Health Questionnaire (PHQ-9) Public Domain Beck Depression Inventory (BDI) The Psychological Corporation Hamilton Rating Scale for Depression (HAM-D) Public Domain Montgomery-Asberg Depression Rating Scale (MADRS) Public Domain Zung Self-Rating Depression Scale American Medical Association Item 9, practitioner-administered screening tool used in the diagnosing, monitoring and measuring depression severity (Kroenke & Williams, 2001). The PHQ-9 has good diagnostic properties within the primary care setting (Gilbody, et al., 2007). Item 21, self-administered, valid and reliable tool used for the diagnosis and rating of depression (Mullen, et al., 2004). Items 17 to 31, (depending on the version used) practitioner-administered rating scale. The HAM-D is the most widely used tool for the clinical assessment of depressive states (Mullen, et al., 2004). Item 10, practitioner-administered, reliable Instrument used for the evaluation and assessment of depressive symptoms in adults; also helpful in monitoring changes in depression level (Mullen, et al., 2004). Although short, simple and quantitative, this tool fails to capture atypical depressive symptomology (increased appetite, hypersomnia). Note: Patients in distress may score high but are not clinically depressed (Gilbody, et al., 2007). You may also call for VSHP Referral Assistance at , Monday through Friday, 8 a.m. to 5 p.m., ET. Medical records for members with behavioral health diagnosis should reflect efforts that support coordination of medical and behavioral health care. Records may include written correspondence to and/or from behavioral health providers, or inquiries regarding such services, and referrals if appropriate, and follow up with patients to ensure they are taking their medication as directed. 4

7 Antidepressant Medication Management HEDIS Measure Definitions Antidepressant Medication Management Acute Phase The measure looks at the percentage of members 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication and remained on an antidepressant medication treatment. Acute Phase: Effective acute phase is the percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks). Antidepressant Medication Management Continuation Phase Effective continuation phase treatment is considered to last at least 180 days (6 months). Members should be taking their prescribed medication and following their treatment plan. Medical records for members with behavioral health diagnosis should reflect efforts that support coordination of medical and behavioral health care. Records may include written correspondence to and/or from behavioral health providers, or inquiries regarding such services, and referrals if appropriate, and follow up with patients to ensure they are taking their medication as directed. Codes to Identify Major Depression Description ICD-9-CM Major depression , , 298.0, 300.4, 309.1, 311 Codes to Identify Visit Type Description CPT HCPCS UB Revenue ED x, 0981 Outpatient, intensive outpatient and partial hospitalization , , 99078, , , , , , , , , , 99411, 99412, CPT 90801, 90802, , , , 90845, 90847, 90849, 90853, 90857, 90862, 90870, 90875, 90876, , , 99238, 99239, G0155, G0176, G0177, G0409-G0411, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485 WITH 0510, 0513, , , , 0900, 0901, , 0907, , 0919, 0982, 0983 POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 5

8 References Agency for Healthcare Research and Quality (AHRQ). (2002). U.S. Preventive services task force now finds sufficient evidence to recommends screening adults for depression. Accessed July 19, 2011 from pr2002/deprespr.htm Gilbody S., Richards D., Brealey S., & Hewitt C. (2007). Screening for depression in medical setting with the patient Health Questionnaire (PHQ): A diagnostic meta-analysis. Journal of Internal Medicine; 22(11), Kass-Bartelmes B. L. (2004). Programs and tools to improve the quality of mental health services. Accessed July 19, 2011 from Kessler R.C., Chiu W.T., Demler O., Walters E.E. (2005). Prevalence, severity, and comorbidity of twelve-month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R). Archives of General Psychiatry; 62(6), Kroenke K., & Williams W. (2001). The PHQ-9: Validity of a brief depression severity measure. Journal of Internal Medicine; 16, Mullen J., Endicott J., Hirschfeld R.M., Yonkers K., Targum S.D., Bullinger A.L. (2004). Manual of rating scales for the assessment of mood disorders. AstraZeneca Pharmaceuticals LP; Wilimington Delaware. Pignone M.P., Gaynes B.N., Rushton J.L., Burchell C.M., Orleans C.T., Mulrow C.D., Lohr K. (2002) Screening for depression in adults: A summary of the evidence for the U.S. preventive services task force. Annals of Internal Medicine; 136: RAND Health Partners in Care. Hope for those who struggle with hope, Research Highlights. Accessed July 19, 2011 from Whooley M. A., Avins A., Miranda J., Browner W.S. (1997). Case-finding instruments for depression. Journal of General Internal Medicine; 12, BlueCross BlueShield of Tennessee 1 Cameron Hill Circle Chattanooga, TN vshptn.com Volunteer State Health Plan, Inc. (VSHP), BlueCross BlueShield of Tennessee, Inc. (BCBST) and BlueCare are independent licensees of the BlueCross BlueShield Association. VSHP is a licensed HMO affiliate of BCBST. 12PED1579 (8/12)