PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY … · 2019-06-18 · PHARMACEUTICAL ASSISTANCE...

PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY

ANNUAL REPORT TO THE PENNSYLVANIA GENERAL ASSEMBLY

JANUARY 1 - DECEMBER 31, 2018

For the Pennsylvania Department of Aging Director Thomas M. Snedden Administrative Assistant Megan McDaniel Outreach and Enrollment Manager Rebecca D. Lorah, MPA Administrative Officer Janis L. Rhodes Research and Evaluation Chief Theresa V. Brown, MPA Program Analyst Ellaheh Otarod, MBA Program Analyst Antonino G. Vetrano, MPA

Pennsylvania Department of Aging The PACE Program

Forum Place Building 555 Walnut Street

5th Floor Harrisburg, PA 17101-1919

717-787-7313 [email protected]

For Magellan Medicaid Administration, Inc. Officer in Charge Dorinda C. Murray Director, PACE Operations Jean B. Sanders Provider Services Manager Amy E. Brewer Business Services Manager Robert B. Burns Medicare Part D Manager Lilith E. Colbert Clinical Pharmacist Judith Dooley, RPh Senior Health Outcomes Scientist Debra A. Heller, PhD, MPH Health Outcomes Scientist Shivani R. Khan, PhD Clinical Pharmacist Michelle LaSure, RPh Clinical Pharmacist Colleen M. Moyer, RPh Cardholder Services Manager Sally A. Murphy Former Business Services Manager Donald G. Smith LAN/WAN Manager W. Todd Spacht Quality Assurance Manager Lisa Spiegel Systems Manager John K. Wheeler

Magellan Medicaid Administration 4000 Crums Mill Road, Suite 301

Harrisburg, PA 17112 717-651-3600

Any questions or comments pertaining to information within this report may be addressed to the Pennsylvania Department of Aging at the address given above.

TABLE OF CONTENTS

Frequently Requested Program Statistics ......................................................................................... 1

History ............................................................................................................................................... 3

Administration ................................................................................................................................... 5

Section 1 – Program Research Highlights .............................................................................. 7-16

Section 2 – Financial Data by Date of Service ...................................................................... 17-32

Table 2.1A Historical Claim and Expenditure Data for PACE Enrolled ........................... 19-21 and Participating Cardholders by Semi-Annual Period Based On Date of Service January 1991 - December 2018

Table 2.1B Historical Claim and Expenditure Data for PACENET Enrolled .................... 22-23 and Participating Cardholders by Semi-Annual Period Based On Date of Service July 1996 - December 2018

Figure 2.1 PACE and PACENET Claim Distribution by Amount Paid per Claim ................ 24 January - December 2018

Figure 2.2 Distribution of PACE Annual Benefit .................................................................. 25 January - December 2018

Figure 2.3 Distribution of PACENET Annual Benefit .......................................................... 26 January - December 2018

Table 2.2 Total Prescription Cost, Expenditures, Offsets, and Recoveries ....................... 27 January - December 2018

Table 2.3 Claims and Expenditures by Program, Product Type, ...................................... 28 and Payment Source January - December 2018

Figure 2.4 PACE and PACENET Enrollment, Claims, and ................................................. 29 Claims Expenditures by Calendar Year 1988-2018

Figure 2.5A PACE Total Enrolled and Participating Cardholders ......................................... 30 By Month January 2008 – January 2019

Figure 2.5B PACENET Total Enrolled and Participating Cardholders .................................. 31 By Month January 2008 – January 2019

Section 3 – Program Data by Date of Payment ..................................................................... 33-44

Table 3.1 Historical PACE and PACENET Reimbursement Formulas .............................. 35 July 1984 - December 2018

Table 3.2A PACE High Expenditure and High Volume Claims ....................................... 36-38 January - December 2018

Table 3.2B PACENET High Expenditure and High Volume Claims ................................ 39-41 January - December 2018

Table 3.3 PACE and PACENET Number and Percent of ............................................ 42-43 Expenditures and Claims by Manufacturer January - December 2018

Table 3.4 Manufacturers' Rebate Cash Receipts by Quarter/Year .................................... 44 Billed and by Fiscal Year Received January 1991 - December 2018

Section 4 – Cardholder Utilization Data ................................................................................. 45-58

Table 4.1 PACE and PACENET Cardholder Enrollments by Quarter .......................... 47-49 July 1984 – December 2018

Table 4.2A PACE Cardholder Enrollment, Participation, Utilization, ............................... 50-51 and Expenditures by Demographic Characteristics January - December 2018

Table 4.2B PACENET Cardholder Enrollment, Participation, Utilization, ....................... 52-53 and Expenditures by Demographic Characteristics January - December 2018

Table 4.3 Other Prescription Insurance Coverage of PACE and ....................................... 54 PACENET Enrolled Cardholders January - December 2018

Table 4.4 Part D Cardholder Enrollment, Participation, and Expenditures ................... 55-56 January - December 2018

Table 4.5 Annual Drug Expenditures for PACE/PACENET Enrolled ................................. 57 By Total Drug Spend, Part D Status, and LIS Status January - December 2018

Figure 4.1 PACE Generic Utilization Rates by Quarter ...................................................... 58 December 1988 - December 2018

Section 5 – County Data .......................................................................................................... 59-64

Table 5.1 Number and Percent of PACE and PACENET Cardholders ........................ 61-63 and Number of Providers by County January - December 2018

Figure 5.1 Percent of Elderly Enrolled in PACE/PACENET and ......................................... 64 Percent Urban Population by County January - December 2018

Section 6 - Provider Data ......................................................................................................... 65-72

Table 6.1 PACE Claims by Product and Provider Type .................................................... 67 January - December 2018

Table 6.2 PACE Expenditures and Average State Share by Product .............................. 68 and Provider Type January - December 2018

Table 6.3 PACENET Claims and Expenditures by Provider Type ..................................... 69 January - December 2018

Table 6.4 PACENET Claims by Product and Provider Type, ............................................ 70 January - December 2018

Table 6.5 PACENET Expenditures and Average State Share by ...................................... 71 Product and Provider Type January - December 2018

Section 7 - Therapeutic Class Data and Opioid Utilization Data.......................................... 73-92

Section 7, Part A - General Therapeutic Class Data ......................................................... 75-84

Table 7.1A Number and Percent of PACE Claims, State Share Expenditures, .............. 77-78 and Cardholders with Claims by Therapeutic Class January – December 2018

Table 7.1B Number and Percent of PACENET Claims, State Share .............................. 79-80 Expenditures, and Cardholders with Claims by Therapeutic Class January – December 2018

Figure 7.1 Percent of PACE and PACENET State Share Expenditures ............................. 81 By Therapeutic Class January - December 2018

Figure 7.2 Number and Percent of PACE and PACENET Claims ................................. 82-83 with a Prospective Review Message by Therapeutic Class January - December 2018

Section 7, Part B – Opioid Utilization Data ........................................................................ 85-92

Table 7.2 PACE/PACENET Opioid Utilization ................................................................... 88 January – December 2018

Table 7.3 PACE/PACENET Opioid Utilization by County ............................................. 89-90 January – December 2018

Table 7.4 Opioid Retrospective Drug Utilization Review Interventions .............................. 91 January – December 2018

Section 8 - Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) .............. 93-96 Appendix A - PACE/PACENET Survey on Health and Well-Being 2018 Report, .................... 97-124

The PACE Application Center 2018 Report, University of Pennsylvania and PACE/PACENET Behavioral Health Lab Program 2018 Report, and The PACE Academic Detailing Program 2018 Report

Appendix B - The PACE/PACENET Medical Exception Process........................................... 125-126

Appendix C - American Hospital Formulary Service (AHFS) Classifications ......................... 127-128

Appendix D – PACE Prospective Drug Utilization Review Criteria ........................................ 129-159

Appendix E - State Funded Pharmacy Programs Utilizing the PACE Program Platform ....... 160-166

FREQUENTLY REQUESTED PROGRAM STATISTICS The table below provides frequently requested Program information and lists references within the Annual Report for additional details.

2018 PACE AND PACENET SUMMARY PACE PACENET REFER TO:

DEMOGRAPHIC DATA Total enrolled for 2018 89,885 172,780 Tables 4.2, A and B % Participating 72.4% 75.9% Tables 4.2, A and B Avg. age for enrolled 79.7 78.7 Tables 4.2, A and B Female, avg. age 80.6 79.2 Male, avg. age 77.0 77.7 % Female 75.1% 66.6% Tables 4.2, A and B % Own residence 50.0% 63.4% Tables 4.2, A and B % Rent 29.8% 23.0% Tables 4.2, A and B % Married 8.1% 33.5% Tables 4.2, A and B Avg. Income $11,802 $21,281 Tables 4.2, A and B % Cardholders in urban counties 41.2% 37.0% Table 5.1 % Cardholders in rural counties 13.9% 14.7% Table 5.1 BENEFIT DATA Avg. total expenditures per enrolled cardholder $2,076 $2,648 Table 4.4 Avg. total expenditures per participant $2,865 $3,490 Table 4.4 Avg. total expenditures per claim $94.24 $114.74 Table 4.4 Avg. state share per enrolled cardholder $518 $574 Table 4.4 Avg. state share per participant $716 $757 Table 4.4 Avg. state share per claim $23.53 $24.88 Table 4.4 Avg. cardholder share per enrolled cardholder $118 $226 Table 4.4 Avg. cardholder share per participant $163 $298 Table 4.4 Avg. cardholder share per claim $5.37 $9.80 Table 4.4 Avg. TPL share per enrolled cardholder $1,439 $1,848 Table 4.4 Avg. TPL share per participant $1,987 $2,435 Table 4.4 Avg. TPL share per claim $65.33 $80.05 Table 4.4

2018 percent change in state share per claim 0.5% decrease

3.4% increase

Table 4.4, 2017 and 2018

Avg. claims per participant 30.4 30.4 Tables 4.2, A and B Avg. number of therapeutic classes per participant 4.8 4.9 Tables 7.1, A and BUTILIZATION DATA (by date of payment) Total claims 1,991,806 3,988,541 Tables 6.1 and 6.4 Avg. claims per enrolled cardholder 22.2 23.1 Tables 6.1 and 6.4 Generic utilization rate 85.6% 84.6% Tables 6.1 and 6.4 PAYMENT DATA Total Program payout $46.59 M $99.20 M Table 2.3 Avg. weekly Program payout $0.90 M $1.91 M Table 2.3 Avg. annual Program payout per pharmacy $15,342 $32,665 Tables 2.3 and 5.1 % Program payout to chain pharmacies 56.8% 59.0% Tables 6.2 and 6.3

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PENNSYLVANIA PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY

History

The Pharmaceutical Assistance Contract for the Elderly (PACE) Program was enacted in November 1983 and implemented on July 1, 1984. Its purpose is to assist qualified state residents who are 65 years of age or older in paying for their prescription medications. The PACE legislation was amended in 1987 for reauthorization and, in 1992, for the manufacturers’ rebate reauthorization and additional cost containment initiatives.

The legislature expanded income eligibility for PACE on four occasions: 1985, 1991, 1996, and 2003. The 1996 legislation also created the PACE Needs Enhancement Tier (PACENET). In July 2001, Act 2001-77, the Pennsylvania Master Tobacco Settlement, increased PACENET income eligibility by $1,000. Recognizing that the nominal increases in Social Security income were making enrollees ineligible for PACE, the legislature also created a limited PACE moratorium, effective January 1, 2001, until December 31, 2002, which permitted enrollees to remain in benefit even though their incomes exceeded the eligibility limits. Late in 2002, Act 2002-149 extended the moratorium for the PACE enrollment and expanded it to include the PACENET enrollment as well. While this moratorium expired on December 31, 2003, cardholders who were enrolled prior to the expiration, and had their eligibility periods extending into 2004, were permitted to remain in the Program until their eligibility end date.

In November 2003, Act 2003-37 enabled an unprecedented expansion for enrollment eligibility in the Programs, modified the $500 annual PACENET deductible, and changed the PACE copay structure. The legislation raised the income limits for PACE to $14,500 for individuals and $17,700 for married couples; it boosted the income cap for PACENET to $23,500 for single persons and to $31,500 for married couples. With a $480 deductible divided into monthly $40 amounts, PACENET paid benefits after the first $40 in prescription costs each month. Beginning in 2004, PACE and PACENET had a two-tiered prescription copayment structure. The PACE copayment became $6 for generic drugs and $9 for brand name products. The PACENET copayment remained at the original amounts of $8 for generics and $15 for brand name drugs. Act 37 allowed for adjustments to the copayments to reflect increasing drug prices over time. However, the copayments have remained unchanged.

The Program has undergone recent eligibility changes with Act 87 of 2018 raising the PACENET income limits by $4,000, reaching $27,500 for single persons and $35,500 for married couples. The Program anticipates 14,500 new enrollees in addition to the 3,000 who retained enrollment through the previous moratorium.

Act 37 instituted federal upper limits (FUL) in the provider reimbursement formula and raised the dispensing fee fifty cents. The Program began to reimburse pharmacies the lower of three prices: the Average Wholesale Price (AWP) minus 10%, plus a $4.00 dispensing fee; the Usual and Customary charge to the cash-paying public; or, the most current FUL established in the Medicaid program, plus a $4.00 dispensing fee. All payment methods include the subtraction of the cardholder’s copayment.

The federal Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 created a new outpatient prescription drug benefit, Part D of Medicare. Prior to the full implementation of Medicare Part D and beginning in June 2004, low income, non-HMO, PACE enrollees (134,393 cardholders over 18 months) were auto-enrolled into the interim Medicare Drug Discount Card and Transitional Assistance Program. They received a discount card that allowed for $600 per year in drug expenses in 2004 and again in 2005. Additional cardholders,

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estimated at 30,000, received this assistance through cards issued by their HMO. The PACE Program covered the Medicare drug card copayments for the auto-enrolled cardholders. The Medicare Transitional Assistance Program was a source of significant drug coverage for cardholders, with known savings in Program benefit payments of $112 million for the auto-enrolled cardholders. The Medicare Part D drug benefit began in January 2006. The PACE Program elected to be a qualified State Pharmacy Assistance Program which, along with the passage of state Act 111 in July 2006, allowed for the creation of PACE Plus Medicare. The successful launch of “PACE Plus Medicare” on September 1, 2006, saw thousands of cardholders take advantage of the features of both PACE and Medicare Part D. With the goal of providing seamless coverage, PACE provides benefits when Medicare Part D does not, for example, during the deductible and the coverage gap, for drugs excluded under MMA, for drugs not in a plan’s formulary, and for copayment differentials between the Part D plan coverage and the PACE and PACENET copayments. The Program pays the Medicare premiums for Part D coverage for PACE cardholders. Act 111 also eliminated the monthly deductible for PACENET cardholders. PACENET cardholders who choose to forego Part D coverage are now responsible for a monthly benchmark premium payment ($32.59 in 2006; $28.45 in 2007; $26.59 in 2008; $29.23 in 2009; $32.09 in 2010; $34.07 in 2011, $34.32 in 2012; $36.57 in 2013; $35.50 in 2014; $33.91 in 2015; $35.30 in 2016; $39.45 in 2017; $37.18 in 2018; and $37.03 in 2019) to the Program. The benchmark annual premium payment remains lower than the prior $40 per month deductible. In 2019, through Act 87 in 2018, the Program began to pay the Part D late enrollment penalty for cardholders when the penalty is more than the regional benchmark premium. Act 111 of 2006 recreated the PACE and PACENET moratoriums thereby permitting some 14,000 seniors to maintain their PACE or PACENET status despite disqualifying increases in their overall income due to Social Security cost-of-living increases. The PACE moratorium expired at the end of 2006; the PACENET moratorium continued through 2007. The Act revised provider reimbursement by adjusting the Average Wholesale Price formula from AWP minus 10% to AWP minus 12%, plus a $4.00 dispensing fee. Act 69 of 2008 recreated the PACE and PACENET moratoriums, thereby permitting 15,400 seniors to maintain their Program enrollment in 2010 despite disqualifying increases in their overall 2008 income due to Social Security cost-of-living increases. Act 21 of 2011 extended the moratorium until December 31, 2013, allowing 31,000 persons to remain enrolled. Act 12 of 2014 established the moratorium expiration date for December 31, 2015, preserving the enrollment for 28,000 older adults. This Act also instituted the exclusion of Medicare Part B premium costs from the definition of total income used for income eligibility determination. As of May 2014, 46,000 cardholders retained their enrollment in the Program due to these two provisions of Act 12. Act 91 in 2015 extended the PACE and PACENET moratoriums until December 2017. In July of 2015, 10,000 cardholders retained enrollment due to the Part B premium exclusion provision and 11,400 older persons remained enrolled due to the Social Security cost-of-living exclusion. The cardholder enrollment renewal process conducted in November 2016 determined that 12,200 persons maintained enrollment because of the moratoriums and 18,300 members benefited due to the Medicare Part B premium exclusion from total income. The November 2017 enrollment renewal found that 14,000 members retained enrollment through the moratorium allowance. The 2018 enrollment renewal had 9,700 PACE enrollees remaining in the Program due to the moratorium. Act 62 of 2017 extended the moratoriums until December of 2019. The Program’s pharmacy reimbursement formula fundamentally changed in 2016 with the passage of Act 169 in November 2016. If a National Average Drug Acquisition Cost (NADAC) per unit is available for a prescribed medication, the Program payment will be the lower of the NADAC per unit with the addition of a professional dispensing fee of $13 per prescription and the subtraction of the cardholder’s copayment, or the pharmacy’s usual and customary charge for the

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drug with the subtraction of the copayment. If the NADAC is unavailable, the payment will be the lower of the wholesale acquisition cost plus 3.2% with the addition of the dispensing fee minus the cardholder’s copayment, or the pharmacy’s usual and customary charge less the copayment. This change applies to claims when the Program is the primary payer. On November 20, 2017, the dispensing fee was reduced to $10.49.

PACE covers all medications requiring a prescription in the Commonwealth, as well as insulin, insulin syringes, and insulin needles, unless a manufacturer does not participate in the Manufacturers’ Rebate Program. PACE does not cover experimental medications, medications for hair-loss or wrinkles, or over-the-counter (OTC) medications that can be purchased without a prescription. With appropriate documentation, PACE covers Drug Efficacy Study Implementation (DESI) medications. PACE requires generic substitution of brand multi-source products when an approved, Food and Drug Administration (FDA) A-rated generic is available. At the time of dispensing, a cardholder may encounter a prospective drug utilization review edit; PACE will not reimburse the prescription unless the pharmacist or physician documents the medical necessity for it. The Department of Aging recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. Appendix B contains a description of the PACE/PACENET medical exception process.

Cardholders enrolled in Part D plans conform to the reimbursement limits established by the plans, some of which allow up to a ninety-day supply. Otherwise, cardholders not enrolled in a Part D Plan receive a thirty-day supply or 100 units (tablets or capsules) whichever is less. The Program guarantees reimbursement to the provider (including nearly 3,000 Pennsylvania pharmacies) within 21 days, paying interest on any unpaid balance after 21 days. Six types of providers dispense PACE/PACENET-funded prescriptions to cardholders. Most providers are either independent pharmacies or chain pharmacies. Other provider types include institutional pharmacies, nursing home pharmacies, mail order pharmacies, and dispensing physicians. All providers may offer mail order services if they are enrolled as a mail order pharmacy and if they follow specialized program requirements pertaining to record keeping and cardholder verification procedures.

Act 87 of 2018 requires coordinating prescription filling and refilling to improve medication adherence, known as medication synchronization. The Act compels the Program to develop a medication therapy management program in consultation with the pharmacy community and reviewed by the reconstituted Advisory Board for the Program.

Manufacturers for innovator products pay the Program a rebate similar to the federal “best price” Medicaid rebate. Generic manufacturers paid an 11% rebate based on the average manufacturer price (AMP). An inflation penalty applies to innovator products if annual price increases exceed the consumer price index. The inflation penalty rebate was discontinued for generic products at the end of 2006. Effective January 2010, the federal Medicaid flat rebate rate increased from 15.1% of the AMP to 23.1%, and the generic rate increased from 11% to 13%.

Administration

The Pennsylvania Department of Aging administers the PACE/PACENET Program. A contractor directly responsible to the Department assists in conducting many of the day-to-day operations. Four primary operational responsibilities of the Program are to process applications, reimburse providers for prescriptions, protect enrollees from adverse drug events, and obtain the most cost-efficient reimbursement possible for the Program. Administrative responsibilities include research and policy development, monitoring and evaluating operations and ensuring that the mandates of the Act and Program regulations are met. Activities in these areas include conducting audits of

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not only the providers, but also of the cardholders and the contracting agency. The Program routinely reviews medication utilization profiles of the cardholders and dispensing practices of the providers and physicians. The Department also evaluates the procedures used to implement the Program, identifies any trends which may be relevant for future administration, and scrutinizes all expenditures.

The Department of Aging receives funds through restricted revenue accounts to serve as the administrative and fiscal agent for other Commonwealth-sponsored drug reimbursement programs. Pharmaceutical claims for the Chronic Renal Disease Program, Cystic Fibrosis Program, Spina Bifida Program, Metabolic Conditions Program, including Maple Syrup Urine Disease Program and the Phenylketonuria Program (all within the Department of Health), and the two Special Pharmaceutical Benefits Programs (Department of Health for SP1 and Department of Human Services for SP2) are processed through the PACE/PACENET system. The program also adjudicates claims for two programs in the Department of Insurance, the Workers’ Compensation Security Fund and the Pennsylvania Automobile Catastrophic Loss Benefits Continuation Fund (ended in March 2019). The PACE Program serves as the fiscal agent for the General Assistance Program (Department of Human Services), the Special Pharmaceutical Assistance Program, and the Chronic Renal Disease Program for the collection of rebates from pharmaceutical manufacturers. The Program processes eligibility applications for the Chronic Renal Disease Program and for the SP1 Program.

The PACE Program conducts benefit outreach and assistance for persons identified by the Board of Probation and Parole. Prescription claim processing and program management support is provided to the Department of Corrections.

Program enrollment support given to the Department of Military Affairs includes PACE/PACENET application processing, Part D Plan coordination, and prescription claim processing for veterans residing in state-supported veteran homes.

The Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) is available to assist all adult Pennsylvanians with the cost of prescription drugs. PA PAP outreaches to those who are uninsured or under-insured by helping them to apply for prescription assistance through various programs. Details about the Clearinghouse are found in Section 8 of this report.

Appendix E provides program support details for the numerous state funded pharmacy programs that utilize the PACE Program Platform.

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SECTION 1

PROGRAM RESEARCH HIGHLIGHTS

7

8

INTE

RVEN

TIONS, GEN

ERAL PROGRAM ASSESSM

ENTS, A

ND M

EDICATION ADHER

ENCE STUDIES

PACE/PACEN

ET COLLABORATIVE RESEA

RCH AND EVALU

ATION PROJECTS, 2

008 – 2019, M

ARCH 2019 UPDATE

INTE

RVEN

TIONS

TOPIC

TITLE / RESEA

RCH GROUP

DESCRIPTION

ASSESSM

ENT

FOR

DEP

RESSION,

ANXIETY

, AND

SLEEP

DISORDER

S

TELEPHONE‐BASED

BEH

AVIORAL HEA

LTH

ASSESSM

ENT FO

R SEN

IORS ON

NEW

PSY

CHOTR

OPIC

MED

ICATION

Behavioral H

ealth Lab

oratory,

Medical School, University of

Pennsylvan

ia

Results from

aPA

CE statew

ide collabo

rativ

e care program

by th

e Be

havioral Health

Lab

oratory (begun

in 200

8) su

pport

concerns re

lated to psychotropic med

ication prescribing in th

e elde

rly and

raise

add

ition

al que

stions abo

ut off‐labe

l or

inap

prop

riate prescrib

ing. Ove

rall, 45.0% of participan

ts did not meet criteria for an

y men

tal h

ealth disorder with lo

w

symptoms indicated. (Ab

out 4

2% of P

hase II partic

ipan

ts were minim

ally sy

mptom

atic.) Just 6% m

et the criteria for

anxiety disorders. Th

e stud

y foun

d that older, com

mun

ity dwellin

g pa

tients received ne

w psychotropic med

ications m

ore

than

wha

t might be expe

cted

based

on their relatively low sy

mptom

burde

n. M

any repo

rted

that th

e prescriptio

n was fo

r a psycho

social stressor (4

3.8%

), while 15.8%

were un

aware of th

e reason

for the

prescrip

tion.

Interven

tion aim

s include assigning individuals with clin

ically significan

t symptoms to m

inim

al m

onitoring or monitoring

with care m

anagement an

d social service support to determ

ine whether the clin

ical services are im

pacting outcomes.

Outcomes ana

lyses s

how th

at enh

anced care m

anagem

ent improv

es sy

mptom

s and

overall functio

ning

relativ

e to

stan

dard m

onito

ring services alone

. In th

e high

symptom

group

, care man

agem

ent a

dvice ha

s led

to re

ferrals to specialist

care. With

low sy

mptom

patients, th

e assessmen

t explores reasons fo

r the

psychotropic med

ication an

d consideration of

discon

tinua

tion after p

ersis

tence of m

easured low sy

mptom

s.

Care m

anagement cases are asked at the nine w

eeks follo

w up about their satisfaction le

vel. There is a very high leve

l of en

rolle

e satisfaction with the care m

anagement service (> 95% satisfaction).

An ana

lysis

of p

atient chron

ic pain foun

d sig

nifican

t differen

ces in levels of dep

ression, anxiety, and

qua

lity of life betwee

n those who

experience interferen

ce of p

ain versus th

ose who

do no

t. Tw

o program

s, SUSTAIN and CREST (see Appendix A), promote non‐pharmacological interventions through

assessm

ent

and assistance that addresses psychosocial stressors for cardholders and their caregivers. SU

STAIN is an effective

engagemen

t in collabo

rativ

e men

tal h

ealth

care services re

gardless of p

atients’ geo

grap

hic locatio

n. Program

pa

rticipation rate was sign

ificantly highe

r in rural com

pared to urban

/sub

urba

n coun

ties. This private‐public partnership

received the Bronze Award as part of the nationally recogn

ized 2015 American Psychiatric Association Achievement

Awards.

In 201

8, th

ree pu

blications app

eared in pee

r‐review

ed jo

urna

ls (see

App

endix A).

ACADEM

IC

DET

AILING

UPDATING PHYSICIANS ABOUT

CHANGING THER

APIES IN

COMPLICATE

D DISEA

SE STA

TES

The Division of Pharmaco‐

epidem

iology and Pharmaco‐

economics of the Brigh

am and

Women’s Hospital/H

arvard

Medical School

PACE offers

a long‐stan

ding physician education program

(see Appendix A). P

hysicians at the Harvard M

edical School

train Pen

nsylvan

ia‐based

clin

ical educators to m

eet one‐on‐one with clin

icians who care for man

y patients enrolle

d in

PACE. During the office visits, begun

in 200

5, th

e ed

ucators p

rovide

objectiv

e, re

search‐based

inform

ation ab

out e

ffective

drug

s and

non

‐med

ication therap

eutic

options fo

r com

mon

chron

ic con

ditio

ns. Ed

ucators have lo

gged nearly 28,000

visits. Re

cent effo

rts led

to an expa

nsion of visits and

geo

grap

hical reach to

add

ress th

e man

agem

ent o

f chron

ic and

acute pa

in.

During 2018, five m

odules accounted for 92% of the 3,122 visits during the year to 1,200 prescribers.

The

chronic pain m

odule (1

,110

visits) a

ddresses th

e grow

ing prob

lem of p

ain am

ong elde

rly patients. A

chieving

functio

nal goa

ls that do no

t pose ha

rm from

side

effe

cts, encou

rage add

ictio

n, or c

ontribute to drug ab

use is challeng

ing

in th

is pa

tient pop

ulation be

cause of issues su

ch as a

ltered ph

armacod

ynam

ics/ph

armacok

inetics w

ith in

crea

sing age,

polyph

armacy, poten

tial cog

nitiv

e de

ficits, h

eigh

tene

d risk of fractures from fa

lls, and

organ

‐spe

cific vulne

rabilities.

9

Soo

n after the

release of th

e chronic pa

in m

odule, m

anagingacute pain in

the elderly(785

visits) presented

the ne

ed

for safe, effe

ctive pa

in re

lief a

mon

g olde

r adu

lts across a

rang

e of se

ttings. Ac

hieving functio

nal goa

ls with

out p

osing

harm

from

side

effe

cts, add

ictio

n or poten

tial o

verdose is challeng

ing in th

is pa

tient pop

ulation du

e to similar issue

s in

trea

ting chronic pa

in. Th

is mod

ule includ

es optim

izing

the use of non

‐opioid alternatives before considering op

ioids a

nd

follo

wing several gen

eral prin

ciples fo

r prescrib

ing op

ioids for acute pain if op

ioids a

re necessary.

C

urrent evide

nce‐ba

sed go

als for treating hyp

ertension (6

21 visits) informs h

ealth

care professio

nals ab

out the

recommen

ded bloo

d pressure ta

rgets for differen

t patient pop

ulations and

the efficacy of differen

t med

ications used to

achieve bloo

d pressure goa

ls. Edu

catio

n materials for p

atients a

re part o

f the

mod

ule an

d em

phasize

the be

nefits o

f a

healthy life style an

d pa

tient adh

eren

ce to

med

ications to

kee

p bloo

d pressure und

er con

trol.

C

hronic obstructive pulm

onary disease (COPD) (212

visits) u

pdates clin

icians abo

ut assessin

g the compa

rativ

e effectiven

ess a

nd sa

fety of m

edications used to m

anage the symptom

s of C

OPD

. Practitione

rs hear the

latest evide

nce

regarding ap

prop

riate th

erap

y an

d learn the be

nefits, risks, and

value

of treatmen

t options to

improv

e the qu

ality

of

prescribing an

d pa

tient care.

The

elder ab

use m

odule (1

57 visits) raises a

waren

ess a

mon

g prim

ary care practition

ers o

f the

scop

e an

d risk factors for

elde

r abu

se and

how

to re

spon

d to su

spected ab

use, as w

ell as to prov

ide up

dated eviden

ce on the evalua

tion an

d man

agem

ent o

f cog

nitiv

e im

pairm

ent. Clin

icians app

reciate the de

finition

s of e

lder abu

se, lea

rning ho

w to

iden

tify risk

factors for abu

se and

neglect, and

how

to fo

llow up on

suspected cases.

For e

ach topic, staff d

evelop

s prin

t materials, trains th

e ed

ucators, m

anages th

e interven

tion, and

offe

rs con

tinuing

ed

ucation cred

its. Th

e ph

ysician faculty

develop

s con

tent based

upo

n common

drugs used by and

con

ditio

ns affe

cting the

elde

rly. Ed

ucators d

istrib

ute these do

cumen

ts to

physic

ians during face‐to‐face m

eetin

gs: compreh

ensiv

e review

s of

biom

edical literature, kno

wn as eviden

ce documen

ts; d

istillations of k

ey inform

ation used

as the

basis for the

disc

ussio

n be

twee

n practitione

r and

the ed

ucator, kno

wn as su

mmary documents; p

atient an

d caregive

r brochures an

d tear‐off

sheets, in

clud

ing resources for add

ition

al inform

ation an

d supp

ort; an

d, laminated

, pocket‐siz

ed quick re

ference cards for

health care prov

iders o

n treatm

ent a

nd drug efficacy. These m

aterials located at www.alosahealth.org.

In 201

8, m

odule evalua

tion surveys for all topics m

easured strong

physic

ian agreem

ent in respon

se to

the qu

estio

ns abo

ut

whe

ther th

e prog

ram ben

efits th

e well‐b

eing

of p

atients. Satisfactio

n elem

ents with

the high

est a

gree

men

t scores

includ

ed: the

PAC

E acad

emic detailer d

iscussed the be

nefits o

f spe

cific th

erap

ies; th

e de

tailer e

xplained

assessm

ent too

ls an

d ho

w I can use them

in m

y practic

e to se

lect th

erap

y; and

, the

acade

mic detailer p

resented

evide

nce on

the efficacy

and safety drugs and

therap

eutic

alte

rnatives. Evaluation of three m

odules, non‐steroidal anti‐inflam

matory

drugs/coxib use, acid suppression, and anti‐psychotics in

dicate red

uction in

the m

edications targeted.

In 200

8‐20

10, a parallel p

rogram

delivered

three ed

ucationa

l mod

ules th

at fo

cused on

preventing the ne

ed fo

r ho

spita

lizations and

institu

tiona

lizations: cogn

itive im

pairm

ent a

nd associated be

havioral problem

s (70

9 visits), falls an

d mob

ility problem

s (66

8 visits), and

incontinen

ce (8

23 visits). The

se to

pics have be

en upd

ated

and

relaun

ched

. Late in

201

8, detailers began

visits with

clin

icians to

share inform

ation ab

out the

Pen

nsylvania’s D

iabe

tes P

revention

Prog

ram, including

the locatio

n of free

, local patient edu

catio

n sites fu

nded

by the CD

C. The

first m

odule in 201

9 will be

an upd

ate for the

trea

tmen

t of d

iabe

tes.

10

ACADEM

IC

DET

AILING

EVALU

ATION

EFFECTS OF ACADEM

IC

DET

AILING ON THE

TREA

TMEN

T OF DIABET

ES

Wilkes University School o

f Pharmacy an

d M

agella

n

Health/PACE

This prog

ram evaluation stud

y was designe

d to m

easure th

e effects o

f acade

mic detailin

g, sp

ecifically examining

prescribing pa

tterns before an

d after p

rescrib

ers p

artic

ipated

in th

e prog

ram’s 201

3 diabetes man

agement module. Th

e mod

ule prov

ided

inform

ation on

the compa

rativ

e effectiven

ess a

nd sa

fety of d

iabe

tes m

edications, p

resented

evide

nce

regarding ap

prop

riate th

erap

y strategies, and

weigh

ed th

e be

nefits, risks, and

value

of treatmen

t options with

the intent

to im

prov

e the qu

ality

of p

rescrib

ing an

d pa

tient care. This interrupted

time serie

s evaluation focused on

the third

diab

etes edu

catio

nal o

utreach interven

tion that was presented

to 704

prescrib

ers in 20

13‐14. In ad

ditio

n to th

e grou

p of

prescribers w

ho re

ceived

the diab

etes m

anagem

ent training, th

e evalua

tion an

alysis also in

clud

es a com

parison

group

of

prescribers w

ho did not re

ceive the training

.

The qu

ality

metric

s ide

ntified

for this s

tudy:

Prescribing metform

in in

older patients w

ith diabe

tes

Prescribing of HMG‐CoA

redu

ctase inhibitors (statin

s) in

diabe

tic patients

Prescribing of eith

er an an

gioten

sin‐con

verting‐en

zyme (ACE

) inh

ibito

r or a

n an

gioten

sin II re

ceptor blocker (A

RB)

for p

atients w

ho have bo

th diabe

tes a

nd hypertension

Av

oida

nce of lo

ng‐acting sulfo

nylureas (chlorprop

amide, glybu

ride) in

older patients w

ith diabe

tes

The results did not dem

onstrate differen

ces b

etwee

n the interven

tion an

d compa

rison

group

s with

respect to the four

metric

s. H

owever, m

ost p

rescrib

ers in the de

tailed grou

p ha

d be

en exposed

to m

ore than

one

wave of diabe

tes training

since 200

7 an

d the qu

ality

metric

s have be

come the stan

dard of care. The

find

ings are con

sistent with

a ceilin

g effect in

the mea

sured metric

s, su

ggestin

g that m

ost p

rescrib

ers w

ere follo

wing trea

tmen

t guide

lines during the evalua

tion pe

riod.

These results have be

en accep

ted for p

ublication in American Hea

lth & Drug Ben

efits in 20

19.

GEN

ERAL

PRO

GRA

M ASSESSM

ENTS

TO

PIC

TITLE / RESEA

RCH GROUP

DESCRIPTION

SATISFACTION

SURVEY

S PACE/PACEN

ET SURVEY

ON

HEA

LTH AND W

ELL‐BEING

Magella

n Health/PACE

The Survey on

Hea

lth and

Well‐B

eing

provides inform

ation about the cardholder population. Questions measure

cardholders’ self‐reported

health status, self‐reported

medication adherence and affordab

ility, transportation access,

and satisfaction with their PACE/PACEN

ET cove

rage

. Su

rvey data are frequen

tly lin

ked with other im

portan

t data

sources, in

cluding prescription records, M

edicare services records, and vital statistics records, and are used for program

evaluation and original research studies. Include

d in th

e PA

CE/PAC

ENET new

enrollm

ent a

pplication, th

e op

tiona

l en

rollm

ent survey gathers impo

rtan

t information ab

out a

person’s h

ealth

immed

iately prio

r to joining PA

CE. Th

e op

tiona

l rene

wal su

rvey is m

ailed to existing cardho

lders throu

ghou

t the

yea

r. M

ost ren

ewal su

rvey que

stions are th

e same as th

e ne

w enrollm

ent survey, but a fe

w que

stions are differen

t. The

rene

wal su

rvey provide

s impo

rtan

t information ab

out the

cardho

lder’s hea

lth after being

in PAC

E. A

nnua

l upd

ates allo

w th

e stud

y of cha

nges over tim

e.

Results from 2017‐18: The

201

7‐18

rene

wal su

rvey re

spon

se ra

te was 46.7%

. Ap

proxim

ately 25

% of ren

ewal su

rvey

respon

dents ind

icated

that th

ey did not com

plete high

scho

ol, w

ith 8% re

porting an

8th grade

or less e

ducatio

n.

Und

erstan

ding

the ed

ucationa

l backgroun

d of th

e po

pulatio

n he

lps to en

sure th

at cardh

olde

r com

mun

ications are at a

n ap

prop

riate re

ading level. Amon

g cardho

lders w

ho were en

rolled in PAC

E at th

e tim

e that th

ey com

pleted

the survey,

85% re

ported

that th

ey were either “extrem

ely” or “

quite

a bit”

satisfie

d with

PAC

E. A

mon

g PA

CENET enrolled

cardho

lders, 75%

were “extremely” or “

quite

a bit”

satisfie

d with

PAC

ENET. An

othe

r 11%

of P

ACE en

rollees and

16%

of

PACE

NET enrollees were “m

oderately” sa

tisfie

d. The

se data indicate high levels of sa

tisfaction with

both Prog

rams. W

hen

asked to ra

te th

eir c

urrent health

, 69%

of e

nrolled respon

dents ind

icated

that th

eir h

ealth

was eith

er excellent, very go

od,

or goo

d, with

the remaining

31%

indicatin

g either fa

ir or poo

r hea

lth. Th

e 20

17‐18 survey also

add

ressed

self‐repo

rted

iss

ues w

ith tran

sportatio

n access. Approximately 40% of survey respondents rep

orted

that they had

exp

erien

ced any

activity limitations due to transportation difficulties in the past ye

ar, a

nd 17% reported

they had

exp

erienced such

11

limitationsfreq

uen

tly. N

early two thirds (63%) of responden

ts received

some form

of tran

sportation help

during the

year from fam

ily m

embers, friends, or outside sources.

Additio

nal results from

the 20

17‐18 survey are presented

in App

endix A.

OUTR

EACH

PACE APPLICATION CEN

TER

Benefits Data Trust,

Phila

delphia

The PA

CE App

lication Ce

nter (A

ppen

dix A) con

ducts d

ata‐driven

outreach an

d ap

plication assis

tance to con

nect

Penn

sylvan

ia’s se

niors w

ith pub

lic ben

efit prog

rams. The

Cen

ter sub

mits PAC

E ap

plications fo

r eligible persons and

enrolls

eligible persons in

the Med

icare Pa

rt D Low

Income Su

bsidy (Extra Help). Th

e Ce

nter con

ducts m

ail, teleph

one, and

commun

ity‐based

outreach. In 2018, 2

1,000 households ap

plie

d for at least one ben

efit, receiving $77 m

illion in

benefits. (See Ap

pend

ix A fo

r the

full 20

18 re

port.)

PACE En

rollm

ent Outreach: Th

e Ce

nter uses P

rope

rty Tax an

d Re

nt Reb

ate rolls, and

ene

rgy, fo

od and

prescrip

tion

assis

tance listin

gs to

iden

tify en

rollm

ent c

andida

tes. In 2018, there were 185,000 outreach attem

pts unique to PACE an

d

12,400 PACE ap

plications submitted.

Low In

come Su

bsidy (LIS) Outreach: Th

e PA

CE Program

, by wrapp

ing arou

nd th

e Pa

rt D ben

efit, in

curs costs th

at cou

ld be

offset by LIS be

nefits w

hich provide

fina

ncial h

elp to lo

w income en

rollees. In 2018, the Center submitted 7,700

applications on behalf of older Pennsylvan

ians, the result of 39

,500 outreach actions.

MED

ICAT

ION UTILIZA

TION STU

DIES

TOPIC

TITLE / RESEA

RCH GROUP

DESCRIPTION

MED

ICATION

ADHER

ENCE

INITIAL MED

ICATION

ADHER

ENCE IN THE ELDER

LY

University of the Sciences in

Phila

delphia and M

agella

n

Health/PACE

Initial m

edication ad

herence de

scrib

es th

e fillin

g of new

med

ication prescriptio

ns. Th

is pilo

t study explored the feasibility

of using PACE claim reve

rsals as a proxy in

dicator of initial m

edication non‐adherence. Th

e stud

y specifically evaluated

diffe

rences in

claim

reversal ra

tes, as w

ell as the

timing of re

versals, betwee

n electron

ic and

non

‐electronic prescriptio

ns.

Und

erstan

ding

the po

tential impa

ct of e

lectronic prescribing (e‐prescrib

ing) on initial m

edication ad

herence is tim

ely given

increa

ses in e‐prescribing which have occurred

in part a

s a re

sult of provisio

ns of the

Med

icare Mod

ernizatio

n Ac

t.

Results of chi‐squ

are an

alyses in

dicated that electronic prescriptio

n claims w

ere more likely than

other prescrip

tion origin

type

s to be

reversed

, and

that differen

ces a

mon

g prescriptio

n origins w

ere greater for re

versals o

ccurrin

g after the

subm

ission da

y compa

red with

same‐da

y reversals. Th

e au

thors concluded that electronic prescriptions are associated

with a higher rate of claim reversals an

d m

ay reflect poorer initial adherence. Electronic prescriptions may be m

ore

likely to be forgotten or otherwise not picke

d up because the electronic delivery of the prescription to the pharmacy

byp

asses the patient. The

stud

y confirm

ed th

e im

portan

ce of u

nderstan

ding

the po

tential effe

ct of e

lectronic prescriptio

n tran

smiss

ion on

initial m

edication ad

herence in th

e elde

rly. Th

e results were pu

blish

ed in

the Septem

ber 2

016 iss

ue of

the Journal of Managed

Care & Specialty Pharm

acy.

PHARMACY

ACCESS

ACCESSIBILITY OF PHARMACY

SERVICES IN

HIGH‐ AND LOW‐

INCOME PEN

NSY

LVANIA

COUNTIES


Phila

delphia and M

agella

n

Health/PACE

This research build

s on several p

rior studies of pharmacy deserts, a term used to describe ge

ograp

hic areas where

pharmacy services are scarce or difficult to obtain. Ph

armacy de

serts c

an occur as a

result of large geog

raph

ic distan

ces

requ

ired to re

ach ph

armacies, or a

s a re

sult of to

o few pha

rmacies located

in a den

sely‐pop

ulated

area. O

ne accep

ted

defin

ition

from

existing literature specifically id

entifies p

harm

acy de

serts a

s low

‐income area

s whe

re at lea

st a th

ird of the

po

pulatio

n lives m

ore than

one

mile from

an ou

tpatient pha

rmacy. This study compared the availa

bility of pharmacies

and the ave

rage

straigh

t‐lin

e distance between home residen

ce and the nearest outpatient pharmacy for

PACE/PACEN

ET cardholders in

five high‐income and five lo

w‐income counties.

The average distan

ce to

the closest p

harm

acy was sh

orter in the low‐in

come grou

p, which was influ

enced largely by one

urba

n coun

ty, P

hilade

lphia Co

unty, w

here th

e average straight‐line

distan

ce to

the ne

arest o

utpa

tient pha

rmacy was only

0.1 mile. In contrast, three lo

wer income rural counties (M

ifflin, Forest, and Sullivan Counties) were id

entified

as

potential pharmacy deserts. In these counties, betw

een

56% and 77% of the population lived m

ore than

a m

ile away

12

from the closest outpatient pharmacy. W

ith an average distan

ce of 4

.0 m

iles to the closest p

harm

acy, Sullivan

Cou

nty

demon

strated the lowest a

pparen

t accessib

ility. Th

is study confirm

ed that geograp

hic accessibility varies substan

tially

for PACE/PACEN

ET cardholders across Pennsylvan

ia, a

nd that pharmacy deserts ap

pea

r to exist in

seve

ral rural areas of

the state. Re

sults were presen

ted at th

e AM

CP M

anaged

Care & Spe

cialty Pha

rmacy An

nual M

eetin

g in April 20

16.

PHARMACY

ACCESS AND

MED

ICATION

ADHER

ENCE

MED

ICATION ADHER

ENCE IN

PHARMACY DESER

T AND

NON‐DESER

T AREA

S


Phila

delphia and M

agella

n

Health/PACE

This stud

y expa

nded

the investigation of poten

tial pha

rmacy de

sert areas in

Pen

nsylvania to add

ress th

e po

tential impa

ct

of lo

w pha

rmacy access on med

ication ad

herence. The study specifically examined

refill ad

herence m

easures for oral

diabetes medications am

ong PACE/PACEN

ET elderly residing in three counties previously identified

as potential

pharmacy deserts (Fo

rest, M

ifflin

, and

Sullivan

Cou

nties) and

in se

ven no

n‐ph

armacy de

sert cou

nties. Two varia

tions on

the prop

ortio

n of days c

overed

(PDC

), prescriptio

n‐ba

sed PD

C an

d interval‐based

PDC

, were used

to m

easure re

fill

adhe

rence level.

Chi‐squ

are an

d regressio

n an

alyses re

sults indicated that while

elderly in non‐desert regions had

slightly higher

adherence levels than

those living in desert regions, these differences were not statistically significan

t.

Althou

gh th

is stud

y did no

t find statistically sign

ificant differen

ces in med

ication ad

herence as a fu

nctio

n of pha

rmacy

desert re

gion

resid

ence, the

limite

d nu

mbe

r of cou

nties e

xamined

may limit the gene

ralizab

ility of the

find

ings. Future

research is plann

ed to

examine ph

armacy de

sert re

gion

s and

associated he

alth m

easures a

cross b

road

er re

gion

s of the

state. Th

e results of this s

tudy

were presen

ted at th

e Internationa

l Society fo

r Pha

rmacoe

cono

mics a

nd Outcomes

Research (ISP

OR) ‐2

1st A

nnua

l Interna

tiona

l Mee

ting in M

ay 201

6.

PRESCRIPTION

OPIOID

UTILIZA

TION

ASSOCIATION BET

WEE

N

PSY

CHOTH

ERAPEU

TIC DRUG

USE AND PRESCRIPTION

OPIOID USE AMONG OLD

ER

ADULTS

Magella

n Health/PACE

Prior research ha

ssug

gested

an increased use of prescrip

tion op

ioids a

mon

g ad

ults with

men

tal hea

lth problem

s. Two

related stud

ies o

f PAC

E/PA

CENET elderly in

vestigated

if psychothe

rape

utic drug use is associated

with

prescrip

tion op

ioid

use. This research used

pha

rmacy claims d

ata to evaluate the use of prescrip

tion op

ioids a

nd psychothe

rape

utic

med

ications (a

nxiolytic

s, se

dativ

es, h

ypno

tics, antidep

ressan

ts and

antipsychotic agents). Prescriptio

n op

ioid dosages

were converted to m

orph

ine milligram equ

ivalen

ts (M

ME). Ch

i‐squ

ared

tests a

nd m

ultiv

ariate lo

gistic re

gressio

n mod

els

were used

for a

nalyses.

The first stud

y, which was cross‐sectio

nal, foun

d that th

e odds of prescription opioid use during 2017 in

creased

with

anxiolytic, sedative or hyp

notic use (OR=2

.61) or an

tidep

ressan

t use (OR=2

.42) in the same year. Am

ong prescriptio

n op

ioid users, 1

.43%

used prescriptio

n op

ioids a

t high do

sage (d

efined

as >

90 M

ME/da

y for ≥

90 con

secutiv

e da

ys). Use at

high

opioid do

sage was sign

ificantly associated with

anxiolytic

, sed

ative, or h

ypno

tic use (O

R=1.50

) and

antidep

ressan

t use

(OR=

1.60

).

Usin

g a retrospe

ctive coho

rt design, th

e second

stud

y evalua

ted whe

ther psychothe

rape

utic m

edication use in 201

3 was

associated

with

new

ly in

itiating prescriptio

n op

ioid use in

201

4. Com

pared to patients w

ho did not use anxiolytic

s,

seda

tives, o

r hyp

notic

s, th

ose who

used them

were more likely to initiate prescriptio

n op

ioids (15

.3% versus 2

0.9%

, p<

.000

1). Sim

ilarly

, com

pared to antidep

ressan

t non

‐users, antidep

ressan

t users were more likely to initiate prescriptio

n op

ioids (15

.4% versus 2

0.2%

, p<.00

01). Multivariate lo

gistic regression in

dicated

that the odds of prescription opioid

initiation in

crea

sed with anxiolytic, sed

ative, a

nd hyp

notic use by 36% (OR=1

.36; p<.0001) an

d with antidep

ressan

t use

by 30% (OR=1

.30; p

<.0001).

The combined results of these studies show that older ad

ults who use psychotherapeutic drugs are at greater risk for

prescription opioid use and

suggest tha

t clin

icians sh

ould carefully evaluate op

ioid use amon

g olde

r patients u

sing

anxiolytics o

r antidep

ressan

ts to

minim

ize risks for adverse con

sequ

ences o

f opioids, including

overdose. Patients w

ith

men

tal h

ealth

problem

s sho

uld also be qu

eried ab

out p

ain expe

riences to

optim

ize treatm

ent.

13

MED

ICATION

ADHER

ENCE

AND HEA

LTH

OUTC

OMES

IMPACT OF MED

ICATION

ADHER

ENCE ON HEA

LTHCARE

UTILIZA

TION AND COSTS

AMONG ELD

ERLY W

ITH

DIABET

ES


Phila

delphia and M

agella

n

Health/PACE

This retrospe

ctive stud

y of PAC

E/PA

CENET elderly examined

predictors o

f adh

eren

ce to

oral antidiabe

tic th

erap

ies a

s well

as associatio

ns betwee

n oral antidiabe

tic m

edication ad

herence an

d he

alth care utilizatio

n. For elderly who

used oral

antid

iabe

tic m

edications in

201

5, re

fill‐b

ased

adh

eren

ce during the subseq

uent 12 mon

ths w

as m

easured using PD

C, with

ad

herence de

fined

as P

DC > 0.80. O

utcome mea

sures include

d an

y ho

spita

lization, to

tal h

ospital visits, len

gth of stay, and

ho

spita

lization costs d

uring the same 12

‐mon

th period. M

ultiv

ariate lo

gistic re

gressio

n mod

els, ze

ro‐in

flated ne

gativ

e bino

mial regression mod

els, and

two‐pa

rt re

gressio

n mod

els w

ere used

to evaluate associations betwee

n diab

etes

med

ication ad

herence an

d the he

alth outcome mea

sures.

Elde

rly who

were Afric

an‐American

or w

ho were curren

tly m

arrie

d were less likely th

an other elderly to

be ad

herent to

oral antidiabe

tic th

erap

y. Living in a pha

rmacy de

sert was not associated with

med

ication ad

herence. A

djusting for

baselin

e characteristics, nonad

herent elderly were twice as likely as ad

herent elderly to be hospitalized at least once

during the study period (OR=2

.03, p

<.0001). M

edication nonad

heren

ce was also associated with higher numbers of

hospital visits, lo

nge

r lengths of stay, a

nd higher hospitalization costs.

This research was con

ducted

to fu

lfill the requ

iremen

ts fo

r a doctoral degree that will be gran

ted in 201

9, and

future

publication of th

e fin

ding

s is p

lann

ed.

PRE

VIOUS STUDIES

TOPIC

TITLE / RESEA

RCH GROUP

DESCRIPTION

MED

ICATION

ADHER

ENCE

AND HEA

LTH

OUTC

OMES

PROTO

N PUMP IN

HIBITOR

ADHER

ENCE AND FRACTU

RE

RISK IN

THE ELDER

LY

Magella

n Health/PACE an

d The

Medicine, H

ealth, and Aging

Project at Penn State

University

Results of several re

cent stud

ies s

uggest th

at lo

ng‐term use of p

roton pu

mp inhibitors (P

PIs) m

ay be associated

with

an

increased risk of fracture. The goal of this study was to examine the relationship betw

een m

edication adherence and

fracture risk am

ong elderly PPI u

sers. The

stud

y coho

rt includ

ed 1,604

com

mun

ity‐dwellin

g PP

I users and

23,67

2 no

n‐users w

ho were en

rolled in th

e PA

CE Program

. Prop

ortio

n of Days C

overed

(PDC

) was com

puted to m

easure adh

eren

ce based

on prescriptio

n refill patterns. Tim

e‐de

pend

ent C

ox propo

rtiona

l hazards m

odels w

ere used

to estim

ate ad

justed

hazard ratio

s of P

PI use/adh

eren

ce fo

r fracture risk while con

trollin

g for d

emog

raph

ics, com

orbidity, b

ody mass ind

ex, smok

ing an

d no

n‐PP

I med

ication use. The

ov

erall inciden

ce of a

ny fracture per 100

person‐years w

as 8.7 fo

r PPI users and

5.0 fo

r non

‐users. A grad

ient in fracture

risk according to PPI adh

eren

ce was observed. R

elative to non

‐users, fracture ha

zard ra

tios a

ssociated with

the high

est

adhe

rence (PDC

> 0.80), intermed

iate (P

DC 0.40‐0.79

), an

d lowest (PD

C < 0.40

) adh

eren

ce levels were 1.46

(p < 0.000

1),

1.30

(p = 0.02), and

0.95 (p = 0.75), respe

ctively.

These results provide further eviden

ce that PPI u

se m

ay in

crease risk in the elderly an

d highlight the need

for clinicians

to periodically reassess elderly patients’ individualized needs for ongo

ing PPI therapy, while

weighing potential risks

and benefits. Th

e fin

ding

s were pu

blish

ed in Calcified Tissue International in Ap

ril 201

4.

IMPROVING

BRAIN HEA

LTH

AND QUALITY

OF LIFE

THE RHYTH

M EXPER

IENCE AND

AFR

ICANA CULTURE TR

IAL‐‐

REA

CT!

University of Pittsburgh and

University of Pennsylvan

ia,

Alzheim

er’s Association, and

Magella

n Health/PACE

The PA

CE program

supp

orts re

search re

lated to im

prov

ing the lives of cardh

olde

rs. In 20

16, the

REA

CT!

Project b

egan

to

explore whe

ther African

dan

ce and

edu

catio

n classes improv

e brain he

alth or q

uality of life fo

r older African

American

s be

twee

n 65

‐75 years o

ld. Letters to

Program

enrollees in

vite th

em to

talk with

researchers to de

term

ine if they are

eligible. Th

e project ran

domly assigns participan

ts to take classes in either African

dan

ce or African

a culture and

education. C

lasses are about one hour long an

d occur three days per week for a total o

f six months. At the

beginning

an

d en

d of th

e stud

y, partic

ipan

ts perform

a walking

test, com

plete mem

ory tasks, and

fill ou

t surveys abo

ut th

eir h

ealth

an

d moo

d. The

stud

y will examine whe

ther brain health

, fitn

ess levels o

r qua

lity of life im

prov

es becau

se of a

ctivities.

INTE

RVEN

TION

FOR M

ILD

INDIVIDUALIZE EVER

YDAY

ACTIVITIES—

IDEA

Older persons

with

mild

cog

nitiv

e im

pairm

ents are at‐risk for increasing disability an

d de

men

tia. D

espite th

e common

concep

tion that in

dividu

als w

ith m

ild cog

nitiv

e im

pairm

ent d

o no

t have disability in daily activities, recen

t research at th

e University

of P

ittsburgh

has sh

own that th

ey dem

onstrate im

paire

d pe

rforman

ce (i.e., preclin

ical disa

bility) in

cog

nitiv

ely‐

14

COGNITIVE

IMPAIRMEN

T

Occupational Therapy

Departm

ent at the University

of Pittsburgh and M

agella

n

Health/PACE

focused da

ily activities, such as grocery sh

opping

and

paying pills. Th

is study examines

the efficacy of the IDEA

interven

tion to optimize perform

ance in

daily activities an

d to delay the decline to frank disab

ility in

older ad

ults who

have m

ild cogn

itive im

pairm

ent. Successful interven

tion m

ay help to offset both finan

cial and emotional burdens to

family m

embers. In

201

6, PAC

E sent letters o

f invita

tion to cardh

olde

rs living

in Pittsburgh

. Partic

ipan

ts develop

ed

effective strategies to

work throug

h an

d arou

nd barrie

rs to

daily activities. The

y set a

goa

l to ad

dress b

arrie

rs, d

evelop

a

plan

to add

ress th

e go

al, d

o the plan

, and

che

ck whe

ther th

e plan

requ

ires revising

. Multip

le se

ssions are com

pleted

in th

e ho

me ov

er a 5‐w

eek pe

riod with

a re

gistered

occup

ationa

l the

rapist.

IMPROVED

HEA

LTH

STATU

S AND

AVOIDANCE

OF NURSING

HOME EN

TRY

AND LATE

R

ENTR

Y IN

TO

WAIVER

PROGRAMS

PACE EN

ROLLMEN

T PROVIDES

ADVANTA

GE FO

R LOW

INCOME, PRE‐MED

ICAID

SENIORS

Pennsylvan

ia Departm

ents of

Aging an

d Public W

elfare,

Office of Long‐Te

rm Living,

Magella

n Health/PACE, M

ercer

Gove

rnmen

t Human

Services

Consulting, and the Health

Policy Institute at Georgetown

University

A 20

10 ana

lysis

dem

onstrates tha

t the

PAC

E Prog

ram su

pports m

any seniors p

rior to their M

edicaid en

rollm

ent. Da

ta

compa

re con

sumers w

ho “ha

d” and

“did no

t have” PAC

E in a five‐yea

r period prior to using long

‐term care or nursin

g waiver services. R

esults suggest PACE en

rollm

ent en

ables seniors to remain in

the community longe

r, with better

health, and to delay en

try into and utilization of long‐term

care and waiver services. Finding

s include

:

Average leng

th of n

ursin

g facility stay over a

5‐year p

eriod was 40 da

ys less fo

r previou

s PAC

E en

rolled.

PA

CE m

embe

rs were olde

r at e

ntry in

to a nursin

g facility by

2.8 years.

Th

e ages at w

aiver e

ntry sh

ow PAC

E mem

bers were olde

r by 3.1 years.

Later a

ge of e

ntry in

to nursin

g facilities p

rovide

d an

estim

ated

ann

ual savings of $

728.8 M.

De

ferred

waiver p

rogram

produ

ced estim

ated

ann

ual savings of $

86.5 M

.

PACE

enrollees who

have subseq

uent M

edicaid en

rollm

ent h

ave lower costs becau

se of e

arlier P

ACE coverage.

Th

e Prog

ram ta

kes a

dvan

tage of its id

eal position

to edu

cate th

ose PA

CE se

niors, who

are sp

ecifically kno

wn to

be in

come eligible, abo

ut th

e compreh

ensiv

e he

alth care coverage available throug

h Med

icaid, produ

cing

a

unique

, efficien

t outreach an

d im

prov

ed coo

rdination with

Med

icaid.

Analysts at M

ercer G

overnm

ent H

uman

Services C

onsulting

evaluated

the stud

y an

d were prep

ared

to certify results.

SELF‐RATE

D

HEA

LTH

IMPACT OF VANTA

GE POINT

ON THE ASSOCIATION

BET

WEEN SELF‐RATE

D HEA

LTH

AND M

ORTA

LITY

Magella

n Health/PACE an

d The

Medicine, H

ealth, and Aging


University

Num

erou

s studies dem

onstrate th

at se

lf‐rated he

alth predicts m

ortality. The goal of this study was to exp

lore how self‐

rating vantage point affects mortality prediction. Su

bjects in

clud

ed 137

,188

PAC

E en

rollees.

Three self‐rated

health van

tage points were used: global, a

ge‐comparative (others of same age) an

d tim

e comparative

(present vs. o

ne year ago

). M

ultiv

ariate Cox propo

rtiona

l‐hazards re

gressio

n was used to predict su

bseq

uent m

ortality

over tw

o years, con

trollin

g for d

emog

raph

ics a

nd m

edication‐ba

sed comorbidity.

Whe

n compa

ring glob

al and

age‐com

parativ

e ratin

gs, 73%

of p

ersons re

ported

equ

al globa

l and

age‐com

parativ

e scores;

19% had

age‐com

parativ

e scores th

at excee

ded glob

al sc

ores; and

, 8% indicated age‐compa

rativ

e scores worse th

an

glob

al. Ag

e compa

rativ

e scores worse th

an globa

l increased

risk of m

ortality, while age‐com

parativ

e scores excee

ding

glob

al sc

ores re

duced risk. The

impa

ct of a

ge‐com

parativ

e de

viation from

globa

l was strong

er in you

nger age group

s.

Controlling

for g

loba

l self‐rated

health

, self‐a

ssessed chan

ge over the

past y

ear in either dire

ction increased mortality risk,

but the

effe

ct varied by age (interactio

n p < .0

01), with

the grea

test im

pact observed am

ong yo

unger e

lderly aged 65

‐79.

These results suggest that comparative ratings are particularly useful w

hen used alongside global ratings, and that

potential age

differences in van

tage

point mean

ing may have a bearing on m

ortality prediction.

PHYSICAL

ACTIVITY AND

BRAIN HEA

LTH

HEA

LTHY BRAIN RESEA

RCH

STUDY

Physical Activity an

d W

eight

Man

agemen

t Research Center

at the University of Pittsburgh

and M

agella

n Health/PACE

Physical activity is linke

d to im

proved brain function. M

any stud

ies e

xamining the effect of p

hysic

al activity

on brain

health have focused on

structured

form

s of m

oderate‐to‐vigorou

s inten

sity exercise usin

g supe

rvise

d exercise. It is u

nclear

whe

ther brain and

cog

nitiv

e functio

n can be

improv

ed or sustained

with

differen

t patterns o

f phy

sical activity

. The study,

in 2015‐16, sough

t to show the effect of interm

ittent physical activity effective for im

proving brain structure and

function as well as cogn

itive function. Pa

rticipan

ts are 75 to 85 years o

ld who

can

partic

ipate in m

oderate intensity

exercise. Th

ey com

plete ba

selin

e an

d six

‐mon

th assessm

ents and

atten

d he

alth and

phy

sical activity

classes.

15

FALLS

PREV

ENTION

FALLS‐FR

EE PA

Graduate School o

f Public

Health, U

niversity of

Pittsburgh

The Ce

nters for Dise

ase Co

ntrol and

Prevention prov

ided

fund

s for th

is tw

o‐year re

search grant. Resea

rchers at the

Graduate School o

f Public Hea

lth at the University of Pittsburgh and the PA Departm

ent of Aging examined

county leve

l falls in

cidence and the effect of the Dep

artm

ent’s Hea

lthy Step

s for Older Adu

lts and Hea

lthy Step

s in Motion projects.

A physician education componen

t included

surveying physicians who see older ad

ults in their practice and offering

mailed and onlin

e educational m

aterials (healthyaging.pitt.ed

u) with CME/CEU

credits. Finding

s from th

e evalua

tion of

the He

althy Step

s program

s were incorporated

into well‐received Preven

ting Falls Amon

g the Elde

rly m

odule de

velope

d by

Alosa Health

for the

PAC

E Prog

ram’s acade

mic detailin

g effort in

201

4.

STATIN USE

ASSOCIATION BET

WEEN

STATIN USE AND FRACTU

RE

RISK AMONG THE ELDER

LY

Magella

n Health/PACE an

d The

Medicine, H

ealth, and Aging


University

The im

pact of statin

s (widely used

to trea

t hyp

erlip

idem

ia) o

n fracture risk is still und

er deb

ate. The goal of this study was

to examine the association betw

een statin use and fracture risk am

ong the elderly by follo

wing 5,524 new statin users

and 27,089 non‐users for an

ave

rage

of 3.5 years.

Time‐de

pend

ent C

ox propo

rtiona

l hazards m

odels w

ere used

to estim

ate ad

justed

hazard ratio

s of statin

use fo

r fracture

risk while con

trollin

g for d

emog

raph

ics, com

orbidity, b

ody mass ind

ex, smok

ing status, alcoh

ol use, and

certain

therap

eutic

classes. Th

e incidence of an

y fracture per 100 person‐years was 3.0 for statin users and 7.8 for non‐users.

Relative to non‐users, the hazard ratio associated with statin use was 0.86 (p < 0.001). Statin users with higher an

d

lower average

daily dose were associated

with 18% and 9% decreased

fracture risk, respectively.

The hazard ratio for atorvastatin was 0.81 (p < 0.001), and the effects were not sign

ifican

t for simvastatin and

pravastatin. Th

e protective effect of statin user ap

peared to be stronger am

ong users older than

85 years old. Th

ese

results su

ggested statin use is associated with

redu

ced fracture risk amon

g the elde

rly, and

the effect m

ay be de

pend

ent

on age and

statin ty

pe. Th

e be

neficial effe

ct of statin

on bo

ne m

ay be he

lpful in the preven

tion of fractures a

mon

g elde

rly.

BER

EAVEM

ENT

AND

MORTA

LITY

MORTA

LITY

FOLLOWING

WIDOWHOOD:

THE ROLE OF PRIOR SPOUSA

L HEA

LTH

Magella

n Health/PACE, The

Medicine, H

ealth, and Aging


University, and Emory

University Rollins School o

f Public Health

Prior research ha

s sho

wn that widow

hood

is associated with

increased mortality risk; how

ever, it is n

ot clear whe

ther th

e rapidity of the

prede

ceased

spou

se’s hea

lth declin

e affects this risk

. Th

is study used group‐based

trajectory m

odelin

g to

describe predeceased spouses’ patterns of health decline an

d examined associations with post‐w

idowhood survival.

Subjects includ

ed 9,967

PAC

E/PA

CENET cardh

olde

rs who

were widow

ed betwee

n 20

00 and

200

6. The

prede

ceased

and

be

reaved

spou

ses’ health

trajectorie

s in the year before widow

hood

were evalua

ted for three

mea

sures: the

Com

bine

d Co

morbidity Score, inp

atient hospitalized

days, and

ambu

latory visits. Multiv

ariate Cox propo

rtiona

l hazards m

odels w

ere

used

to evaluate whe

ther th

e pred

ecea

sed spou

se’s pattern of h

ealth

declin

e affected

the subseq

uent su

rvival of the

be

reaved

spou

se, w

hile con

trollin

g for the

bereaved spou

se’s own historical hea

lth trajectory and

other fa

ctors.

Multip

le trajectory patterns o

f hea

lth declin

e be

fore dea

th emerged in th

e pred

ecea

sed sample. A

mon

g pred

ecea

sed

hospice users, stab

le lo

w and

late onset com

orbidity patterns w

ere bo

th associated with

greater m

ortality in th

e be

reaved

, relative to chron

ic high comorbidity (H

R=1.47

and

1.62, re

spectiv

ely). Re

lativ

e to stab

le m

edium levels of

ambu

latory visits amon

g the pred

eceased, chron

ically high visit levels were associated

with

a lo

wer m

ortality rate in

the

bereaved

(HR=

0.67

), while very low visit levels w

ere associated

with

highe

r post‐widow

hood

mortality in th

e be

reaved

(HR=

1.32

). These results dem

onstrate the utility of group‐based

trajectory m

odels for describing patterns of end‐of‐life

decline and suggest that unan

ticipated deaths may be associated with greater post‐w

idowhood m

ortality risk for

bereaved spouses.

16

SECTION 2

FINANCIAL DATA

BY DATE OF SERVICE

17

18

TAB

LE 2

.1A

HIS

TOR

ICAL

CLA

IM A

ND

EXP

END

ITU

RE

DAT

A FO

R P

ACE

ENR

OLL

ED A

ND

PAR

TIC

IPAT

ING

CAR

DH

OLD

ERS

BY

SEM

I-AN

NU

AL P

ERIO

D B

ASED

ON

DAT

E O

F SE

RVI

CE

JAN

UAR

Y 19

91 -

DEC

EMB

ER 2

018

PAG

E 1

CLA

IMS

PER

CLA

IMS

PER

AVER

AGE

SEM

I-AN

NU

ALEN

RO

LLED

PAR

TIC

IPAT

ING

TOTA

LEN

RO

LLED

PAR

TIC

IPAT

ING

TOTA

LST

ATE

SHAR

EPE

RIO

DC

ARD

HO

LDER

SC

ARD

HO

LDER

SC

LAIM

SC

ARD

HO

LDER

CAR

DH

OLD

EREX

PEN

DIT

UR

ESPE

R C

LAIM

JAN

-JU

N 1

991

405,

358

337,

684

5,28

0,37

613

.03

15.6

4$1

16,0

74,6

18$2

86.3

5$3

43.7

4$2

1.98

JUL-

DEC

199

139

4,05

532

4,57

44,

677,

159

11.8

714

.41

$109

,871

,650

$278

.82

$338

.51

$23.

49

JAN

-JU

N 1

992

399,

721

326,

469

4,65

6,98

611

.65

14.2

6$1

16,0

82,5

06$2

90.4

1$3

55.5

7$2

4.93

JUL-

DEC

199

238

5,10

331

3,43

04,

602,

261

11.9

514

.68

$117

,081

,602

$304

.03

$373

.55

$25.

44

JAN

-JU

N 1

993

376,

916

310,

438

4,40

2,17

111

.68

14.1

8$1

13,0

68,7

54$2

99.9

8$3

64.2

2$2

5.68

JUL-

DEC

199

335

7,77

729

6,80

24,

456,

223

12.4

615

.01

$116

,164

,381

$324

.68

$391

.39

$26.

07

JAN

-JU

N 1

994

354,

819

293,

462

4,32

0,15

912

.18

14.7

2$1

15,4

13,5

42$3

25.2

7$3

93.2

8$2

6.72

JUL-

DEC

199

434

0,60

728

1,46

54,

404,

257

12.9

315

.65

$119

,100

,741

$349

.67

$423

.15

$27.

04

JAN

-JU

N 1

995

331,

965

277,

461

4,38

3,96

813

.21

15.8

0$1

21,1

47,2

11$3

64.9

4$4

36.6

3$2

7.63

JUL-

DEC

199

531

7,71

926

3,57

64,

347,

335

13.6

816

.49

$122

,158

,872

$384

.49

$463

.47

$28.

10

JAN

-JU

N 1

996

306,

062

253,

283

4,24

4,19

013

.87

16.7

6$1

20,8

68,6

54$3

94.9

2$4

77.2

1$2

8.48

JUL-

DEC

199

629

2,75

523

8,96

34,

204,

461

14.3

617

.59

$120

,429

,840

$411

.37

$503

.97

$28.

64

JAN

-JU

N 1

997

286,

126

236,

157

4,28

6,47

814

.98

18.1

5$1

16,7

32,8

47$4

07.9

8$4

94.3

0$2

7.23

JUL-

DEC

199

727

6,18

022

6,80

64,

358,

892

15.7

819

.22

$123

,482

,056

$447

.11

$544

.44

$28.

33

JAN

-JU

N 1

998

267,

225

222,

465

4,23

5,61

915

.85

19.0

4$1

26,8

72,5

48$4

74.7

8$5

70.3

0$2

9.95

JUL-

DEC

199

825

7,00

921

3,69

44,

331,

390

16.8

520

.27

$137

,146

,444

$533

.63

$641

.79

$31.

66

JAN

-JU

N 1

999

246,

467

208,

992

4,31

6,58

817

.51

20.6

5$1

42,4

12,9

78$5

77.8

2$6

81.4

3$3

2.99

JUL-

DEC

199

923

8,38

820

0,92

14,

450,

893

18.6

722

.15

$153

,596

,648

$644

.31

$764

.46

$34.

51

JAN

-JU

N 2

000

237,

017

202,

683

4,44

9,10

218

.77

21.9

5$1

60,6

15,3

39$6

77.6

5$7

92.4

5$3

6.10

JUL-

DEC

200

023

0,75

219

7,77

74,

530,

829

19.6

422

.91

$169

,886

,476

$736

.23

$858

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$37.

50

JAN

-JU

N 2

001

225,

325

197,

082

4,55

8,33

920

.23

23.1

3$1

78,6

50,9

79$7

92.8

6$9

06.4

8$3

9.19

JUL-

DEC

200

121

8,57

619

0,54

04,

590,

216

21.0

024

.09

$187

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,534

$859

.29

$985

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$40.

92

JAN

-JU

N 2

002

216,

719

190,

131

4,55

8,00

021

.03

23.9

7$1

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88,8

89$8

98.8

1$1

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.50

$42.

74

JUL-

DEC

200

220

9,73

718

3,31

84,

605,

906

21.9

625

.13

$203

,591

,448

$970

.70

$1,1

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9$4

4.20

JAN

-JU

N 2

003

209,

761

182,

654

4,55

2,66

221

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24.9

3$2

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92.1

0$1

,139

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$45.

71

JUL-

DEC

200

320

7,14

418

0,46

04,

683,

173

22.6

125

.95

$221

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$1,0

69.3

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30

EXPE

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DAT

A FO

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JAN

UAR

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91 -

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JAN

-JU

N 2

004

215,

486

189,

762

4,67

5,69

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24.6

4$2

09,7

31,9

50$9

73.3

0$1

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.24

$44.

86

JUL-

DEC

200

420

9,23

718

3,97

04,

639,

594

22.1

725

.22

$178

,165

,448

$851

.50

$968

.45

$38.

40

JAN

-JU

N 2

005

209,

512

182,

450

4,60

2,80

221

.97

25.2

3$1

66,4

96,0

79$7

94.6

9$9

12.5

6$3

6.17

JUL-

DEC

200

520

3,95

617

7,66

74,

628,

809

22.7

026

.05

$208

,631

,707

$1,0

22.9

3$1

,174

.29

$45.

07

JAN

-JU

N 2

006

199,

426

172,

092

4,48

2,46

122

.48

26.0

5$1

96,3

69,2

22$9

84.6

7$1

,141

.07

$43.

81

JUL-

DEC

200

619

4,88

416

4,17

44,

071,

755

20.8

924

.80

$126

,433

,882

$648

.76

$770

.12

$31.

05

JAN

-JU

N 2

007

203,

104

167,

796

3,61

9,45

617

.82

21.5

7$8

1,20

2,59

5$3

99.8

1$4

83.9

4$2

2.44

JUL-

DEC

200

718

3,83

915

0,27

33,

487,

882

18.9

723

.21

$98,

984,

305

$538

.43

$658

.70

$28.

38

JAN

-JU

N 2

008

164,

728

133,

656

3,01

4,59

618

.30

22.5

5$7

0,09

6,78

1$4

25.5

3$5

24.4

6$2

3.25

JUL-

DEC

200

816

0,80

212

5,31

92,

878,

017

17.9

022

.97

$76,

070,

500

$473

.07

$607

.01

$26.

43

JAN

-JU

N 2

009

145,

634

119,

773

2,68

2,43

618

.42

22.4

0$5

5,42

6,88

9$3

80.5

9$4

62.7

7$2

0.66

JUL-

DEC

200

914

1,98

811

4,16

92,

546,

781

17.9

422

.31

$63,

035,

614

$443

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$552

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$24.

75

JAN

-JU

N 2

010

138,

520

113,

130

2,37

9,42

717

.18

21.0

3$5

6,13

1,54

0$4

05.2

2$4

96.1

7$2

3.59

JUL-

DEC

201

013

4,10

410

6,53

52,

175,

106

16.2

220

.42

$61,

572,

767

$459

.14

$577

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$28.

31

JAN

-JU

N 2

011

128,

440

103,

356

2,22

1,68

017

.30

21.5

0$4

5,30

7,89

8$3

52.7

6$4

38.3

7$2

0.39

JUL-

DEC

201

112

5,09

698

,265

2,06

1,53

416

.48

20.9

8$4

2,77

7,76

4$3

41.9

6$4

35.3

3$2

0.75

JAN

-JU

N 2

012

119,

166

95,4

072,

091,

129

17.5

521

.92

$42,

297,

874

$354

.95

$443

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$20.

23

JUL-

DEC

201

211

6,82

291

,020

1,94

3,20

616

.63

21.3

5$3

7,25

2,37

6$3

18.8

8$4

09.2

8$1

9.17

JAN

-JU

N 2

013

114,

935

88,4

421,

904,

685

16.5

721

.54

$36,

975,

064

$321

.70

$418

.07

$19.

41

JUL-

DEC

201

310

9,90

783

,756

1,76

7,78

116

.08

21.1

1$3

5,19

1,93

3$3

20.2

0$4

20.1

7$1

9.91

JAN

-JU

N 2

014

119,

491

90,2

231,

810,

547

15.1

520

.07

$36,

412,

429

$304

.73

$403

.58

$20.

11

JUL-

DEC

201

411

7,57

787

,627

1,73

0,40

014

.72

19.7

5$3

9,22

6,75

5$3

33.6

3$4

47.6

6$2

2.67

JAN

-JU

N 2

015

113,

731

84,9

521,

673,

305

14.7

119

.70

$40,

128,

728

$352

.84

$472

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$23.

98

JUL-

DEC

201

510

9,98

180

,521

1,55

3,82

014

.13

19.3

0$3

9,47

3,69

0$3

58.9

1$4

90.2

3$2

5.40

JAN

-JU

N 2

016

104,

377

75,4

911,

324,

489

12.6

917

.54

$36,

625,

398

$350

.90

$485

.16

$27.

65

JUL-

DEC

201

610

0,75

671

,489

1,24

8,40

512

.39

17.4

6$3

0,69

8,15

0$3

04.6

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29.4

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JAN

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N 2

017

95,3

9566

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1,18

5,54

312

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17.7

1$2

7,81

1,61

3$2

91.5

4$4

15.4

8$2

3.46

JUL-

DEC

201

792

,001

63,8

351,

106,

552

12.0

317

.33

$26,

378,

502

$286

.72

$413

.23

$23.

84

JAN

-JU

N 2

018

86,2

6460

,261

1,05

0,86

612

.18

17.4

4$2

4,40

8,02

3$2

82.9

5$4

05.0

4$2

3.23

JUL-

DEC

201

881

,581

55,5

5392

8,92

211

.39

16.7

2$2

2,18

4,73

1$2

71.9

4$3

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JULY

199

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201

8

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JUL-

DEC

199

61,

523

740

2,33

11.

533.

15$8

23$0

.54

$1.1

1$0

.35

JAN

-JU

N 1

997

9,06

36,

369

75,7

218.

3511

.89

$592

,426

$65.

37$9

3.02

$7.8

2

JUL-

DEC

199

712

,523

9,00

714

9,18

711

.91

16.5

6$2

,676

,259

$213

.71

$297

.13

$17.

94

JAN

-JU

N 1

998

18,0

5312

,683

175,

085

9.70

13.8

0$2

,909

,397

$161

.16

$229

.39

$16.

62

JUL-

DEC

199

818

,673

13,8

0423

2,84

612

.47

16.8

7$4

,738

,127

$253

.74

$343

.24

$20.

35

JAN

-JU

N 1

999

22,2

7216

,649

263,

010

11.8

115

.80

$5,5

19,3

95$2

47.8

2$3

31.5

2$2

0.99

JUL-

DEC

199

922

,187

16,8

8530

9,28

013

.94

18.3

2$7

,416

,866

$334

.29

$439

.26

$23.

98

JAN

-JU

N 2

000

25,7

3919

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339,

481

13.1

917

.18

$8,3

71,6

58$3

25.2

5$4

23.6

2$2

4.66

JUL-

DEC

200

025

,446

19,6

3038

1,07

414

.98

19.4

1$1

0,19

3,85

9$4

00.6

1$5

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6.75

JAN

-JU

N 2

001

29,5

2222

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412,

077

13.9

618

.61

$11,

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086

$381

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$508

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$27.

31

JUL-

DEC

200

129

,278

23,2

8447

7,95

416

.32

20.5

3$1

3,84

9,68

3$4

73.0

4$5

94.8

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8.98

JAN

-JU

N 2

002

35,5

0827

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540,

878

15.2

319

.60

$16,

333,

097

$459

.98

$591

.91

$30.

20

JUL-

DEC

200

236

,146

28,6

1161

3,52

816

.97

21.4

4$2

0,06

9,08

6$5

55.2

2$7

01.4

5$3

2.71

JAN

-JU

N 2

003

39,2

6331

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644,

800

16.4

220

.79

$21,

627,

367

$550

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$697

.41

$33.

54

JUL-

DEC

200

340

,148

31,8

6972

0,68

717

.95

22.6

1$2

5,65

3,45

6$6

38.9

7$8

04.9

7$3

5.60

JAN

-JU

N 2

004

93,8

6172

,605

1,30

5,26

613

.91

17.9

8$4

8,95

8,31

9$5

21.6

0$6

74.3

1$3

7.51

JUL-

DEC

200

410

5,01

882

,631

1,92

1,31

018

.30

23.2

5$7

1,80

0,23

4$6

83.6

9$8

68.9

3$3

7.37

JAN

-JU

N 2

005

123,

399

94,9

792,

176,

264

17.6

422

.91

$81,

372,

126

$659

.42

$856

.74

$37.

39

JUL-

DEC

200

512

5,10

899

,242

2,45

0,95

319

.59

24.7

0$9

6,44

8,83

5$7

70.9

2$9

71.8

6$3

9.35

JAN

-JU

N 2

006

134,

715

108,

462

2,70

8,71

020

.11

24.9

7$1

00,4

73,8

23$7

45.8

3$9

26.3

5$3

7.09

JUL-

DEC

200

614

1,09

910

9,86

72,

684,

515

19.0

324

.43

$77,

093,

600

$546

.38

$701

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$28.

72

JAN

-JU

N 2

007

162,

966

127,

001

2,63

0,62

916

.14

20.7

1$5

9,09

4,94

3$3

62.6

2$4

65.3

1$2

2.46

JUL-

DEC

200

714

7,62

711

6,36

92,

687,

888

18.2

123

.10

$85,

506,

499

$579

.21

$734

.79

$31.

81

JAN

-JU

N 2

008

176,

161

136,

910

2,95

0,98

816

.75

21.5

5$6

8,07

2,71

4$3

86.4

2$4

97.2

1$2

3.07

JUL-

DEC

200

818

2,45

213

7,83

43,

078,

477

16.8

722

.33

$89,

908,

365

$492

.78

$652

.29

$29.

21

JAN

-JU

N 2

009

177,

553

140,

328

2,96

3,53

016

.69

21.1

2$6

6,83

3,67

1$3

76.4

2$4

76.2

7$2

2.55

EXPE

ND

ITU

RES

EXPE

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PER

EN

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PAR

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6 - D

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8

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EN

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LLED

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PAR

TIC

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ARD

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JUL-

DEC

200

918

4,29

114

1,68

93,

023,

686

16.4

121

.34

$91,

218,

108

$494

.97

$643

.79

$30.

17

JAN

-JU

N 2

010

189,

558

148,

953

2,87

7,85

215

.18

19.3

2$7

8,56

0,90

4$4

14.4

4$5

27.4

2$2

7.30

JUL-

DEC

201

019

2,60

114

7,46

22,

849,

518

14.7

919

.32

$101

,307

,460

$526

.00

$687

.01

$35.

55

JAN

-JU

N 2

011

194,

040

151,

302

3,09

6,29

315

.96

20.4

6$6

5,22

3,93

9$3

36.1

4$4

31.0

8$2

1.07

JUL-

DEC

201

119

3,62

714

8,68

73,

064,

463

15.8

320

.61

$62,

924,

015

$324

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$423

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$20.

53

JAN

-JU

N 2

012

190,

699

149,

039

3,03

2,17

815

.90

20.3

4$6

4,05

3,62

3$3

35.8

9$4

29.7

8$2

1.12

JUL-

DEC

201

218

9,62

014

5,55

22,

983,

628

15.7

320

.50

$58,

325,

715

$307

.59

$400

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$19.

55

JAN

-JU

N 2

013

186,

979

143,

936

2,92

2,48

615

.63

20.3

0$5

8,08

2,93

7$3

10.6

4$4

03.5

3$1

9.87

JUL-

DEC

201

318

3,03

213

9,39

72,

853,

565

15.5

920

.47

$58,

084,

897

$317

.35

$416

.69

$20.

36

JAN

-JU

N 2

014

181,

792

138,

181

2,58

4,27

614

.22

18.7

0$5

6,59

8,68

1$3

11.3

4$4

09.6

0$2

1.90

JUL-

DEC

201

416

8,59

712

8,30

72,

502,

791

14.8

419

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$58,

463,

645

$346

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$455

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$23.

36

JAN

-JU

N 2

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166,

664

128,

678

2,44

0,19

414

.64

18.9

6$5

9,29

2,99

3$3

55.7

6$4

60.7

9$2

4.30

JUL-

DEC

201

516

5,21

512

6,05

62,

413,

594

14.6

119

.15

$61,

336,

086

$371

.25

$486

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$25.

41

JAN

-JU

N 2

016

163,

178

125,

025

2,28

5,18

614

.00

18.2

8$6

0,17

6,27

5$3

68.7

8$4

81.3

1$2

6.33

JUL-

DEC

201

616

1,21

112

2,15

32,

246,

297

13.9

318

.39

$55,

064,

136

$341

.57

$450

.78

$24.

51

JAN

-JU

N 2

017

159,

877

121,

327

2,15

9,10

713

.50

17.8

0$5

2,85

9,41

4$3

30.6

3$4

35.6

8$2

4.48

JUL-

DEC

201

715

6,74

911

7,64

12,

097,

708

13.3

817

.83

$49,

612,

810

$316

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$421

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$23.

65

JAN

-JU

N 2

018

156,

389

117,

128

2,02

2,41

912

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17.2

7$5

0,56

3,64

0$3

23.3

2$4

31.7

0$2

5.00

JUL-

DEC

201

816

3,45

711

8,02

61,

965,

094

12.0

216

.65

$48,

641,

157

$297

.58

$412

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$24.

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PERCENT OF ENROLLED CARDHOLDERS

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TE S

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UR

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8.36

25

38.9

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27.6

%

8.2%

8.8%

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3.1%

1.3%

0.7%

0.5%

0.8%

0.8%

0.3%

0.3%

0%5%10%

15%

20%

25%

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PERCENT OF ENROLLED CARDHOLDERS

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574.

17

26

JAN - JUN JUL - DEC CALENDARYEAR

TOTAL PRESCRIPTION COST (DATE OF SERVICE) 327,727,573$ 316,347,856$ 644,075,429$ MEDICARE PART D PREMIUMS 10,524,198 9,263,961 19,788,159 GROSS CLAIMS/PREMIUMS SUBTOTAL 338,251,771 325,611,817 663,863,588 96.4%

MHS CONTRACT OPERATIONS (INCLUDES POSTAGE) 8,565,700 8,934,322 17,500,023 2.5%

PDA ADMINISTRATION PERSONNEL 525,873 433,384 959,257 OPERATIONS 153,627 14,268 167,895 GROSS PDA ADMIN. SUBTOTAL 679,500 447,652 1,127,152 0.2%

OTHER ADMINISTRATION PHARMACY AUDITS 332,500 350,000 682,500 THIRD PARTY RECOVERY SERVICES 347,298 416,761 764,059 GROSS OTHER ADMIN. SUBTOTAL 679,798 766,761 1,446,559 0.2%

BEHAVIORAL HEALTH INTERVENTIONS 362,565 350,158 712,724 0.1%

ENROLLMENT OUTREACH 1,060,326 1,338,033 2,398,359 0.3%

PRESCRIBER EDUCATION 875,000 750,000 1,625,000 0.2%

GROSS EXPENDITURES 350,474,660 338,198,743 688,673,403 100.0%

PRESCRIPTION COST OFFSETS PART D/OTHER PAYER OFFSETS (226,890,891) (221,670,944) (448,561,835) -65.1% CARDHOLDER COPAYMENTS (25,865,020) (23,851,023) (49,716,043) -7.2%

TOTAL OFFSETS (252,755,911) (245,521,967) (498,277,878) -72.4%

FEDERAL GRANT FOR PRESCRIBER EDUCATION (186,000) (244,000) (430,000) RECOVERIES MANUFACTURER REBATES (20,374,860) (19,183,083) (39,557,943) AUDIT ADJUSTMENTS IN CHECKWRITES (180,211) (341,204) (521,415) THIRD-PARTY REIMBURSEMENTS AND TRANSFERS (619,945) (4,870,666) (5,490,611) COMBINED RECOVERIES (21,175,016) (24,394,953) (45,569,969) PRIOR YEARS' REBATE REFUNDS 2,546 - 2,546

NET RECOVERIES (21,172,470) (24,394,953) (45,567,423) -6.6%

NET PRESCRIPTION CLAIM EXPENDITURES STATE SHARE FOR RX BEFORE RECOVERIES 74,971,663 70,825,888 145,797,551 21.2% STATE SHARE FOR RX AFTER RECOVERIES 53,799,192 46,430,936 100,230,128 14.6%

NET STATE EXPENDITURES INCLUDING PREMIUMS AND ADMINISTRATION 76,360,279$ 68,037,823$ 144,398,102$ 21.0%

AUDIT ADJUSTMENTS ARE BY RECOVERY DATE; AUDITS OCCURRED IN CY 2017 AND 2018.REBATES ($39.6 M) ARE 27.1% OF TOTAL STATE SHARE PRESCRIPTION DRUG COST ($145.8 M).TOTAL PRESCRIPTION COST DOES NOT INCLUDE CLAIMS PROCESSED SOLELY BY OTHER PAYERS.

TABLE 2.2TOTAL PRESCRIPTION COST, EXPENDITURES, OFFSETS, AND RECOVERIES

JANUARY - DECEMBER 2018

EXPENDITURES, RECOVERIES, OFFSETS% OF TOTAL

GROSS EXPENDITURES

NOTES: TABLE USES DATE OF SERVICE REFERENCE CLAIM COST FILE FOR ANNUAL DRUG EXPENDITURES.

27

PRO

GR

AMPR

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59,6

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35.1

0$4

,585

,149

$1.9

4$1

8,66

8,19

8$7

.90

$56,

164,

129

$23.

77TO

TAL

3,98

7,51

3$3

19,2

17,2

32$8

0.05

$10,

168,

011

$2.5

5$2

8,91

9,02

4$7

.25

$99,

204,

797

$24.

88

PAC

E/PA

CEN

ETBR

AND

PRIM

ARY

151,

804

$0$0

.00

$696

,195

$4.5

9$1

,994

,392

$13.

14$5

7,01

1,88

5$3

75.5

6SE

CO

ND

ARY

747,

025

$377

,558

,180

$505

.42

$1,9

78,3

08$2

.65

$11,

131,

988

$14.

90$5

7,95

1,57

3$7

7.58

TOTA

L89

8,82

9$3

77,5

58,1

80$4

20.0

6$2

,674

,503

$2.9

8$1

3,12

6,38

0$1

4.60

$114

,963

,457

$127

.90

GEN

ERIC

PRIM

ARY

2,21

5,50

2$0

$0.0

0$4

,886

,668

$2.2

1$1

2,75

4,77

6$5

.76

$15,

085,

538

$6.8

1SE

CO

ND

ARY

2,85

2,97

0$7

1,00

3,65

5$2

4.89

$2,6

06,8

41$0

.91

$13,

666,

876

$4.7

9$1

5,74

8,55

6$5

.52

TOTA

L5,

068,

472

$71,

003,

655

$14.

01$7

,493

,509

$1.4

8$2

6,42

1,65

2$5

.21

$30,

834,

094

$6.0

8

ALL

PRO

DU

CTS

PRIM

ARY

2,36

7,30

6$0

$0.0

0$5

,582

,862

$2.3

6$1

4,74

9,16

8$6

.23

$72,

097,

423

$30.

46SE

CO

ND

ARY

3,59

9,99

5$4

48,5

61,8

35$1

24.6

0$4

,585

,149

$1.2

7$2

4,79

8,86

4$6

.89

$73,

700,

128

$20.

47TO

TAL

5,96

7,30

1$4

48,5

61,8

35$7

5.17

$10,

168,

011

$1.7

0$3

9,54

8,03

2$6

.63

$145

,797

,551

$24.

43

TAB

LE 2

.3

CLA

IMS

AN

D E

XPEN

DIT

UR

ES B

Y PR

OG

RA

M, P

RO

DU

CT

TYPE

, AN

D P

AYM

ENT

SOU

RC

E

THIR

D P

ARTY

LIA

BILI

TY

(TPL

) PAY

MEN

TSC

ARD

HO

LDER

PR

EMIU

M P

AYM

ENTS

C

ARD

HO

LDER

C

OPA

YMEN

TSST

ATE

SHAR

E EX

PEN

DIT

UR

ES

SOU

RC

E: P

DA/

CLA

IMS

HIS

TOR

Y, C

ARD

HO

LDER

, AN

D D

RU

G F

ILES

NO

TE:

DAT

A IN

CLU

DE

OR

IGIN

AL, P

AID

PAC

E AN

D P

ACEN

ET C

LAIM

S BY

DAT

E O

F SE

RVI

CE.

TO

TAL

C

LAIM

S

JAN

UA

RY

- DEC

EMB

ER 2

018

PAC

E/PA

CEN

ET

PAYE

R S

TATU

S

28

CAL

END

AR Y

EAR

ENR

OLL

MEN

TC

LAIM

SG

RO

SS E

XPEN

DIT

UR

ESN

ET E

XPEN

DIT

UR

ES A

FTER

REC

OVE

RIE

S

1988

AN

NU

AL

ENR

OLL

MEN

T 51

2,73

7

1988

CLA

IMS

11,3

70,9

67

1988

GR

OSS

EX

PEN

DIT

UR

E$1

83,8

18,2

45

1988

NET

EX

PEN

DIT

UR

E$1

72,8

97,6

82

2018

AN

NU

AL

ENR

OLL

MEN

T25

8,05

220

18 C

LAIM

S5,

967,

301

2018

GR

OSS

EX

PEN

DIT

UR

E$1

45,7

97,5

5120

18 N

ET

EXPE

ND

ITU

RE

$100

,230

,128

FIG

UR

E 2.

4PA

CE

AND

PAC

ENET

EN

RO

LLM

ENT,

CLA

IMS,

AN

D C

LAIM

S EX

PEN

DIT

UR

ESB

Y C

ALEN

DAR

YEA

R19

88-2

018

9

SOU

RC

E: P

DA/

CAR

DH

OLD

ER F

ILE

CLA

IMS

HIS

TOR

Y.N

OTE

:D

ATA

INC

LUD

E O

RIG

INAL

, PAI

D C

LAIM

S BY

DAT

E O

F SE

RVI

CE.

AN

NU

AL E

NR

OLL

MEN

T TO

TALS

AR

E BA

SED

ON

CAR

DH

OLD

ERS

WH

O W

ERE

ENR

OLL

ED F

OR

AN

Y PO

RTI

ON

OF

THE

YEAR

.R

ECO

VER

IES

INC

LUD

E TH

IRD

PAR

TY P

AYM

ENTS

, MAN

UFA

CTU

RER

S' R

EBAT

E, A

ND

RES

TITU

TIO

NS.

29

156,

688

140,

908

130,

824

121,

013

112,

513

109,

631

99,5

59

106,

548

97,9

30

89,0

55

80,9

52

73,0

94

114,

691

101,

943

94,3

70

86,4

1579

,393

73,2

8064

,896

67,3

52

57,8

69

51,4

1246

,456

39,2

91

0

25,0

00

50,0

00

75,0

00

100,

000

125,

000

150,

000

175,

000

200,

000

NUMBER OF PERSONSFI

GU

RE

2.5A

PAC

E TO

TAL

ENR

OLL

ED A

ND

PAR

TIC

IPAT

ING

CAR

DH

OLD

ERS

BY

MO

NTH

JAN

UAR

Y 20

08 -

JAN

UAR

Y 20

19

PAC

E En

rolle

dPA

CE

Parti

cipa

ting

SOU

RC

E: E

ND

-OF-

MO

NTH

PAC

E EN

RO

LLED

TAK

EN F

RO

M M

R-0

-01A

REP

OR

T, P

ARTI

CIP

ATIN

G T

AKEN

FR

OM

CLA

IMS

HIS

TOR

Y BA

SED

ON

DAT

E O

F SE

RVI

CE

1

11.4

%D

ECR

EASE

7.7%

D

ECR

EASE

8.1%

D

ECR

EASE

9.2%

D

ECR

EASE

7.0%

IN

CR

EASE

8.1%

D

ECR

EASE

3.8%

INC

REA

SE14

.1%

DEC

REA

SE

9.1%

D

ECR

EASE

11.2

%

DEC

REA

SE9.

6%

DEC

REA

SE

9.1%

D

ECR

EASE

2008

2009

2010

2011

2012

2013

2014

2015

9.7%

D

ECR

EASE

15.4

%

DEC

REA

SE

2016

11.0

%

DEC

REA

SE

10.1

%

DEC

REA

SE

2017

7.2%

DEC

REA

SE

7.4%

DEC

REA

SE

2018

7.5%

DEC

REA

SE

8.4%

DEC

REA

SE

7.0%

D

ECR

EASE

2.6%

DEC

REA

SE

30

152,

476

164,

777

171,

007

178,

127

177,

303

176,

483

167,

862

155,

575

152,

010

150,

003

145,

872

152,

561

110,

043

113,

994

117,

499

121,

887

120,

445

117,

329

109,

979

100,

939

96,5

8394

,118

90,0

0787

,874

0

25,0

00

50,0

00

75,0

00

100,

000

125,

000

150,

000

175,

000

200,

000

NUMBER OF PERSONS

FIG

UR

E 2.

5BPA

CEN

ET T

OTA

L EN

RO

LLED

AN

D P

ARTI

CIP

ATIN

G C

ARD

HO

LDER

S B

Y M

ON

THJA

NU

ARY

2008

-JA

NU

ARY

2019

PAC

ENET

Enr

olle

dPA

CEN

ET P

artic

ipat

ing

SOU

RC

E: E

ND

-OF-

MO

NTH

PAC

ENET

EN

RO

LLED

TAK

EN F

RO

M M

R-0

-01A

REP

OR

T, P

ARTI

CIP

ATIN

G T

AKEN

FR

OM

CLA

IMS

HIS

TOR

Y BA

SED

ON

DAT

E O

F SE

RVI

CE

1

1.2%

D

ECR

EASE

3.7%

IN

CR

EASE

7.3%

D

ECR

EASE

6.3%

D

ECR

EASE

8.

2%

DEC

REA

SE

2.3%

D

ECR

EASE

4.3%

D

ECR

EASE

1.3%

D

ECR

EASE

2.6%

D

ECR

EASE

2008

2009

2010

2011

4.4%

D

ECR

EASE

2.8%

D

ECR

EASE

2012

2013

2014

2.6%

D

ECR

EASE

2015

2016

3.7%

INC

REA

SE

8.1%

INC

REA

SE

2017

3.8%

INC

REA

SE

3.1%

INC

REA

SE

4.2%

IN

CR

EASE

2018

4.6%

INC

REA

SE

2.4%

D

ECR

EASE

0.5%

INC

REA

SE0.

5%D

ECR

EASE

4.9%

DEC

REA

SE

31

32

SECTION 3

PROGRAM DATA BY DATE OF

PAYMENT

33

34

TIM

E PE

RIO

DPA

CE

REI

MBU

RSE

MEN

T FO

RM

ULA

PAC

ENET

REI

MBU

RSE

MEN

T FO

RM

ULA

July

1, 1

984

- Jun

e 30

, 198

5Th

e le

sser

of e

ither

the

Aver

age

Who

lesa

le P

rice

(AW

P) p

lus

a $2

.50

disp

ensi

ng fe

e or

the

Usu

al a

nd C

usto

mar

y C

harg

e (U

&C),

then

sub

tract

ing

a $4

.00

card

hold

er c

opay

men

t.

Not

App

licab

le

July

1, 1

985

- Jun

e 30

, 199

1Th

e le

sser

of e

ither

the

AWP

plus

a $

2.75

dis

pens

ing

fee

or th

e U

&C, t

hen

subt

ract

ing

a $4

.00

card

hold

er c

opay

men

t.N

ot A

pplic

able

July

1, 1

991

- Nov

embe

r 21,

199

6Th

e le

sser

of e

ither

the

AWP

plus

a $

2.75

dis

pens

ing

fee

or th

e U

&C, t

hen

subt

ract

ing

a $6

.00

card

hold

er c

opay

men

t.N

ot A

pplic

able

Nov

embe

r 22,

199

6 - D

ecem

ber 3

1, 2

003

The

less

er o

f eith

er th

e AW

P m

inus

10%

plu

s a

$3.5

0 di

spen

sing

fe

e, o

r the

U&C

, the

n su

btra

ctin

g a

$6.0

0 ca

rdho

lder

cop

aym

ent.

The

less

er o

f eith

er th

e AW

P m

inus

10%

plu

s a

$3.5

0 di

spen

sing

fe

e, o

r the

U&C

, the

n su

btra

ctin

g a

copa

ymen

t of $

8.00

for

gene

rics

and

$15.

00 fo

r bra

nd p

rodu

cts.

Janu

ary

1, 2

004

- Jul

y 9,

200

6Th

e le

sser

of e

ither

AW

P m

inus

10%

plu

s a

$4.0

0 di

spen

sing

fee,

or

the

U&C

, or t

he F

eder

al U

pper

Lim

it (F

UL)

for a

gen

eric

pr

oduc

t plu

s a

$4.0

0 di

spen

sing

fee,

then

sub

tract

ing

a co

paym

ent o

f $6.

00 fo

r gen

eric

s an

d $9

.00

for b

rand

pro

duct

s.

The

copa

ymen

t can

be

adju

sted

ann

ually

.

The

less

er o

f eith

er A

WP

min

us 1

0% p

lus

a $4

.00

disp

ensi

ng fe

e,

or th

e U

&C, o

r the

FU

L fo

r a g

ener

ic p

rodu

ct p

lus

a $4

.00

disp

ensi

ng fe

e, th

en s

ubtra

ctin

g a

copa

ymen

t of $

8.00

for g

ener

ics

and

$15.

00 fo

r bra

nd p

rodu

cts.

The

cop

aym

ent c

an b

e ad

just

ed

annu

ally

.

July

10,

200

6 - N

ovem

ber 3

0, 2

016

The

less

er o

f eith

er A

WP

min

us 1

2% p

lus

a $4

.00

disp

ensi

ng fe

e,

or th

e U

&C, o

r the

Fed

eral

Upp

er L

imit

(FU

L) fo

r a g

ener

ic

prod

uct p

lus

a $4

.00

disp

ensi

ng fe

e, th

en s

ubtra

ctin

g a

copa

ymen

t of $

6.00

for g

ener

ics

and

$9.0

0 fo

r bra

nd p

rodu

cts.

Th

e co

paym

ent c

an b

e ad

just

ed a

nnua

lly.

The

less

er o

f eith

er A

WP

min

us 1

2% p

lus

a $4

.00

disp

ensi

ng fe

e,

or th

e U

&C, o

r the

FU

L fo

r a g

ener

ic p

rodu

ct p

lus

a $4

.00

disp

ensi

ng fe

e, th

en s

ubtra

ctin

g a

copa

ymen

t of $

8.00

for g

ener

ics

and

$15.

00 fo

r bra

nd p

rodu

cts.

The

cop

aym

ent c

an b

e ad

just

ed

annu

ally

.

Dec

embe

r 1, 2

016

- Nov

embe

r 19,

201

7Th

e le

sser

of e

ither

the

Nat

iona

l Ave

rage

Dru

g Ac

quis

ition

Cos

t (N

ADAC

) plu

s a

$13.

00 d

ispe

nsin

g fe

e or

the

U&C

, the

n su

btra

ctin

g a

copa

ymen

t of $

6.00

for g

ener

ics

and

$9.0

0 fo

r br

and

prod

ucts

. The

Who

lesa

le A

cqui

sitio

n C

ost (

WAC

) plu

s 3.

2% p

lus

a $1

3.00

dis

pens

ing

fee,

then

sub

tract

ing

the

copa

ymen

t, is

use

d w

hen

NAD

AC is

una

vaila

ble.

The

less

er o

f eith

er th

e N

atio

nal A

vera

ge D

rug

Acqu

isiti

on C

ost

(NAD

AC) p

lus

a $1

3.00

dis

pens

ing

fee

or th

e U

&C, t

hen

subt

ract

ing

a co

paym

ent o

f $8.

00 fo

r gen

eric

s an

d $1

5.00

for

bran

d pr

oduc

ts. W

AC p

lus

3.2%

plu

s a

$13.

00 d

ispe

nsin

g fe

e,

then

sub

tract

ing

the

copa

ymen

t, is

use

d w

hen

NAD

AC is

un

avai

labl

e.

Nov

embe

r 20,

201

7 - P

rese

ntTh

e le

sser

of e

ither

NAD

AC p

lus

a $1

0.49

dis

pens

ing

fee

or th

e U

&C, t

hen

subt

ract

ing

a co

paym

ent o

f $6.

00 fo

r gen

eric

s an

d $9

.00

for b

rand

pro

duct

s. W

AC p

lus

3.2%

plu

s a

$10.

49

disp

ensi

ng fe

e, th

en s

ubtra

ctin

g th

e co

paym

ent,

is u

sed

whe

n N

ADAC

is u

nava

ilabl

e.

The

less

er o

f eith

er N

ADAC

plu

s a

$10.

49 d

ispe

nsin

g fe

e or

the

U&C

, the

n su

btra

ctin

g a

copa

ymen

t of $

8.00

for g

ener

ics

and

$15.

00 fo

r bra

nd p

rodu

cts.

WAC

plu

s 3.

2% p

lus

a $1

0.49

di

spen

sing

fee,

then

sub

tract

ing

the

copa

ymen

t, is

use

d w

hen

NAD

AC is

una

vaila

ble.

HIS

TOR

ICA

L PA

CE

AN

D P

AC

ENET

REI

MB

UR

SEM

ENT

FOR

MU

LAS

TAB

LE 3

.1

JULY

198

4 - D

ECEM

BER

201

8

35

PAG

E 1

% O

FAL

LM

ANU

FAC

TUR

ERPR

OD

UC

TST

REN

GTH

ND

C9

CLA

IMS

CLA

IMS

PRO

DU

CT

DES

CR

IPTI

ON

BOEH

RIN

GER

ING

ELH

EIM

SPIR

IVA

18 M

CG

0059

7007

5$1

,480

,062

3.16

18,

649

0.43

16R

ESPI

RAT

OR

Y AG

ENT

BRIS

TOL-

MYE

RS

SQU

IBB

ELIQ

UIS

5 M

G00

0030

894

$1,3

72,2

302.

932

13,8

380.

691

ANTI

CO

AGU

LAN

TBR

ISTO

L-M

YER

S SQ

UIB

BEL

IQU

IS2.

5 M

G00

0030

893

$1,1

50,6

742.

463

11,5

450.

584

ANTI

CO

AGU

LAN

TSA

NO

FI-A

VEN

TIS

LAN

TUS

SOLO

STAR

100/

ML

0008

8221

9$9

91,2

602.

124

6,77

40.

3426

DIA

BETE

S TR

EATM

ENT

JOH

NSO

N &

JO

HN

SON

XAR

ELTO

20 M

G50

4580

579

$775

,415

1.66

57,

820

0.39

22AN

TIC

OAG

ULA

NT

MER

CK

JAN

UVI

A10

0 M

G00

0060

277

$681

,288

1.45

66,

689

0.34

28D

IABE

TES

TREA

TMEN

TG

LAXO

SMIT

HKL

INE

ADVA

IR D

ISKU

S25

0-50

MC

G00

1730

696

$640

,097

1.37

77,

416

0.37

23R

ESPI

RAT

OR

Y AG

ENT

ASTR

A ZE

NEC

ASY

MBI

CO

RT

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100

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CK

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MG

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1977

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KN

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0046

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250

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ARD

HO

LDER

VOLU

ME

TAB

LE 3

.2B

PAC

ENET

HIG

H E

XPEN

DIT

UR

E AN

D H

IGH

VO

LUM

E C

LAIM

SJA

NU

ARY

- DEC

EMB

ER 2

018

RAN

K BY

TOTA

LEX

PEN

DIT

UR

ES(A

LL S

OU

RC

ES)

EXPE

ND

ITU

RES

APO

TEX

ATO

RVA

STAT

IN C

ALC

IUM

10 M

G60

5052

578

$158

,862

$7,6

770.

011,

164

$166

,539

14,6

550.

3724

ACC

OR

D H

EALT

HC

ARE

CLO

PID

OG

REL

75 M

G16

7290

218

$122

,007

$7,6

710.

011,

165

$129

,678

13,3

600.

3327

ASC

END

AMLO

DIP

INE

BESY

LATE

5 M

G67

8770

198

$132

,001

$7,4

810.

011,

190

$139

,482

21,1

960.

535

WAT

SON

LOR

AZEP

AM0.

5 M

G00

5910

240

$61,

937

$5,7

500.

011,

419

$67,

687

10,8

180.

2748

LEAD

ING

LOR

AZEP

AM0.

5 M

G69

3150

904

$64,

879

$5,5

060.

011,

462

$70,

384

11,3

700.

2943

ASC

END

AMLO

DIP

INE

BESY

LATE

10 M

G67

8770

199

$86,

131

$4,9

960.

011,

586

$91,

127

12,8

850.

3232

TEVA

TRAZ

OD

ON

E H

CL

50 M

G50

1110

433

$74,

368

$4,7

700.

001,

632

$79,

138

10,5

270.

2650

LUPI

NLI

SIN

OPR

IL20

MG

6818

0098

1$8

2,29

6$4

,123

0.00

1,80

1$8

6,41

912

,829

0.32

33C

ARAC

OM

ETO

PRO

LOL

TAR

TRAT

E25

MG

5766

4050

6$7

6,23

6$4

,113

0.00

1,80

5$8

0,34

911

,711

0.29

41TE

VATR

AMAD

OL

HC

L50

MG

0009

3005

8$7

2,02

7$4

,037

0.00

1,82

0$7

6,06

412

,519

0.31

36

MYL

ANM

ETO

PRO

LOL

TAR

TRAT

E25

MG

0037

8001

8$9

4,89

7$3

,847

0.00

1,87

9$9

8,74

415

,646

0.39

20LU

PIN

LISI

NO

PRIL

10 M

G68

1800

980

$78,

495

$3,8

390.

001,

882

$82,

333

12,9

150.

3231

MYL

ANFU

RO

SEM

IDE

20 M

G00

3780

208

$82,

465

$3,4

740.

002,

005

$85,

939

17,3

820.

4415

LEAD

ING

FUR

OSE

MID

E40

MG

6931

5011

7$5

5,97

3$3

,082

0.00

2,17

1$5

9,05

511

,716

0.29

40M

YLAN

FUR

OSE

MID

E40

MG

0037

8021

6$5

6,62

3$2

,405

0.00

2,51

3$5

9,02

812

,518

0.31

37

SOLC

O H

EALT

HC

ARE

FUR

OSE

MID

E40

MG

4354

7040

2$5

4,93

5$2

,169

0.00

2,66

5$5

7,10

412

,111

0.30

38SO

LCO

HEA

LTH

CAR

EFU

RO

SEM

IDE

20 M

G43

5470

401

$49,

614

$1,9

600.

002,

823

$51,

574

10,7

360.

2749

ACC

OR

D H

EALT

HC

ARE

HYD

RO

CH

LOR

OTH

IAZI

DE

25 M

G16

7290

183

$49,

467

$1,5

390.

003,

206

$51,

005

13,7

600.

3426

TOTA

L $1

70,5

97,2

13$4

5,29

3,39

345

.69

$215

,890

,607

929,

900

23.3

188

PR

OD

UC

TS

TOTA

L $3

55,4

57,3

69$9

9,13

9,22

410

0.00

$454

,596

,594

3,98

8,54

110

0.00

ALL

PRO

DU

CTS

SOU

RC

E: P

DA

CLA

IMS

HIS

TOR

YN

OTE

: DAT

A IN

CLU

DE

OR

IGIN

AL, P

AID

PAC

ENET

CLA

IMS

BY D

ATE

OF

PAYM

ENT.

TO

TAL

CLA

IMS

INC

LUD

E D

EDU

CTI

BLE

CLA

IMS

AND

CO

PAID

CLA

IMS.

41

PAG

E 1

ASS

OC

IATE

D N

DC

RA

NK

BY

% O

F A

LL%

OF

ALL

MA

NU

FAC

TUR

ERLA

BEL

ER C

OD

ESEX

PEN

DIT

UR

ESEX

PEN

DIT

UR

ESEX

PEN

DIT

UR

ES

CLA

IMS

CLA

IMS

BOEH

RIN

GER

ING

ELH

EIM

0005

4 , 0

0597

1$1

1,45

7,55

5 7.

8%14

0,49

52.

3%

NO

VO N

OR

DIS

K00

169

2$8

,970

,569

6.

1%77

,195

1.3%

GLA

XOSM

ITH

KLIN

E00

007 ,

001

73, 1

9515

,497

023

$8,5

48,9

37

5.9%

134,

813

2.3%

BRIS

TOL-

MYE

RS

SQU

IBB

0000

3 , 0

0056

, 000

87, 6

3653

4$8

,404

,596

5.

8%81

,674

1.4%

ELI L

ILLY

0000

2 , 0

0777

5$7

,426

,529

5.

1%36

,597

0.6%

PFIZ

ER00

008,

000

09, 0

0013

, 000

25, 0

0046

, 00

049,

000

69, 0

0071

, 002

06, 0

0409

, 59

762,

607

93, 6

1570

, 617

03, 6

3010

6$7

,424

,482

5.

1%78

,294

1.3%

JOH

NSO

N &

JO

HN

SON

1014

7 , 5

0458

, 578

94, 5

9676

7$7

,321

,415

5.

0%50

,920

0.9%

SAN

OFI

0002

4, 0

0039

, 000

68, 0

0075

, 000

88,

0095

58

$6,6

87,1

57

4.6%

46,0

310.

8%

MER

CK

0000

6, 0

0085

, 665

829

$6,1

45,3

92

4.2%

53,5

000.

9%

NO

VAR

TIS

0006

5, 0

0078

, 001

68, 0

0185

, 002

81,

0078

1 , 0

0998

, 613

14, 6

6685

10$5

,805

,359

4.

0%31

2,61

65.

2%

ASTR

A ZE

NEC

A00

186 ,

003

1011

$5,1

87,4

65

3.6%

43,5

140.

7%

ASTE

LLAS

0046

9 , 5

1248

12$4

,408

,025

3.

0%31

,899

0.5%

ACTA

VIS

0022

8, 0

0456

, 004

72, 0

0591

, 162

52,

4596

3, 5

2544

, 620

3713

$4,0

97,3

04

2.8%

266,

817

4.5%

ALLE

RG

AN00

023 ,

119

80, 6

0758

14$3

,474

,065

2.

4%52

,672

0.9%

AMG

EN55

513 ,

584

06, 7

2511

15$3

,270

,236

2.

2%6,

464

0.1%

VALE

ANT

0018

7, 1

3548

, 242

08, 2

5010

, 65

649,

66

490,

686

82, 9

9207

16$2

,802

,235

1.

9%64

,063

1.1%

TAB

LE 3

.3PA

CE

AN

D P

AC

ENET

NU

MB

ER A

ND

PER

CEN

T O

F EX

PEN

DIT

UR

ES A

ND

CLA

IMS

BY

MA

NU

FAC

TUR

ERJA

NU

AR

Y - D

ECEM

BER

201

8

42

PAG

E 2

ASS

OC

IATE

D N

DC

RA

NK

BY

% O

F A

LL%

OF

ALL

MA

NU

FAC

TUR

ERLA

BEL

ER C

OD

ESEX

PEN

DIT

UR

ESEX

PEN

DIT

UR

ESEX

PEN

DIT

UR

ES

CLA

IMS

CLA

IMS

TAB

LE 3

.3PA

CE

AN

D P

AC

ENET

NU

MB

ER A

ND

PER

CEN

T O

F EX

PEN

DIT

UR

ES A

ND

CLA

IMS

BY

MA

NU

FAC

TUR

ERJA

NU

AR

Y - D

ECEM

BER

201

8

MYL

AN00

037,

003

78, 4

2292

, 495

02, 5

1079

, 51

525

17$2

,680

,240

1.

8%43

2,85

27.

2%

TEVA

0009

3, 0

0172

, 005

55, 0

0703

, 501

11,

5128

5 , 5

7844

, 593

10, 6

3459

, 685

4618

$2,4

03,0

97

1.6%

316,

315

5.3%

ABBO

TT00

032,

000

51, 0

0074

19$2

,245

,466

1.

5%19

,952

0.3%

TAKE

DA

6476

420

$2,0

14,4

68

1.4%

18,8

810.

3%

GIL

EAD

SC

IEN

CES

1558

4 , 6

1958

21$1

,714

,516

1.

2%9,

723

0.2%

PHAR

MAC

YCLI

CS

5796

222

$1,6

67,9

34

1.1%

691

0.0%

CEL

GEN

E59

572 ,

688

1723

$1,6

63,4

89

1.1%

1,15

90.

0%

AMN

EAL

5374

6 , 6

5162

24$1

,329

,821

0.

9%13

5,23

22.

3%

END

O/Q

UAL

ITES

T00

254,

006

03, 4

9884

, 609

51, 6

3481

, 64

376,

672

53, 6

7979

, 687

7425

$1,2

91,8

59

0.9%

117,

269

2.0%

TOTA

L , T

OP

25 M

ANU

FAC

TUR

ERS

$118

,442

,207

81

.1%

2,52

9,63

842

.3%

TOTA

L , A

LL O

THER

$2

7,54

3,56

2 18

.9%

3,45

0,70

957

.7%

TOTA

L , A

LL M

ANU

FAC

TUR

ERS

$145

,985

,769

10

0.0%

5,98

0,34

710

0.0%

MAN

UFA

CTU

RER

DAT

A AR

E SU

MM

ARIZ

ED B

Y TH

E FI

RST

FIV

E D

IGIT

S O

F TH

E 11

-DIG

IT N

ATIO

NAL

DR

UG

CO

DE,

i.e.

, LAB

ELER

CO

DE.

SOU

RC

E: P

DA

CLA

IMS

HIS

TOR

YN

OTE

: DAT

A IN

CLU

DE

OR

IGIN

AL, P

AID

CLA

IMS

BY D

ATE

OF

PAYM

ENT.

43

91-9

2TH

RO

UG

H08

-09

09-1

010

-11

11-1

212

-13

13-1

414

-15

15-1

616

-17

17-1

818

-19

YTD

REC

EIPT

SR

ECEI

PTS

REC

EIPT

SR

ECEI

PTS

REC

EIPT

SR

ECEI

PTS

REC

EIPT

SR

ECEI

PTS

REC

EIPT

SR

ECEI

PTS

REC

EIPT

STO

TAL

JAN

-DEC

199

1$2

2,77

1,62

7$0

$2,0

49$0

$0$2

26$0

($3)

$0$0

$0$2

2,77

3,89

9JA

N-D

EC 1

992

$30,

143,

789

$0$3

,395

$3$0

$0$1

5,43

8$2

2$0

($2,

072)

$0$3

0,16

0,57

6JA

N-D

EC 1

993

$32,

017,

138

$0$0

$0$0

$16,

846

$4$0

($55

,253

)$0

$31,

978,

736

JAN

-DEC

199

4$3

0,66

6,41

0$0

$0$2

$0$0

$0$1

8$0

$0$0

$30,

666,

431

JAN

-DEC

199

5$3

2,64

2,77

8$0

$0$6

0,16

2$0

$0$2

03$0

$0$0

$32,

703,

143

JAN

-DEC

199

6$3

1,17

9,24

8$0

$0$0

$4,6

02$3

32$0

($7)

$0$0

$0$3

1,18

4,17

4JA

N-D

EC 1

997

$38,

800,

695

$3,2

03$2

,397

$0$4

,835

($67

2)$0

$400

$0($

3,48

4)$0

$38,

807,

374

JAN

-DEC

199

8$4

8,87

5,57

9$1

57$1

,117

$0($

724)

($25

,719

)$0

$749

$0$2

3$0

$48,

851,

182

JAN

-DEC

1999

$52,

516,

910

$26,

070

$0$0

$14,

948

$21,

133

$0$1

,746

$0($

31,2

49)

$0$5

2,54

9,55

7JA

N-D

EC20

00$5

8,98

8,16

4$0

$0$0

$15,

860

$13,

351

$0$7

11$0

$0$0

$59,

018,

086

JAN

-DEC

2001

$58,

243,

251

$0($

277)

($23

7)$4

,089

$9,9

34$0

$139

$0($

1)$0

$58,

256,

898

JAN

-DEC

2002

$75,

838,

084

($61

9,51

5)($

21,5

93)

$0$6

7,12

6$2

36,9

61$2

$195

$0$0

$0$7

5,50

1,26

1JA

N-D

EC20

03$1

00,9

35,3

40$7

99,3

65$9

0,48

0($

17,4

38)

$110

,126

$60,

352

$0$2

04$0

$93

$0$1

01,9

78,5

21JA

N-D

EC20

04$1

23,9

46,9

63$2

48,1

95($

319,

331)

$13,

490

$219

,104

$287

,753

$2,8

63$3

,692

$0($

15,1

00)

$0$1

24,3

87,6

29JA

N-D

EC20

05$1

32,7

66,9

01$2

47,8

35($

37,8

32)

$4,1

54$1

04,2

07$8

4,20

8$1

,860

$17,

780

$0($

2,43

6)$2

$133

,186

,679

JAN

-DEC

2006

$118

,795

,473

$466

,618

($10

4,61

9)$4

,105

$205

,036

$8,1

33$3

,637

$37,

766

$1,9

98$8

,081

$300

$119

,426

,529

JAN

-DEC

2007

$70,

010,

078

$3,1

92,4

81$5

42,4

78$1

89,7

71$7

8,23

5$1

1,23

3$1

88,9

98$1

48,7

73$8

,528

($1,

832)

($28

,262

)$7

4,34

0,48

1JA

N-D

EC20

08$5

6,98

1,37

5$2

,561

,190

($47

,469

)$5

79,5

16($

62,8

75)

$274

,759

$62,

197

$164

,909

($2,

127)

$5,4

32$1

21$6

0,51

7,02

8JA

N-D

EC20

09$1

1,78

2,45

5$5

1,97

6,63

3$9

92,3

11$7

28,0

39$1

,622

,644

$137

,799

$106

,008

($3,

489)

$249

($4,

013)

$54

$67,

338,

689

JAN

-DEC

2010

$0$4

,120

,823

$66,

372,

460

$3,6

39,4

21$2

,020

,192

($71

,790

)$9

5,51

1$5

,085

($42

8)$7

,257

($3,

031)

$76,

185,

500

JAN

-DEC

2011

$0$0

$8,7

99,4

54$3

7,77

6,05

2$1

,402

,578

$201

,910

$628

,050

$15,

373

$7,7

65$2

7,77

9$4

33$4

8,85

9,39

4JA

N-D

EC20

12$0

$0$0

$3,6

28,7

94$3

4,64

7,24

9$1

,057

,554

$563

,869

$91,

130

($1,

484)

$80,

790

$82

$40,

067,

984

JAN

-DEC

2013

$0$0

$0$0

$0$3

5,76

7,45

2$8

58,0

86$3

63,5

92$1

72,5

30$2

2,29

3($

22,2

07)

$37,

161,

744

JAN

-MAR

2014

$0$0

$0$0

$0$1

,184

,063

$7,9

85,7

23$2

18,6

64$1

75,9

47($

7,11

5)$0

$9,5

57,2

82AP

R-J

UN

2014

$0$0

$0$0

$0$0

$7,8

76,4

75$8

07,8

20$1

29,0

06$5

$0$8

,813

,305

JUL-

SEP

2014

$0$0

$0$0

$0$0

$8,3

81,0

94$3

29,5

39$1

28,8

37($

7,53

2)$5

$8,8

31,9

43O

CT-

DEC

2014

$0$0

$0$0

$0$0

$8,4

48,0

01$1

,338

,268

$93,

181

($11

,394

)$0

$9,8

68,0

55JA

N-M

AR20

15$0

$0$0

$0$0

$0$3

29,6

81$9

,476

,097

$838

,138

$40,

050

($51

)$1

0,68

3,91

6AP

R-J

UN

2015

$0$0

$0$0

$0$0

$0$9

,381

,267

$170

,895

$37,

435

$26,

986

$9,6

16,5

83JU

L-SE

P20

15$0

$0$0

$0$0

$0$0

$10,

019,

213

$26,

094

$23,

313

($6,

176)

$10,

062,

443

OC

T-D

EC20

15$0

$0$0

$0$0

$0$0

$8,8

97,1

54$4

27,8

45$1

6,32

6$2

29$9

,341

,553

JAN

-MAR

2016

$0$0

$0$0

$0$0

$0$1

,706

,334

$4,9

56,8

91$3

4,75

4$6

,290

$6,7

04,2

69AP

R-J

UN

2016

$0$0

$0$0

$0$0

$0$0

$9,0

32,8

35$7

5,54

7($

843)

$9,1

07,5

39JU

L-SE

P20

16$0

$0$0

$0$0

$0$0

$0$1

0,38

4,74

4$1

89,2

58$2

2,37

3$1

0,59

6,37

5O

CT-

DEC

2016

$0$0

$0$0

$0$0

$0$0

$8,9

32,2

11$4

42,7

02$1

7,45

3$9

,392

,366

JAN

-MAR

2017

$0$0

$0$0

$0$0

$0$0

$2,7

14,4

23$8

,315

,623

$13,

251

$11,

043,

298

APR

-JU

N20

17$0

$0$0

$0$0

$0$0

$0$0

$8,7

61,8

29$3

5,39

9$8

,797

,228

JUL-

SEP

2017

$0$0

$0$0

$0$0

$0$0

$0$9

,640

,520

$3,4

35$9

,643

,955

OC

T-D

EC20

17$0

$0$0

$0$0

$0$0

$0$0

$9,3

87,9

88$3

6,30

6$9

,424

,294

JAN

-MAR

2018

$0$0

$0$0

$0$0

$0$0

$0$5

,935

,345

$4,8

07,1

06$1

0,74

2,45

1AP

R-J

UN

2018

$0$0

$0$0

$0$0

$0$0

$0$0

$8,5

32,7

13$8

,532

,713

JUL-

SEP

2018

$0$0

$0$0

$0$0

$0$0

$0$0

$4,5

41,8

99$4

,541

,899

OC

T-D

EC20

18$0

$0$0

$0$0

$0$0

$0$0

$0$0

$0

TOTA

L$1

,127

,902

,261

$63,

023,

054

$76,

275,

020

$46,

545,

671

$40,

517,

394

$39,

258,

972

$35,

564,

340

$43,

023,

347

$38,

198,

078

$42,

910,

960

$17,

983,

870

$1,5

71,2

02,9

65

NO

TE: I

NC

LUD

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ECEI

VED

TH

RO

UG

H D

ECEM

BER

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8.

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ARTE

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SOU

RC

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DA

CH

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REC

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OR

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ON

STA

TE S

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FOR

WEE

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DIN

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ECEM

BER

28,

201

8.

TAB

LE 3

.4M

AN

UFA

CTU

RER

S' R

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TE C

ASH

REC

EIPT

SB

Y Q

UA

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R/Y

EAR

BIL

LED

AN

D B

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L YE

AR

REC

EIVE

D

JAN

UA

RY

1991

- D

ECEM

BER

201

8

44

SECTION 4

CARDHOLDER UTILIZATION

DATA

45

46

PAGE 1

NEWLYQUARTER ENROLLED

1st JUL-SEP 1984 273,001 100.0 273,001PROGRAM OCT-DEC 1984 23,561 7.9 296,562YEAR JAN-MAR 1985 20,941 6.6 317,503

APR-JUN 1985 69,436 17.9 386,939

2nd JUL-SEP 1985 38,750 10.0 389,177PROGRAM OCT-DEC 1985 20,522 5.0 409,699YEAR JAN-MAR 1986 18,770 4.4 428,469

APR-JUN 1986 17,367 3.9 445,836

3rd JUL-SEP 1986 23,595 5.6 420,776PROGRAM OCT-DEC 1986 14,982 3.4 435,758YEAR JAN-MAR 1987 18,130 4.0 453,888

APR-JUN 1987 18,853 4.0 472,741

4th JUL-SEP 1987 26,133 5.9 439,967PROGRAM OCT-DEC 1987 10,432 2.3 450,399YEAR JAN-MAR 1988 13,429 2.9 463,828

APR-JUN 1988 13,944 2.9 477,772

CUMULATIVE ENROLLMENTNEWLY AT END

QUARTER ENROLLED OF QUARTER


APR-JUN 1989 57,406 12.7 451,547


APR-JUN 1990 40,169 9.8 408,493


APR-JUN 1991 46,020 12.4 371,592


APR-JUN 1992 44,986 12.2 369,919


APR-JUN 1993 41,397 12.1 341,361


APR-JUN 1994 33,967 10.4 325,090


APR-JUN 1995 31,995 10.5 304,153


APR-JUN 1996 22,518 8.1 279,397

ENROLLED

ENROLLED ENROLLMENTS

PACEJULY 1988 - JUNE 1996

% OF NEWLY

TABLE 4.1PACE AND PACENET CARDHOLDER ENROLLMENTS BY QUARTER

PACE

JULY 1984 - JUNE 1988% OF NEWLY CUMULATIVE

47

PAGE 2

% OF ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY NEWLY AT END NEWLY NEWLY AT END

QUARTER ENROLLED OF QUARTER ENROLLED ENROLLED OF QUARTER

13th JUL-SEP 1996 4,127 1.5 267,049PROGRAM OCT-DEC 1996 9,332 3.6 260,678 1,523 100.0 1,523YEAR JAN-MAR 1997 23,797 8.6 275,607 5,771 100.0 5,771

APR-JUN 1997 30,602 11.6 264,414 9,088 100.0 9,088

14th JUL-SEP 1997 4,536 1.8 257,291 1,949 17.7 11,037PROGRAM OCT-DEC 1997 8,694 3.5 250,671 3,801 29.5 12,889YEAR JAN-MAR 1998 16,693 6.6 251,915 5,710 48.5 11,771

APR-JUN 1998 22,838 9.3 245,553 7,419 53.8 13,802

15th JUL-SEP 1998 4,375 1.8 237,753 879 5.8 15,213PROGRAM OCT-DEC 1998 8,042 3.5 230,722 1,504 9.4 15,964YEAR JAN-MAR 1999 14,744 6.4 231,049 3,216 19.9 16,164

APR-JUN 1999 20,672 9.1 227,041 4,722 27.2 17,372

16th JUL-SEP 1999 4,086 1.8 221,535 761 4.2 18,195PROGRAM OCT-DEC 1999 7,981 3.7 217,103 1,510 8.1 18,655YEAR JAN-MAR 2000 18,146 8.2 220,896 4,169 21.6 19,298

APR-JUN 2000 25,583 11.8 217,140 6,125 30.1 20,375


APR-JUN 2001 24,932 12.0 207,193 6,603 28.9 22,875


APR-JUN 2002 22,742 11.4 198,629 9,938 32.7 30,346


APR-JUN 2003 21,287 10.9 194,961 9,654 29.7 32,520


APR-JUN 2004 28,312 14.3 197,600 43,224 49.7 87,007

21st JUL-SEP 2004 4,222 2.2 194,488 7,598 8.1 94,002PROGRAM OCT-DEC 2004 6,717 3.5 191,669 15,186 15.3 99,572YEAR JAN-MAR 2005 13,536 7.0 193,946 25,934 28.2 92,035

APR-JUN 2005 19,467 10.2 190,273 35,063 34.2 102,622

22nd JUL-SEP 2005 3,935 2.1 187,696 6,301 5.9 107,240PROGRAM OCT-DEC 2005 9,001 4.8 188,495 15,579 13.3 116,755YEAR JAN-MAR 2006 14,476 7.6 190,654 25,774 20.8 123,687

APR-JUN 2006 23,477 12.5 187,311 42,841 33.4 128,212

23rd JUL-SEP 2006 2,084 1.1 184,106 3,182 2.5 127,978PROGRAM OCT-DEC 2006 5,269 2.9 179,240 11,330 8.5 132,764YEAR JAN-MAR 2007 8,687 4.8 182,332 19,571 14.6 134,018

APR-JUN 2007 11,621 6.5 178,746 26,974 19.7 136,805


APR-JUN 2008 9,712 6.3 155,026 29,033 17.2 169,043

ENROLLED

CUMULATIVE

PACE PACENET

JULY 1996 - DECEMBER 2018


48

PAGE 3

ENROLLMENT CUMULATIVE % OF ENROLLMENT NEWLY AT END NEWLY NEWLY AT END

QUARTER OF QUARTER ENROLLED ENROLLED OF QUARTER


APR-JUN 2009 8,521 6.3 134,590 23,075 13.8 167,488


APR-JUN 2010 7,344 5.7 128,651 29,944 16.8 178,574


APR-JUN 2011 6,438 5.4 118,605 20,912 11.6 181,016


APR-JUN 2012 7,259 6.5 110,863 13,971 7.8 178,290


APR-JUN 2013 5,971 5.7 104,853 11,836 6.8 173,220

30th JUL-SEP 2013 966 0.9 102,787 2,555 1.5 170,876PROGRAM OCT-DEC 2013 2,273 2.2 101,375 6,018 3.5 173,456YEAR JAN-MAR 2014 3,917 3.5 112,062 10,068 6.4 156,997

APR-JUN 2014 5,651 5.1 110,606 13,673 8.7 157,043

31st JUL-SEP 2014 1,476 1.3 109,951 3,305 2.1 157,043PROGRAM OCT-DEC 2014 3,547 3.3 106,796 7,754 5.0 154,936YEAR JAN-MAR 2015 5,286 5.0 105,769 11,599 7.5 155,082

APR-JUN 2015 6,680 6.4 104,325 15,074 9.7 154,768

32nd JUL-SEP 2015 1,059 1.0 102,361 2,762 1.8 153,897PROGRAM OCT-DEC 2015 2,649 2.7 97,995 6,502 4.3 151,429YEAR JAN-MAR 2016 4,099 4.2 96,726 9,905 6.6 151,039

APR-JUN 2016 5,511 5.8 95,391 13,242 8.8 150,800

33rd JUL-SEP 2016 1,531 1.6 94,432 4,295 2.8 151,241PROGRAM OCT-DEC 2016 3,038 3.4 89,416 8,147 5.4 149,627YEAR JAN-MAR 2017 4,631 5.3 88,169 11,956 8.0 149,366

APR-JUN 2017 6,233 7.2 86,891 15,145 10.2 148,160

34th JUL-SEP 2017 341 0.4 86,038 2,060 1.4 147,007PROGRAM OCT-DEC 2017 1,781 2.2 81,180 5,211 3.6 145,606YEAR JAN-MAR 2018 3,322 4.1 80,209 8,649 5.9 145,590

APR-JUN 2018 4,456 5.7 77,609 10,743 7.3 147,403

35th JUL-SEP 2018 915 1.2 76,135 2,745 1.9 146,530PROGRAM OCT-DEC 2018 2,214 3.0 73,634 8,809 5.8 152,481YEAR

SOURCE: PDA/MR-0-01A/CARDHOLDER FILENOTE: THE NEWLY ENROLLED NUMBER IS CALCULATED AS A TOTAL FOR THE QUARTER. ENROLLMENT AT END OF QUARTER REPRESENTS THE ENROLLMENT REPORTED ON THE LAST DAY OF THE QUARTER (E.G., 73,634 PACE CARDHOLDERS AND 152,481 PACENET CARDHOLDERS ON THE FILE ON DECEMBER 31, 2018). DURING JAN-MAR 2014, A TOTAL OF 13,280 PACENET CARDHOLDERS WERE MOVED TO PACE AND 3,327 NEW PACENET CARDHOLDERS WERE ADDED.

ENROLLED ENROLLED NEWLY

CUMULATIVE % OF

PACE PACENET

JULY 1996 - DECEMBER 2018


49

PAG

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51

PAGE 1

TOTA

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YEAR

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53.4

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27,9

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241,

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18,6

5110

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(%)

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AND

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STAT

EST

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% O

F

TAB

LE 4

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PAC

ENET

CA

RD

HO

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EN

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PA

RTI

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ON

, UTI

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018

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52

PAGE 2

TOTA

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PAC

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CA

RD

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LLM

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PA

RTI

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, UTI

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35,5

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434

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30$3

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$1,0

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1$3

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413

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148

581

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3.9

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$105

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76.2

$32,

884

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OF

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INC

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S W

HO

HAV

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IN T

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PRO

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AM E

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TH

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TH

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INC

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CO

ME

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TO

NO

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CR

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CO

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AND

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ITY

DU

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G T

HE

YEAR

.

53

TAB

LE 4

.3O

THER

PR

ESC

RIP

TIO

N IN

SUR

AN

CE

CO

VER

AG

E O

F PA

CE

AN

D P

AC

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EN

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CA

RD

HO

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AR

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BER

201

8

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UR

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ND

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RES

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LEN

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LLED

SHAR

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NR

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UM

BER

% O

F TO

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CAR

DH

OLD

EREX

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86,8

7696

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954,

934

22.5

$45,

005,

526

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ICAR

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7,14

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923

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100.

01,

979,

788

22.0

$46,

592,

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PAC

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PAC

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F TO

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166,

731

96.5

3,94

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5$5

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7

MED

ICAR

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RT

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2,73

088

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599,

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23.6

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N M

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T D

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VER

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14,0

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7,05

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8,51

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NO

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ESC

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TIO

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3.5

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7$2

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$400

.39

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L PA

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ET E

NR

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ED17

2,78

010

0.0

3,98

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323

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9,20

4,79

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74.1

7

SOU

RC

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CAR

DH

OLD

ER F

ILE,

CLA

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HIS

TOR

YN

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: D

ATA

INC

LUD

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RIG

INAL

, PAI

D C

LAIM

S BY

DAT

E O

F SE

RVI

CE.

SO

ME

CAR

DH

OLD

ERS

WER

E EN

RO

LLED

IN B

OTH

PR

OG

RAM

S FO

R S

OM

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RTI

ON

OF

THE

YEAR

.

NO

T AL

L C

ARD

HO

LDER

S W

ITH

IDEN

TIFI

ED R

X IN

SUR

ANC

E H

AD A

CTI

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HIR

D P

ARTY

CO

VER

AGE

FOR

DR

UG

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EIM

BUR

SED

BY

PAC

E AT

TH

E TI

ME

OF

DIS

PEN

SIN

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OTH

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RES

CR

IPTI

ON

CO

VER

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TIFI

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ER P

RES

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IPTI

ON

CO

VER

AGE

IDEN

TIFI

ED

54

TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES


PAGE 1

PACE PACENET TOTAL

PART D, AUTO-ENROLLED 26,574 37,847 63,418PART D, NOT AUTO-ENROLLED 53,160 114,883 164,860NOT ENROLLED IN PART D 10,151 20,050 29,774TOTAL PACE/PACENET ENROLLED 89,885 172,780 258,052

PART D, AUTO-ENROLLED 21,844 33,007 54,042PART D, NOT AUTO-ENROLLED 37,134 87,636 122,709NOT ENROLLED IN PART D 6,133 10,464 16,371TOTAL PARTICIPATING CARDHOLDERS 65,111 131,107 193,122

PART D, AUTO-ENROLLED 730,494 1,160,286 1,890,780PART D, NOT AUTO-ENROLLED 990,894 2,439,407 3,430,301NOT ENROLLED IN PART D 258,400 387,820 646,220TOTAL CLAIMS 1,979,788 3,987,513 5,967,301

PART D, AUTO-ENROLLED 27.49 30.66 29.81PART D, NOT AUTO-ENROLLED 18.64 21.23 20.81NOT ENROLLED IN PART D 25.46 19.34 21.70ALL PACE/PACENET ENROLLED 22.03 23.08 23.12

PART D, AUTO-ENROLLED $14,521,702 $23,333,051 $37,854,752PART D, NOT AUTO-ENROLLED $17,346,828 $54,937,977 $72,284,804NOT ENROLLED IN PART D $14,724,225 $20,933,769 $35,657,994ALL PACE/PACENET ENROLLED $46,592,754 $99,204,797 $145,797,551

PART D, AUTO-ENROLLED $19.88 $20.11 $20.02PART D, NOT AUTO-ENROLLED $17.51 $22.52 $21.07NOT ENROLLED IN PART D $56.98 $53.98 $55.18ALL PACE/PACENET ENROLLED $23.53 $24.88 $24.43



PART D, AUTO-ENROLLED $48,392,067 $83,314,290 $131,706,358PART D, NOT AUTO-ENROLLED $80,193,065 $234,165,099 $314,358,164NOT ENROLLED IN PART D $759,471 $1,737,842 $2,497,313ALL PACE/PACENET ENROLLED $129,344,603 $319,217,232 $448,561,835

TOTAL CARDHOLDER EXPENDITURES

CARDHOLDER SHARE PER CLAIM

TPL SHARE

STATE SHARE EXPENDITURES

STATE SHARE PER CLAIM

ENROLLED CARDHOLDERS

PARTICIPATING CARDHOLDERS

CLAIMS

CLAIMS PER ENROLLEE

55

TABLE 4.4PART D CARDHOLDER ENROLLMENT, PARTICIPATION, AND EXPENDITURES


PAGE 2

PACE PACENET TOTAL



FULL LIS 12,273 4,086 16,175PARTIAL LIS 1,939 2,370 4,243NO LIS 12,362 31,391 43,000TOTAL AUTO-ENROLLED CARDHOLDERS 26,574 37,847 63,418

PART D LIS STATUS AMONG OTHER PART D ENROLLEDFULL LIS 27,057 13,897 40,140PARTIAL LIS 3,609 8,378 11,789NO LIS 22,494 92,608 112,931TOTAL AUTO-ENROLLED CARDHOLDERS 53,160 114,883 164,860

NOTE:

TOTAL EXPENDITURES (STATE, CARDHOLDER, TPL)

PART D LIS STATUS AMONG PART D AUTO-ENROLLED

TPL SHARE PER CLAIM

AUTO-ENROLLED CARDHOLDERS INCLUDE INDIVIDUALS WHO WERE ENROLLED OR RE-ENROLLED BYPACE/PACENET INTO PART D PARTNER PLANS WITHIN THE TWO YEARS PRIOR TO JANUARY 2018, ANDWHO HAD ACTIVE COVERAGE IN A PACE/PACENET PART D PARTNER PLAN DURING 2018. THE EXPENDITURETOTALS SHOWN ARE BASED ONLY ON CLAIMS THAT WERE RECORDED IN THE PACE/PACENET CLAIMADJUDICATION SYSTEM. THERE MAY BE ADDITIONAL PRESCRIPTION EXPENDITURES THAT WERE NOTSUBMITTED TO PACE/PACENET.

56

TOTA

L D

RU

G S

PEN

D C

ATEG

OR

YPA

RT

D A

ND

LIS

STAT

US

TOTA

L EN

RO

LLED

TOTA

L C

LAIM

STO

TAL

DR

UG

SPE

ND

TOTA

L ST

ATE

SHAR

E

TOTA

L C

ARD

HO

LDER

SH

ARE

TOTA

L TP

L SH

ARE

$0N

O P

ART

D13

,403

0$0

$0$0

$0PA

RT

D-L

IS20

,482

0$0

$0$0

$0PA

RT

D-N

O L

IS31

,045

0$0

$0$0

$0TO

TAL

64,9

300

$0$0

$0$0

$0.0

1-$4

05.0

0N

O P

ART

D5,

952

67,3

75$9

08,5

71$2

56,9

61$6

07,5

27$4

4,08

4PA

RT

D-L

IS16

,543

170,

956

$2,5

22,8

90$2

24,2

08$5

72,6

18$1

,726

,065

PAR

T D

-NO

LIS

39,4

6343

7,88

8$6

,226

,390

$1,2

63,2

40$3

,464

,007

$1,4

99,1

43TO

TAL

61,9

5867

6,21

9$9

,657

,852

$1,7

44,4

09$4

,644

,151

$3,2

69,2

91

$405

.01-

$3,7

50.0

0N

O P

ART

D6,

948

321,

021

$9,3

93,5

64$5

,837

,614

$3,0

29,4

34$5

26,5

17PA

RT

D-L

IS21

,644

643,

511

$33,

486,

340

$3,6

40,5

86$2

,615

,007

$27,

230,

747

PAR

T D

-NO

LIS

49,2

081,

530,

703

$74,

703,

704

$19,

210,

440

$14,

223,

733

$41,

269,

531

TOTA

L77

,800

2,49

5,23

5$1

17,5

83,6

09$2

8,68

8,64

0$1

9,86

8,17

3$6

9,02

6,79

5

> $3

,750

.00

NO

PAR

T D

3,47

125

7,82

4$3

4,11

7,18

7$2

9,56

3,41

9$2

,627

,056

$1,9

26,7

12PA

RT

D-L

IS13

,678

661,

600

$106

,393

,120

$11,

716,

298

$3,4

31,0

58$9

1,24

5,76

4PA

RT

D-N

O L

IS36

,215

1,87

6,42

3$3

76,3

23,6

61$7

4,08

4,78

5$1

9,14

5,60

4$2

83,0

93,2

72TO

TAL

53,3

642,

795,

847

$516

,833

,969

$115

,364

,503

$25,

203,

718

$376

,265

,748

$3,7

50.0

1-$7

,508

.75/

$8,4

17.6

0N

O P

ART

D2,

365

158,

803

$13,

318,

474

$10,

911,

096

$1,6

15,0

42$7

92,3

36PA

RT

D-L

IS9,

162

409,

581

$49,

767,

934

$4,6

12,6

15$2

,026

,011

$43,

129,

308

PAR

T D

-NO

LIS

23,2

981,

064,

983

$131

,857

,921

$32,

231,

209

$11,

025,

666

$88,

601,

046

TOTA

L34

,825

1,63

3,36

7$1

94,9

44,3

29$4

7,75

4,91

9$1

4,66

6,72

0$1

32,5

22,6

89

> $7

,508

.75/

$8,4

17.6

0N

O P

ART

D1,

106

99,0

21$2

0,79

8,71

3$1

8,65

2,32

4$1

,012

,014

$1,1

34,3

76PA

RT

D-L

IS4,

516

252,

019

$56,

625,

186

$7,1

03,6

83$1

,405

,046

$48,

116,

457

PAR

T D

-NO

LIS

12,9

1781

1,44

0$2

44,4

65,7

40$4

1,85

3,57

6$8

,119

,938

$194

,492

,226

TOTA

L18

,539

1,16

2,48

0$3

21,8

89,6

40$6

7,60

9,58

3$1

0,53

6,99

8$2

43,7

43,0

59

TOTA

LN

O P

ART

D29

,774

646,

220

$44,

419,

323

$35,

657,

994

$6,2

64,0

16$2

,497

,313

PAR

T D

-LIS

72,3

471,

476,

067

$142

,402

,351

$15,

581,

092

$6,6

18,6

83$1

20,2

02,5

77PA

RT

D-N

O L

IS15

5,93

13,

845,

014

$457

,253

,755

$94,

558,

465

$36,

833,

344

$325

,861

,946

TOTA

L25

8,05

25,

967,

301

$644

,075

,429

$145

,797

,551

$49,

716,

043

$448

,561

,835

SOU

RC

E: P

DA/

CAR

DH

OLD

ER F

ILE,

CLA

IMS

HIS

TOR

Y

TAB

LE 4

.5A

NN

UA

L D

RU

G E

XPEN

DIT

UR

ES F

OR

PA

CE/

PAC

ENET

EN

RO

LLED

BY

TOTA

L D

RU

G S

PEN

D, P

AR

T D

STA

TUS,

AN

D L

IS S

TATU

SJA

NU

AR

Y - D

ECEM

BER

201

8

NO

TE:

CAT

ASTR

OPH

IC T

HR

ESH

OLD

VAR

IES

BY L

IS S

TATU

S: $

7,50

8.75

FO

R L

IS, $

8,41

7.60

FO

R N

ON

-LIS

DU

RIN

G 2

018.

57

15202530354045505560657075808590

12/8

812

/89

12/9

012

/91

12/9

212

/93

12/9

412

/95

12/9

612

/97

12/9

812

/99

12/0

012

/01

12/0

212

/03

12/0

412

/05

12/0

612

/07

12/0

812

/09

12/1

012

/11

12/1

212

/13

12/1

412

/15

12/1

612

/17

12/1

8

PERCENT SOU

RC

E: P

DA/

MO

NTH

LY C

OST

CO

NTA

INM

ENT

REP

OR

T. D

ATA

INC

LUD

E PA

CE

AND

PAC

ENET

OR

IGIN

AL, P

AID

CLA

IMS

BY D

ATE

OF

SER

VIC

E.

XX

XX

XN

OVE

MB

ER 1

996-

-PAC

E AC

T M

AND

ATES

GEN

ERIC

SU

BSTI

TUTI

ON

OF

A-R

ATED

PR

OD

UC

TS

QU

ARTE

R E

ND

ING

JAN

UAR

Y 20

04--P

ACE

INTR

OD

UC

ES

DIF

FER

ENTI

AL C

OPA

YMEN

TS F

OR

BR

AND

AN

D G

ENER

IC P

RO

DU

CTS

X

XSE

PTEM

BER

200

6--P

ACE

BEG

INS

AUTO

-EN

RO

LLM

ENT

IN M

EDIC

ARE

PAR

T D

DEC

EMB

ER 1

988-

-AM

END

MEN

T TO

PA

GEN

ERIC

DR

UG

LAW

SUM

MER

198

9--F

DA

INVE

STIG

ATIO

NS

OF

FRAU

D IN

TH

E G

ENER

IC IN

DU

STR

Y BE

GIN

JULY

199

0--F

DA

'OR

ANG

E BO

OK'

BEC

OM

ES S

TAN

DAR

D F

OR

GEN

ERIC

SU

BSTI

TUTI

ON

IN P

A JU

LY 1

991-

-PAC

E C

ARD

HO

LDER

CO

PAY

ADJU

STED

TO

$6.

00D

ECEM

BER

199

2--A

MEN

DM

ENT

TO P

ACE

LAW

REQ

UIR

ING

GEN

ERIC

SU

BSTI

TUTI

ON

ON

OR

AL R

XSX

FIG

UR

E 4.

1PA

CE

GEN

ERIC

UTI

LIZA

TIO

N R

ATES

BY

QU

ARTE

RD

ECEM

BER

198

8 -D

ECEM

BER

201

8

58

SECTION 5

COUNTY DATA

59

60

PAG

E 1

NU

MBE

R O

FN

UM

BER

OF

PAC

EPA

CEN

ETTO

TAL

ENR

OLL

EDEN

RO

LLED

NU

MBE

R%

OF

PAR

TIC

IPAT

ING

NU

MBE

R O

FPA

CE

PAC

ENET

PAC

EPA

CEN

ETTO

TAL

CO

UN

TYC

ARD

HO

LDER

SC

ARD

HO

LDER

SEN

RO

LLED

TOTA

LC

ARD

HO

LDER

SPR

OVI

DER

SC

LAIM

SC

LAIM

SST

ATE

SHAR

EST

ATE

SHAR

EST

ATE

SHAR

E

PEN

NSY

LVAN

IA89

,885

172,

780

258,

052

100.

019

3,12

23,

007

78.7

1,97

9,78

83,

987,

513

$46,

592,

754

$99,

204,

797

$145

,797

,551

ADAM

S73

61,

379

2,06

40.

81,

574

1646

.316

,720

34,1

87$2

69,5

15$6

41,9

10$9

11,4

25AL

LEG

HEN

Y8,

338

15,7

6223

,723

9.2

17,4

6128

997

.515

9,83

031

7,00

5$4

,488

,412

$10,

201,

518

$14,

689,

931

ARM

STR

ON

G57

91,

314

1,86

10.

71,

392

1532

.513

,428

30,5

55$2

77,8

21$7

07,8

61$9

85,6

81BE

AVER

1,25

03,

211

4,37

91.

73,

327

4274

.225

,772

65,7

07$6

02,9

15$2

,047

,345

$2,6

50,2

60BE

DFO

RD

712

1,28

31,

966

0.8

1,50

115

16.2

18,7

0732

,165

$600

,869

$882

,451

$1,4

83,3

19

BER

KS2,

227

4,93

87,

037

2.7

5,26

377

76.3

45,4

4010

8,54

8$9

41,7

39$2

,649

,089

$3,5

90,8

28BL

AIR

1,45

82,

799

4,17

71.

63,

074

3976

.634

,667

68,5

33$9

68,4

59$1

,873

,705

$2,8

42,1

64BR

ADFO

RD

616

1,13

61,

731

0.7

1,23

115

27.8

12,6

5823

,683

$278

,159

$567

,784

$845

,942

BUC

KS2,

282

4,97

27,

139

2.8

5,41

613

991

.250

,865

114,

594

$1,6

09,8

34$3

,189

,736

$4,7

99,5

70BU

TLER

1,11

02,

590

3,63

71.

42,

716

4258

.024

,546

56,4

88$6

31,5

73$1

,424

,102

$2,0

55,6

74

CAM

BRIA

1,77

03,

550

5,23

82.

03,

949

4268

.046

,462

88,0

34$1

,374

,744

$2,6

78,9

59$4

,053

,703

CAM

ERO

N51

141

186

0.1

149

152

.71,

232

3,80

4$1

6,11

3$1

13,9

37$1

30,0

50C

ARBO

N71

51,

359

2,04

50.

81,

587

1152

.817

,418

34,4

22$2

76,8

90$6

67,2

06$9

44,0

97C

ENTR

E62

61,

439

2,02

60.

81,

558

2967

.814

,494

38,1

63$2

01,1

98$6

41,4

76$8

42,6

75C

HES

TER

1,84

23,

031

4,79

91.

93,

481

9886

.743

,361

66,9

81$9

06,6

60$1

,781

,953

$2,6

88,6

13

CLA

RIO

N42

395

51,

353

0.5

1,04

111

23.4

12,0

4626

,233

$275

,479

$530

,372

$805

,851

CLE

ARFI

ELD

863

2,04

82,

868

1.1

2,19

716

46.2

19,7

3150

,803

$347

,800

$1,2

15,7

42$1

,563

,542

CLI

NTO

N40

989

21,

278

0.5

1,01

47

54.3

11,6

0828

,468

$149

,330

$511

,674

$661

,004

CO

LUM

BIA

816

1,69

82,

463

1.0

1,93

314

59.2

19,3

8942

,755

$337

,004

$892

,861

$1,2

29,8

65C

RAW

FOR

D80

91,

816

2,56

21.

01,

867

2336

.316

,842

37,1

55$4

69,5

59$9

73,1

39$1

,442

,697

CU

MBE

RLA

ND

1,27

82,

818

4,01

71.

63,

084

7477

.828

,095

63,9

93$5

95,6

50$1

,520

,914

$2,1

16,5

64D

AUPH

IN1,

380

2,57

33,

877

1.5

2,83

560

86.7

26,0

6158

,067

$580

,018

$1,4

52,8

66$2

,032

,884

DEL

AWAR

E2,

699

4,55

67,

147

2.8

5,32

113

999

.553

,848

98,4

18$1

,748

,973

$3,0

07,3

37$4

,756

,310

ELK

234

724

941

0.4

720

1044

.35,

842

18,9

51$1

05,9

25$4

89,1

11$5

95,0

35ER

IE1,

955

3,96

45,

820

2.3

4,31

060

80.0

38,5

5683

,833

$889

,728

$2,2

94,4

93$3

,184

,221

FAYE

TTE

1,66

53,

240

4,83

21.

93,

605

3752

.142

,289

83,2

19$1

,458

,741

$2,5

09,2

70$3

,968

,011

FOR

EST

6117

823

40.

118

32

0.0

1,47

24,

891

$32,

024

$102

,507

$134

,531

FRAN

KLIN

955

2,01

52,

915

1.1

2,17

826

59.7

22,6

2248

,880

$416

,922

$1,0

30,1

66$1

,447

,089

FULT

ON

181

278

447

0.2

319

30.

04,

866

6,85

2$8

5,97

3$1

27,4

25$2

13,3

99G

REE

NE

231

473

687

0.3

513

933

.25,

323

11,0

96$1

30,2

07$2

88,2

40$4

18,4

46

TAB

LE 5

.1N

UM

BER

AN

D P

ERC

ENT

OF

PAC

E AN

D P

ACEN

ET C

ARD

HO

LDER

SAN

D N

UM

BER

OF

PRO

VID

ERS

BY

CO

UN

TYJA

NU

ARY

- DEC

EMB

ER 2

018

POPU

LATI

ON

NU

MBE

R O

F%

UR

BAN

61

PAG

E 2

NU

MBE

R O

FN

UM

BER

OF

PAC

EPA

CEN

ETTO

TAL

ENR

OLL

EDEN

RO

LLED

NU

MBE

R%

OF

PAR

TIC

IPAT

ING

NU

MBE

R O

FPA

CE

PAC

ENET

PAC

EPA

CEN

ETTO

TAL

CO

UN

TYC

ARD

HO

LDER

SC

ARD

HO

LDER

SEN

RO

LLED

TOTA

LC

ARD

HO

LDER

SPR

OVI

DER

SC

LAIM

SC

LAIM

SST

ATE

SHAR

EST

ATE

SHAR

EST

ATE

SHAR

E

TAB

LE 5

.1N

UM

BER

AN

D P

ERC

ENT

OF

PAC

E AN

D P

ACEN

ET C

ARD

HO

LDER

SAN

D N

UM

BER

OF

PRO

VID

ERS

BY

CO

UN

TYJA

NU

ARY

- DEC

EMB

ER 2

018

POPU

LATI

ON

NU

MBE

R O

F%

UR

BAN

HU

NTI

NG

DO

N50

61,

048

1,52

30.

61,

151

831

.311

,760

26,3

39$2

40,3

97$5

77,2

82$8

17,6

79

IND

IAN

A75

11,

576

2,27

20.

91,

652

1839

.916

,623

34,0

57$4

01,8

38$7

69,8

88$1

,171

,726

JEFF

ERSO

N51

21,

092

1,57

40.

61,

216

1238

.514

,551

30,5

33$4

25,1

85$1

,315

,708

$1,7

40,8

94

JUN

IATA

264

574

813

0.3

682

417

.89,

699

21,0

57$1

52,4

26$3

07,9

65$4

60,3

90

LAC

KAW

ANN

A2,

644

3,96

96,

489

2.5

5,18

473

83.7

80,2

4711

5,88

4$1

,691

,746

$2,3

03,2

86$3

,995

,031

LAN

CAS

TER

2,56

05,

951

8,35

53.

26,

273

104

78.7

56,3

5014

0,42

5$1

,017

,574

$3,0

21,2

61$4

,038

,835

LAW

REN

CE

960

2,17

13,

078

1.2

2,36

924

59.7

20,0

3748

,789

$534

,367

$1,4

13,8

77$1

,948

,243

LEBA

NO

N90

02,

004

2,83

91.

12,

048

2573

.418

,127

42,2

72$3

75,4

34$8

55,9

76$1

,231

,409

LEH

IGH

1,70

83,

515

5,13

52.

03,

800

7292

.134

,421

75,1

67$7

07,0

48$1

,651

,619

$2,3

58,6

67

LUZE

RN

E4,

075

6,33

310

,222

4.0

8,06

186

80.0

121,

260

190,

722

$2,2

13,4

22$3

,637

,610

$5,8

51,0

32

LYC

OM

ING

1,11

52,

300

3,35

11.

32,

554

2563

.724

,594

57,2

05$5

95,1

18$1

,154

,806

$1,7

49,9

24

MC

KEAN

359

770

1,10

90.

482

010

36.5

8,62

319

,005

$171

,632

$418

,940

$590

,572

MER

CER

970

2,49

33,

396

1.3

2,48

931

55.5

22,0

8860

,041

$624

,997

$1,5

81,0

72$2

,206

,069

MIF

FLIN

597

1,42

11,

973

0.8

1,60

310

49.5

17,4

3542

,999

$243

,212

$697

,958

$941

,170

MO

NR

OE

1,04

21,

941

2,94

01.

12,

111

3561

.719

,755

40,1

55$4

66,9

97$8

76,2

37$1

,343

,233

MO

NTG

OM

ERY

3,09

75,

917

8,86

83.

46,

635

210

97.1

66,8

0212

8,47

2$1

,697

,441

$3,2

75,2

40$4

,972

,681

MO

NTO

UR

136

266

395

0.2

292

746

.23,

139

5,75

6$5

5,55

9$1

32,0

07$1

87,5

66

NO

RTH

AMPT

ON

1,95

54,

158

5,99

62.

34,

562

6887

.239

,528

93,3

29$7

11,6

82$2

,252

,581

$2,9

64,2

63

NO

RTH

UM

BER

LAN

D1,

384

2,39

63,

699

1.4

2,91

723

65.1

36,7

1666

,884

$659

,414

$1,3

72,1

28$2

,031

,542

PER

RY

365

756

1,10

40.

487

07

11.5

9,25

718

,321

$164

,250

$432

,592

$596

,841

PHIL

ADEL

PHIA

11,7

2015

,463

26,7

5910

.418

,671

445

100.

020

0,65

030

3,86

8$5

,101

,379

$7,7

95,6

11$1

2,89

6,99

0

PIKE

365

691

1,03

60.

470

510

29.2

6,50

811

,866

$165

,935

$278

,643

$444

,578

POTT

ER19

439

958

20.

240

04

0.0

4,06

58,

420

$53,

418

$205

,265

$258

,682

SCH

UYL

KILL

2,06

53,

517

5,48

42.

14,

215

3463

.552

,537

89,5

53$1

,016

,320

$1,7

29,6

19$2

,745

,939

SNYD

ER30

384

61,

122

0.4

928

733

.28,

101

22,9

47$1

36,2

79$4

74,2

77$6

10,5

56

SOM

ERSE

T1,

142

2,21

73,

304

1.3

2,61

317

29.2

31,0

0960

,864

$987

,144

$1,7

63,0

85$2

,750

,229

SULL

IVAN

8314

822

60.

117

41

0.0

1,71

13,

445

$30,

808

$69,

600

$100

,408

SUSQ

UEH

ANN

A40

662

51,

008

0.4

711

816

.08,

786

14,5

74$1

96,0

20$3

05,6

00$5

01,6

20

TIO

GA

429

880

1,27

80.

595

89

9.9

9,65

718

,855

$260

,001

$399

,041

$659

,042

UN

ION

328

779

1,08

60.

486

09

57.2

8,82

920

,607

$138

,319

$511

,540

$649

,859

62

PAG

E 3

NU

MBE

R O

FN

UM

BER

OF

PAC

EPA

CEN

ETTO

TAL

ENR

OLL

EDEN

RO

LLED

NU

MBE

R%

OF

PAR

TIC

IPAT

ING

NU

MBE

R O

FPA

CE

PAC

ENET

PAC

EPA

CEN

ETTO

TAL

CO

UN

TYC

ARD

HO

LDER

SC

ARD

HO

LDER

SEN

RO

LLED

TOTA

LC

ARD

HO

LDER

SPR

OVI

DER

SC

LAIM

SC

LAIM

SST

ATE

SHAR

EST

ATE

SHAR

EST

ATE

SHAR

E

TAB

LE 5

.1N

UM

BER

AN

D P

ERC

ENT

OF

PAC

E AN

D P

ACEN

ET C

ARD

HO

LDER

SAN

D N

UM

BER

OF

PRO

VID

ERS

BY

CO

UN

TYJA

NU

ARY

- DEC

EMB

ER 2

018

POPU

LATI

ON

NU

MBE

R O

F%

UR

BAN

VEN

ANG

O44

31,

100

1,51

90.

61,

144

1245

.210

,081

25,7

22$4

24,5

48$6

71,5

55$1

,096

,103

WAR

REN

272

714

968

0.4

682

1045

.05,

215

16,0

61$1

10,5

93$3

43,3

48$4

53,9

41

WAS

HIN

GTO

N1,

459

3,27

14,

637

1.8

3,49

847

69.2

30,3

7771

,386

$769

,631

$1,9

37,7

20$2

,707

,352

WAY

NE

527

991

1,48

60.

61,

112

1211

.913

,848

25,2

97$2

33,2

85$4

77,9

75$7

11,2

60

WES

TMO

REL

AND

3,28

16,

941

10,0

333.

97,

701

8474

.667

,972

147,

962

$1,7

95,2

29$3

,973

,866

$5,7

69,0

95

WYO

MIN

G26

549

674

80.

355

77

16.5

6,36

312

,501

$116

,101

$241

,547

$357

,647

YOR

K2,

432

5,91

98,

196

3.2

6,10

578

75.3

48,8

7712

9,69

0$8

39,7

75$2

,963

,325

$3,8

03,1

00

SOU

RC

E: P

DA/

CAR

DH

OLD

ER F

ILE;

CLA

IMS

HIS

TOR

YN

OTE

: D

ATA

INC

LUD

E O

RIG

INAL

, PAI

D C

LAIM

S BY

DAT

E O

F SE

RVI

CE.

TO

TAL

NU

MBE

R E

NR

OLL

ED IS

AN

UN

DU

PLIC

ATED

CO

UN

T O

F C

ARD

HO

LDER

S, S

OM

E O

F W

HO

M M

AY H

AVE

BEEN

EN

RO

LLED

IN B

OTH

PR

OG

RAM

S D

UR

ING

TH

E YE

AR.

TH

E PR

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DER

TO

TALS

SH

OW

N E

XCLU

DE

30 O

UT-

OF-

STAT

E M

AIL

OR

DER

PR

OVI

DER

S TH

AT S

UBM

ITTE

D C

LAIM

S IN

201

8.

63

10.2

ADAM

S

10.5

ALLE

GH

ENY

13.3

ARM

STR

ON

G

12.6

BEAV

ER

18.1

BED

FOR

D

9.9

BER

KS16

.7BL

AIR

13.6

BRAD

FOR

D

6.3

BUC

KS

10.7

BUTL

ER

17.9

CAM

BRIA

15.6

CAM

ERO

N

15.5

CAR

BON

9.1

CEN

TRE

5.8

CH

ESTE

R

18.2

CLA

RIO

N

18.0

CLE

ARFI

ELD

18.0

CLI

NTO

N

19.8

CO

LUM

BIA

14.9

CR

AWFO

RD

8.9

CU

MBE

RLA

ND

8.5

DAU

PHIN

7.9

DEL

AWAR

E

14.4

ELK

12.2

ERIE

17.9

FAYE

TTE

14.3

FOR

EST

9.8

FRAN

KLIN

14.6

FULT

ON

10.2

GR

EEN

E

16.7

HU

NTI

NG

DO

N

14.2

IND

IAN

A17.6

JEFF

ERSO

N

16.8

JUN

IATA

15.7

LAC

KAW

ANN

A

8.8

LAN

CAS

TER

16.4

LAW

REN

CE

10.6

LEBA

NO

N

8.6

LEH

IGH

16.4

LUZE

RN

E

15.7

LYC

OM

ING

14.3

MC

KEA

N

14.4

MER

CER

20.1

MIF

FLIN

10.5

MO

NR

OE

6.2

MO

NTG

OM

ERY

10.5

MO

NTO

UR

10.6

NO

RTH

AMPT

ON

19.3

NO

RTH

UM

BER

LAN

D

13.3

PER

RY

12.6

PHIL

ADEL

PHIA

8.5

PIKE

14.8

POTT

ER

19.1

SCH

UYL

KILL

15.1

SNYD

ER

20.3

SOM

ERSE

T

13.7

SULL

IVAN

10.7

SUSQ

UEH

ANN

A

14.6

TIO

GA

13.8

UN

ION

13.5

VEN

ANG

O

10.9

WAR

REN

11.1

WAS

HIN

GTO

N

12.2

WAY

NE

12.9

WES

TMO

REL

AND

13.3

WYO

MIN

G

10.8

YOR

K

FIG

UR

E 5.

1PE

RC

ENT

OF

ELD

ERLY

EN

RO

LLED

IN P

AC

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CEN

ET A

ND

PER

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AN

PO

PULA

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N B

Y C

OU

NTY

(STA

TEW

IDE

PER

CEN

T EN

RO

LLED

= 1

1.3%

)JA

NU

ARY

-DEC

EMB

ER 2

018

0.00

% U

rban

50.0

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Urb

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0.01

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00%

Urb

an

75.0

1-99

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Urb

an

25.0

1-50

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Urb

an

100.

00%

Urb

an

PER

CEN

T U

RBA

N P

OPU

LATI

ON

CO

UN

TIES

WIT

H H

IGH

EST

PER

CEN

T EN

RO

LLED

: SO

MER

SET

(20.

3%),

MIF

FLIN

(20.

1%),

AND

CO

LUM

BIA

(19.

8%)

CO

UN

TIES

WIT

H L

OW

EST

PER

CEN

T EN

RO

LLED

: CH

ESTE

R (5

.8%

), M

ON

TGO

MER

Y (6

.2%

), AN

D B

UC

KS (6

.3%

)

SOU

RC

ES:

CAR

DH

OLD

ER F

ILE,

CLA

IMS

HIS

TOR

Y, A

ND

201

7 IN

TER

CEN

SAL

ESTI

MAT

ES

64

SECTION 6

PROVIDER DATA

65

66

PRO

VID

ERTY

PEN

O.

%N

O.

%N

O.

%N

O.

%N

O.

%

IND

EPEN

DEN

T96

032

.470

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11.0

19,6

513.

154

6,54

185

.963

6,34

610

0.0

PHAR

MAC

IES

DIS

PEN

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176

57.9

7625

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17.1

304

100.

0PH

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S

INST

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NAL

270.

944

09.

621

24.

63,

956

85.9

4,60

810

0.0

PHAR

MAC

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CH

AIN

1,79

360

.513

3,15

511

.737

,395

3.3

971,

733

85.1

1,14

2,28

310

0.0

PHAR

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NU

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HO

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119

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17,6

769.

23,

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2.1

170,

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88.7

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ARM

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S

MAI

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RD

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1.3

2,65

716

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24.

113

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79.7

16,3

9510

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PHAR

MAC

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HO

ME

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1,70

5,55

285

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DAT

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DU

CT

AN

D P

RO

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ER T

YPE

JAN

UA

RY

- DEC

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ER 2

018

67

IND

EPEN

DEN

T$9

,982

,197

63.1

$142

.29

$2,1

57,8

9013

.6$1

09.8

1$3

,671

,470

23.2

$6.7

2$1

5,81

1,55

610

0.0

$24.

85PH

ARM

ACIE

S

DIS

PEN

SIN

G$3

02,0

7395

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,716

.32

$8,7

232.

8$1

14.7

8$4

,560

1.4

$87.

69$3

15,3

5610

0.0

$1,0

37.3

5PH

YSIC

IAN

S

INST

ITU

TIO

NAL

$117

,173

75.9

$266

.30

$9,3

946.

1$4

4.31

$27,

824

18.0

$7.0

3$1

54,3

9110

0.0

$33.

50PH

ARM

ACIE

S

CH

AIN

$16,

235,

373

61.0

$121

.93

$3,9

48,7

0314

.8$1

05.5

9$6

,417

,139

24.1

$6.6

0$2

6,60

1,21

410

0.0

$23.

29PH

ARM

ACIE

S

NU

RSI

NG

HO

ME

$1,6

26,3

2558

.0$9

2.01

$305

,815

10.9

$76.

82$8

69,8

5231

.0$5

.11

$2,8

01,9

9310

0.0

$14.

61PH

ARM

ACIE

S

MAI

L O

RD

ER$9

69,7

2883

.7$3

64.9

7$1

26,1

7110

.9$1

87.7

5$6

3,34

85.

5$4

.85

$1,1

59,2

4610

0.0

$70.

71PH

ARM

ACIE

S

HO

ME

INFU

SIO

N$0

0.0

$0.0

0$1

,020

36.6

$113

.36

$1,7

7063

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4.27

$2,7

9010

0.0

$93.

00PH

ARM

ACIE

S

TOTA

L$2

9,23

2,86

862

.4$1

30.3

5$6

,557

,715

14.0

$105

.78

$11,

055,

963

23.6

$6.4

8$4

6,84

6,54

5$1

00.0

$23.

52

SO

UR

CE:

PD

A/PS

-0-1

00, C

LAIM

S H

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NO

TE: D

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INC

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LAIM

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DAT

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F PA

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T, E

XCLU

DE

PAC

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CLA

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EXPE

ND

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RES

%

TAB

LE 6

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CE

EXPE

ND

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RES

AN

D A

VER

AG

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ATE

SH

AR

E B

Y PR

OD

UC

T A

ND

PR

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DER

TYP

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NU

AR

Y - D

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BER

201

8

PRO

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TYPE

BRAN

D M

ULT

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CE

GEN

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TOTA

L, A

LL P

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DU

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EXPE

ND

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RES

%

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AGE

STAT

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ARE

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AGE

STAT

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ARE

AVER

AGE

STAT

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ARE

AVER

AGE

STAT

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ARE

EXPE

ND

ITU

RES

%

EXPE

ND

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RES

%

BRAN

D S

ING

LE-S

OU

RC

E

68

TAB

LE 6

.3PA

CEN

ET C

LAIM

S A

ND

EXP

END

ITU

RES

BY

PRO

VID

ER T

YPE

JAN

UA

RY

- DEC

EMB

ER 2

018

CO

PAID

TOTA

LC

ARD

HO

LDER

OTH

ER P

AYER

STAT

E SH

ARE

TOTA

LC

LAIM

SC

LAIM

SEX

PEN

DIT

UR

ESEX

PEN

DIT

UR

ESEX

PEN

DIT

UR

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PEN

DIT

UR

ES

IND

EPEN

DEN

T PH

ARM

ACIE

S1,

077

989

176,

714

1,01

2,60

01,

189,

314

29.8

$11,

172,

809

$93,

877,

847

$30,

873,

460

$135

,924

,115

29.9

DIS

PEN

SIN

G

PHYS

ICIA

NS

119

3939

1,05

31,

092

0.0

$17,

882

$4,5

53,3

82$8

18,3

41$5

,389

,605

1.2

INST

ITU

TIO

NAL

PH

ARM

ACIE

S29

271,

238

6,37

07,

608

0.2

$61,

760

$1,4

18,3

71$2

80,3

62$1

,760

,493

0.4

CH

AIN

PH

ARM

ACIE

S1,

813

1,79

337

6,68

22,

058,

159

2,43

4,84

161

.0$2

4,66

0,21

4$1

77,3

28,2

27$5

8,45

4,81

5$2

60,4

43,2

5557

.3

NU

RSI

NG

HO

ME

PHAR

MAC

IES

128

122

37,8

0525

9,51

929

7,32

47.

5$2

,275

,790

$11,

682,

616

$4,2

77,6

04$1

8,23

6,01

04.

0

MAI

L O

RD

ER

PHAR

MAC

IES

5841

4,65

953

,622

58,2

811.

5$8

53,3

14$2

7,52

7,90

4$4

,422

,398

$32,

803,

616

7.2

HO

ME

INFU

SIO

N

PHAR

MAC

IES

63

081

810.

0$9

80$2

6,27

5$1

2,24

4$3

9,49

90.

0

TOTA

L (A

LL

PRO

VID

ERS)

3,23

03,

014

597,

137

3,39

1,40

43,

988,

541

100.

0$3

9,04

2,74

8$3

16,4

14,6

21$9

9,13

9,22

4$4

54,5

96,5

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SECTION 7

THERAPEUTIC CLASS DATA

AND DRUG UTILIZATION

REVIEW DATA

73

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SECTION 7 PART A

GENERAL THERAPEUTIC CLASS DATA

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SECTION 7 PART B

OPIOID UTILIZATION

DATA

85

86

OPIOID UTILIZATION

An operational responsibility of the PACE Program is to protect enrollees from adverse drug events by providing reimbursement for safe and effective medications. PACE has an active program of quality improvement which includes both retrospective and prospective drug utilization review of opioid prescriptions and prescriber education for pain management. The program screens prescriptions using defined criteria related to dosage, therapeutic duplication, and duration of use. Outreach interventions to prescribers focus on the clinical rationale for treatment to ensure that therapies reimbursed by PACE are safe and appropriate for the enrollee’s diagnosed conditions. Cases of suspected overuse that are not substantiated by clinical information from the prescriber are denied for reimbursement.

Table 7.2 shows utilization by several measures. In 2018, 17% of all enrollees had at least one claim for an opioid. Many of these enrollees (71%) had prescription claims covering less than 90 days of therapy. About 5% of chronic opioid users (use exceeded 90 days) also had antineoplastic claims, indicating treatment for cancer.

Retrospective Drug Utilization Review of Prescription Drug History

A clinical team reviews opioid therapies prescribed to cardholders for clinical appropriateness and optimization of therapy. In addition to the PACE claim history, access to data from the Pennsylvania Prescription Drug Monitoring Program (PDMP) provides critical information about prescriptions obtained through sources other than PACE. This retrospective review may prompt actions by the reviewers, such as:

letters to prescribers when the morphine milligram equivalent (MME) dose exceeds 120 requesting from the prescriber a diagnosis appropriate for opioid therapy and the etiology

of pain receiving patient/prescriber opioid use agreements and pain consult results.

The Program grants long term medical exceptions for cardholders with cancer related pain, in hospice care, and for end of life care. Table 7.3 provides opioid use by county. Table 7.4 presents retrospective utilization review results in 2018.

Prospective Drug Utilization Review at the Point of Sale

In 2018 PACE updated the prospective drug utilization review criteria to reduce inappropriate concurrent use of opioids, benzodiazepines, sedative hypnotics, and skeletal muscle relaxants. A 30-day supply limit is the maximum reimbursable amount for all claims in these classes. For cardholders newly starting an opioid, the limit for each prescription is the lesser of 5 days or a quantity of 30, with a maximum morphine milligram equivalent of 50 mg per day, and two fills of the prescription within 60 days. Exceptions include cancer pain, in hospice care, or receiving end of life care. The prospective review criteria address maximum daily dose limits, duration of therapy, and duplicate therapy issues.

Prescriber Education

In 2017, the PACE Academic Detailing program expanded the geographical territory of existing outreach educators to visit more prescribers and provide interactive, evidence-based training on managing pain without the overuse of opioids. The expansion, funded through the 21st Century Cures Act, occurred in counties where regular educational visits had existed as well as in selected counties that were not currently part of the outreach. Practitioners receiving an invitation for a face to face visit are PACE prescribers who reside in target counties designated as high to moderate risk counties by the Pennsylvania Department of Health. Visits continued in 2018 with two pain management modules—chronic pain and acute pain (Appendix A).

87

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88

PAGE 1

COUNTY NAME NO. % OF

ENROLLED NO.% OF OPIOID

USERS NO.% OF OPIOID

USERS

ADAMS 2,064 343 16.6 15 4.4 11 3.2ALLEGHENY 23,723 4,294 18.1 147 3.4 86 2.0ARMSTRONG 1,861 335 18.0 15 4.5 9 2.7BEAVER 4,379 845 19.3 27 3.2 22 2.6BEDFORD 1,966 276 14.0 15 5.4 6 2.2BERKS 7,037 1,112 15.8 41 3.7 27 2.4BLAIR 4,177 869 20.8 59 6.8 37 4.3BRADFORD 1,731 269 15.5 11 4.1 6 2.2BUCKS 7,139 1,251 17.5 91 7.3 61 4.9BUTLER 3,637 684 18.8 28 4.1 18 2.6CAMBRIA 5,238 995 19.0 64 6.4 22 2.2CAMERON 186 37 19.9 1 2.7 1 2.7CARBON 2,045 394 19.3 24 6.1 19 4.8CENTRE 2,026 370 18.3 17 4.6 9 2.4CHESTER 4,799 820 17.1 44 5.4 32 3.9CLARION 1,353 274 20.3 6 2.2 5 1.8CLEARFIELD 2,868 522 18.2 18 3.4 12 2.3CLINTON 1,278 306 23.9 11 3.6 6 2.0COLUMBIA 2,463 439 17.8 12 2.7 5 1.1CRAWFORD 2,562 462 18.0 24 5.2 17 3.7CUMBERLAND 4,017 723 18.0 29 4.0 16 2.2DAUPHIN 3,877 604 15.6 26 4.3 15 2.5DELAWARE 7,147 1,148 16.1 47 4.1 28 2.4ELK 941 187 19.9 2 1.1 2 1.1ERIE 5,820 1,039 17.9 33 3.2 19 1.8FAYETTE 4,832 920 19.0 32 3.5 12 1.3FOREST 234 51 21.8 1 2.0 1 2.0FRANKLIN 2,915 503 17.3 23 4.6 14 2.8FULTON 447 67 15.0 2 3.0 1 1.5GREENE 687 112 16.3 4 3.6 3 2.7HUNTINGDON 1,523 232 15.2 7 3.0 3 1.3INDIANA 2,272 387 17.0 17 4.4 9 2.3JEFFERSON 1,574 286 18.2 17 5.9 9 3.1JUNIATA 813 178 21.9 8 4.5 5 2.8LACKAWANNA 6,489 1,380 21.3 45 3.3 27 2.0LANCASTER 8,355 1,364 16.3 67 4.9 46 3.4LAWRENCE 3,078 610 19.8 21 3.4 15 2.5LEBANON 2,839 436 15.4 27 6.2 20 4.6

TABLE 7.3

TOTAL PACE/PACENET

ENROLLED

PACE/PACENET CARDHOLDERS OPIOID UTILIZATION BY COUNTY JANUARY - DECEMBER 2018

OPIOID USERS USERS WITH MME>90 USERS WITH MME>120

89

PAGE 2

COUNTY NAME NO. % OF

ENROLLED NO.% OF OPIOID

USERS NO.% OF OPIOID

USERS

TABLE 7.3

TOTAL PACE/PACENET

ENROLLED

PACE/PACENET CARDHOLDERS OPIOID UTILIZATION BY COUNTY JANUARY - DECEMBER 2018

OPIOID USERS USERS WITH MME>90 USERS WITH MME>120

LEHIGH 5,135 775 15.1 30 3.9 16 2.1LUZERNE 10,222 1,913 18.7 61 3.2 38 2.0LYCOMING 3,351 641 19.1 24 3.7 13 2.0MCKEAN 1,109 236 21.3 4 1.7 2 0.8MERCER 3,396 658 19.4 16 2.4 7 1.1MIFFLIN 1,973 395 20.0 18 4.6 11 2.8MONROE 2,940 504 17.1 16 3.2 8 1.6MONTGOMERY 8,868 1,472 16.6 89 6.0 54 3.7MONTOUR 395 72 18.2 3 4.2 2 2.8NORTHAMPTON 5,996 998 16.6 32 3.2 14 1.4NORTHUMBERLAND 3,699 731 19.8 34 4.7 21 2.9PERRY 1,104 208 18.8 7 3.4 4 1.9PHILADELPHIA 26,759 3,477 13.0 138 4.0 76 2.2PIKE 1,036 145 14.0 6 4.1 3 2.1POTTER 582 76 13.1 2 2.6 1 1.3SCHUYLKILL 5,484 980 17.9 30 3.1 17 1.7SNYDER 1,122 227 20.2 5 2.2 4 1.8SOMERSET 3,304 588 17.8 16 2.7 8 1.4SULLIVAN 226 34 15.0 4 11.8 3 8.8SUSQUEHANNA 1,008 163 16.2 6 3.7 3 1.8TIOGA 1,278 199 15.6 7 3.5 4 2.0UNION 1,086 198 18.2 9 4.5 6 3.0VENANGO 1,519 260 17.1 8 3.1 6 2.3WARREN 968 188 19.4 7 3.7 6 3.2WASHINGTON 4,637 838 18.1 30 3.6 17 2.0WAYNE 1,486 262 17.6 14 5.3 9 3.4WESTMORELAND 10,033 1,781 17.8 68 3.8 36 2.0WYOMING 748 124 16.6 7 5.6 3 2.4YORK 8,196 1,391 17.0 56 4.0 41 2.9

TOTAL 258,052 44,658 17.3 1,825 4.1 1,089 2.4

SOURCE: PDA/CARDHOLDER FILE, CLAIMS HISTORY AND DRUG FILESNOTE: TOTAL NUMBER ENROLLED IS AN UNDUPLICATED COUNT OF CARDHOLDERS, SOME OF WHOM MAY HAVE BEEN ENROLLED IN BOTH PROGRAMS DURING THE YEAR. OPIOID USERS INCLUDE ACUTE USERS (90 OR FEWER DAYS OF USE IN 2018) AND CHRONIC USERS (MORE THAN 90 DAYS OF USE IN 2018). MME CATEGORIES ARE BASED ON CUMULATIVE DAILY MORPHINE MILLIGRAM EQUIVALENT DOSE EXPOSURE ACROSS ALL PERIODS OF OPIOID USE IN 2018.

90

INTERVENTION CATEGORYNUMBER OF

PERSONS

455

97

16

298

44

SOURCE: PACE UTILIZATION REVIEW

CARDHOLDER RESTRICTED TO 120 MME (NO RESPONSE OR INCOMPLETE RESPONSE)

CANCER/TERMINALLY ILL PATIENTS/LONG TERM CARE, DECEASED, OR NO LONGER ENROLLED IN PACE/PACENET

TABLE 7.4

TOTAL CARDHOLDERS WHOSE PHYSICIANS RECEIVED LETTERS

JANUARY - DECEMBER 2018OPIOID RETROSPECTIVE DRUG UTILIZATION REVIEW INTERVENTIONS

DOSE REDUCTION OR TAPER ATTEMPTED

COMPLETE RESPONSES (ETIOLOGY OF PAIN PROVIDED, SIGNED OPIOID AGREEMENT)

91

92

SECTION 8

PENNSYLVANIA PATIENT

ASSISTANCE CLEARINGHOUSE

93

94

PENNSYLVANIA PATIENT ASSISTANCE PROGRAM CLEARINGHOUSE (PA PAP)

The Pennsylvania Patient Assistance Program Clearinghouse (PA PAP) provides the expertise necessary to determine the likelihood of eligibility for persons of all ages who are seeking assistance from manufacturers’ medication programs. PA PAP has evolved since its beginning in 1999 and, as a result, the Program now accepts applications from individual patients, physician offices, social workers, and other agencies throughout the Commonwealth. The staff gather the patient information required to complete applications and offer guidance and assistance to the patient throughout the application and reapplication processes. Manufacturers offer limited prescription assistance to persons who are not eligible for other forms of drug coverage and who cannot afford the cost of their medications.

The manufacturer programs set their income and eligibility guidelines as individual companies; they limit the products and the length of time for assistance. Typically, the gross household income should be at or below 250% of federal poverty level guidelines, but many manufacturers will consider circumstances of hardship that fall outside their usual guidelines. Household income is just one of many criteria used to determine eligibility for medication. Manufacturers require a wide range of information on company-specific forms which further complicate the application and review process. A substantial amount of coordination needs to occur between the PA PAP coordinator, the patient, and the patient’s physician. Since the inception of Medicare Part D, some manufacturers have instituted programs to assist cardholders while they are in the Part D coverage gap. The requirements for the Medicare Part D coverage gap programs differ from the base programs offered by the manufacturers.

Settlements by the Pennsylvania Attorney General’s office allow PA PAP to help with specific medications for patients who are not eligible for the manufacturers’ assistance programs. Eligible patients can receive a 30-day supply of medication for which they are charged varying copayments based on the program they are enrolled in. At the end of 2018, the Clearinghouse successfully enrolled 109 additional patients into these settlement programs.

Despite the inherent difficulties of completing the application, the lengthy wait for approval from the manufacturer, and the strictly limited amount of medication granted with each approval, the coordinators responded to inquiries from 62,435 patients after seventeen years of operation. In 2018, 14,016 persons received medication assistance through the PA PAP Clearinghouse. The Program successfully enrolled persons to the PACE Program (1,475), PACENET Program (4,574), or other insurance (315). Among the 14,016 persons receiving assistance through the PA PAP Clearinghouse, a total of 48,052 medications were obtained.

PA PAP connects persons with other social services resources, initiates any new Programs that are the result of Attorney General Lawsuit settlements, and assists Part D-enrolled cardholders with obtaining the Low-Income Subsidy (LIS) benefit.

In 2014, PA PAP expanded its scope to assist residents who were paroled from a State Correctional Institution. This project is a combined effort between the Department of Aging and the Department of Probation and Parole. The effort helps willing individuals with their medications, transportation services, Supplemental Nutrition Assistance Program (SNAP), Low-Income Home Energy Assistance Program (LIHEAP), Medical Assistance, enrollment into other state and federally funded programs and other life sustaining benefits. In 2018, the Clearinghouse contacted 8,126 parolees. Of these parolees, 51 were enrolled in one of the Attorney General pharmaceutical settlement programs, 124 in PACE, 179 in SNAP benefits, and 61 in LIS. In addition to the initiatives listed above, Clearinghouse coordinators aided these individuals with finding furniture, physicians, housing, food, and grants to assist with utility bills, as well as many other social service needs.

95

96

APPENDIX A

PACE/PACENET Survey on Health and Well-Being 2018 Report

The PACE Application Center 2018 Report

University of Pennsylvania and PACE/PACENET Behavioral Health Lab Program

2018 Report

The PACE Academic Detailing Program 2018 Report

97

PACE/PACENET Survey on Health and Well-Being 2018 Report Overview Since 2006 PACE/PACENET has conducted an ongoing survey of enrolled cardholders to obtain information about their health status and needs. The PACE/PACENET Survey on Health and Well-Being is administered in two modes -- as an optional component of the PACE/PACENET enrollment application, and as a repeated mail survey offered annually to continuing enrollees. Both modes utilize a brief two-page survey instrument addressing a number of health topics. This report summarizes results obtained through the annual mail survey component during the 2017-18 survey year. For the 2017-18 survey year, topics covered in the survey included self-reported health and health-related quality of life, educational attainment, transportation access, and satisfaction with the coverage and services provided by PACE/PACENET. The survey was mailed to PACE/PACENET enrolled cardholders on a rolling monthly basis between May 2017 and April 2018. Out of 218,859 surveys mailed to cardholders, a total of 102,312 completed surveys had been returned to PACE as of December 31, 2018, yielding a response rate of 46.7%. Of the total 102,312 respondents, 102,258 survey respondents were actively enrolled in PACE/PACENET at the time of survey completion and constitute the reporting sample. Survey Sample Representativeness The table below compares characteristics of the PACE/PACENET population base (all enrolled cardholders who were mailed surveys) and survey respondents.

CHARACTERISTICS OF ALL PACE/PACENET SURVEY RECIPIENTS AND SURVEY RESPONDENTS

CHARACTERISTIC

ALL SURVEY RECIPIENTS (N=218,859)

SURVEY RESPONDENTS

(N=102,258) Program

PACE 36.5% 35.1% PACENET 63.5% 64.9%

Age

65-74 28.4% 26.2% 75-84 41.6% 44.2% 85+ 30.0% 29.6% Mean age (years) 79.9 80.1

Sex

Female 70.6% 72.5% Male 29.4% 27.5%

Residence Type

Community-dwelling 94.3% 96.1% Long-term care setting 5.7% 3.9%

98

CHARACTERISTICS OF ALL PACE/PACENET SURVEY RECIPIENTS AND SURVEY RESPONDENTS (CONTINUED)

CHARACTERISTIC

ALL SURVEY RECIPIENTS (N=218,859)

SURVEY RESPONDENTS

(N=102,258) Race

White 81.2% 86.5% Black 7.1% 5.3% Other Reported Race 1.4% 1.0% Race Not Reported 10.3% 7.2%

Prescription Claims in Prior 6 Months

None 23.0% 14.7% 1-10 30.0% 32,5% 11-20 21.3% 24.5% >20 25.6% 28.4%

Mean number of claims 13.8 15.2 Although the general profile of the survey respondent sample is similar to that of the entire PACE/PACENET population who received surveys, there are still some differences which may limit the generalizability of the survey findings in a number of areas. Relative to the PACE/PACENET population base, the survey respondent sample has a higher representation of females, community-dwelling individuals, individuals reporting white race, and active program participants with recent prescription claims. Proxy Responses Two questions on the survey asked for information about assistance that cardholders may have had in completing the survey, and the nature of the relationship between the proxy respondent and the PACE/PACENET cardholder.

SELF VS PROXY SURVEY RESPONSES (N=102,268)

Number Percent

Self only (PACE/PACENET cardholder) 88,252 86.3%

Cardholder received assistance but participated in answering questions

8,172 8.0%

Proxy only (cardholder did not participate in answering) 3,274 3.2%

No response 2,560 2.5% Only a small proportion (2.5%) of survey responses did not include any information about whether the survey was completed by the cardholder or by a proxy. Most cardholders (86.3%) indicated that they were answering the survey questions alone without any assistance from others. Of the potential proxies, the majority indicated that the cardholder was participating in providing answers to the survey questions.

99

Among survey responses that were based on either a partial or complete proxy report and provided information about the proxy’s relationship to the cardholder, the majority (58.1%) were completed by a son or daughter, followed by a spouse or partner (24.8%), another relative (9.5%), a friend or neighbor (2.6%), a care provider (2.6%), or another unspecified helper (2.3%). For questions about health perceptions that are intended to be based only on self-report, the sample for reporting will exclude proxy responses. Educational Attainment of PACE/PACENET Survey Respondents The following figure shows the reported educational attainment of survey respondents.

EDUCATIONAL ATTAINMENT OF PACE/PACENET SURVEY RESPONDENTS (N=98,810, INCLUDING PROXY RESPONSES)*

* Of the total 102,258 surveys received, 2,642 provided no response to the question about education. An additional 806 responses were unclear and were excluded from the chart.

Three quarters (75.1%) of survey respondents reported that they were high school graduates. Approximately 11% of all survey respondents stated that they had received additional education after high school (including trade school or college) without obtaining a college degree, and 5.3% of respondents reported having college degrees. Health-Related Quality of Life Healthy People 2020 describes health-related quality of life as “a multi-dimensional concept that includes domains related to physical, mental, emotional, and social functioning.”1 Implicit in this definition is the concept that all of the above-listed domains

8.1%

16.7%

58.4%

11.4%5.3%

0%

10%

20%

30%

40%

50%

60%

70%

8th Gradeor Less

9th‐11thGrade

High SchoolGraduate

Some College/Trade School

College Graduate

% of R

espo

nden

ts

100

have an important bearing on an individual’s overall quality of life and well-being. The following health-related quality of life items were included in the PACE/PACENET Survey on Health and Well-Being:

Global self-rated health Age-comparative self-rated health Self-ratings of one-year health change Self-rated cognitive health (two items) Healthy Days measures developed by the Centers for Disease Control and

Prevention (CDC) Each survey measure provides information on a different aspect of respondents’ health-related quality of life. In order to focus on individuals’ perceptions about their own health, reporting for this section is focused on the subset of survey respondents who stated that they completed the survey by themselves, and exclude partial or complete proxy responses. For the first four measures in the bulleted list above, respondents were asked to choose the best response out of five that best described their health. Summary findings for each measure are presented below.

GLOBAL AND AGE-COMPARATIVE SELF-RATED HEALTH (EXCLUDES PROXY RESPONSES)

2.5%

19.7%

47.1%

26.3%

4.5%5.2%

24.9%

44.0%

22.2%

3.7%

0%

10%

20%

30%

40%

50%

Excellent Very Good Good Fair Poor

% of Respondents

Self‐Rated Health

Global RatingAge‐Comparative Rating

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Global and age-comparative self-ratings of health are shown side-by-side in the preceding figure. For both types of ratings, the most frequently-selected category out of the five offered was “good.” For the global health question, 69.2% of respondents indicated that their health was either excellent, very good, or good, with the remaining 30.8% indicating either fair or poor health. When asked to rate their health compared with others their age, 74.1% of respondents chose excellent, very good, or good, and 25.9% indicated fair or poor health. Although 73.1% of respondents provided the same rating level for both questions, the overall age-comparative health ratings were slightly higher on average than the global health ratings. This effect was most noticeable at the extremes of the rating scale. For example, while only 2.5% of persons rated their global health as excellent, 5.2% rated their health as excellent when they were specifically asked to compare their health with that of other people their age.

SELF-RATED HEALTH CHANGE IN THE PAST YEAR (EXCLUDES PROXY RESPONSES)

When asked to assess how much their health had generally changed over the past year, the majority (66.3%) of respondents indicated their health was “about the same” now compared with a year ago, followed by 22.8% who reported their health was “somewhat worse” and 5.8% who reported their health was “somewhat better.” Only 5% of respondents reported large changes by selecting the categories of “much worse” or “much better.” Respondents were also asked about their perceived cognitive health status using two items. The first question asked about the person’s ability to think clearly and concentrate, and the second question asked about memory. As shown in the figure below, most

2.8%

22.8%

66.3%

5.8%2.2%

0%

10%

20%

30%

40%

50%

60%

70%

MuchWorse

SomewhatWorse

About theSame

SomewhatBetter

MuchBetter

% of Respondents

Self‐Rating of Health Change

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respondents reported good, very good, or excellent cognitive health status for both of these questions. Over three quarters (75.5%) of respondents provided the same rating level for both items. Those who provided different answers for the two questions were likely to rate their memory as somewhat poorer than their ability to think clearly and concentrate.

SELF-RATED COGNITIVE HEALTH (EXCLUDES PROXY RESPONSES)

In addition to the self-rated health status measures described above, the CDC’s core Healthy Days measures also contribute to PACE/PACENET’s health-related quality of life assessment. The Healthy Days assessment employs two key questions: first, respondents are asked to estimate the number of days out of the past 30 that their physical health was not good, and then, secondly, are asked to estimate the number of days out of the past 30 that they felt their mental health (including stress, depression, and problems with emotions) was not good. The physical and mental counts of “not good” days out the past 30 are combined to create a composite “unhealthy days” score, as well as the positive complement, “healthy days”, which reflects the number of days out of the past 30 that both physical and mental health were considered to have been good. A fifth measure is based on respondents’ self-report of the number of days out of the past 30 that poor physical or mental health kept them from doing their usual activities. Results for the five Healthy Days measures are summarized on the following pages.

12.9%

32.4%

41.6%

12.0%

1.0%

10.4%

29.7%

42.8%

15.5%

1.7%

0%

10%

20%

30%

40%

50%

Excellent Very Good Good Fair Poor

% of Respondents

Self‐Rated Cognitive Health

Ability to Think Clearlyand ConcentrateMemory

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NUMBER OF DAYS OUT OF PAST 30 THAT PHYSICAL HEALTH WAS NOT GOOD

(EXCLUDES PROXY RESPONSES)

NUMBER OF DAYS OUT OF PAST 30 THAT MENTAL HEALTH WAS NOT GOOD


55.3%

19.0%

8.1% 7.2%10.3%

0%

10%

20%

30%

40%

50%

60%

None 1‐7 Days 8‐14 Days 15‐21 Days 22‐30 Days

% of Respondents

Days of "Not Good" Physical Health

73.2%

13.0%

4.8% 4.5% 4.3%

0%

10%

20%

30%

40%

50%

60%

70%

80%


% of Respondents

Days of "Not Good" Mental Health

3.7% of Respondents Reported 30 "Not Good" DaysMean Number of "Not Good" Days = 3.0

8.6% of Respondents Reported 30 “Not Good” Days Mean Number of “Not Good” Days = 5.9

104

TOTAL UNHEALTHY DAYS OUT OF PAST 30 (EXCLUDES PROXY RESPONSES)

TOTAL HEALTHY DAYS OUT OF PAST 30 (EXCLUDES PROXY RESPONSES)

49.5%

18.8%

8.8% 6.8%

16.1%

0%

10%

20%

30%

40%

50%

60%


% of Respondents

Number of Unhealthy Days

13.4% of Respondents Reported 30 Unhealthy DaysMean Number of Unhealthy Days = 7.5

13.4%

2.5% 4.2%10.5%

69.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%


% of Respondents

Number of Healthy Days

49.5% of Respondents Reported 30 Healthy DaysMean Number of Healthy Days = 22.5

105

NUMBER OF DAYS OUT OF PAST 30 THAT HEALTH LIMITED USUAL ACTIVITIES


Collectively, the health-related quality of life measures indicate that many PACE/PACENET cardholders view their health optimistically. Nevertheless, each measure also demonstrates that a substantial portion of the enrolled population faces significant health challenges and limitations. How Prescriptions Are Obtained from the Pharmacy To improve the Program’s understanding about how cardholders access their PACE and PACENET benefits, the 2017-18 survey included a question about how prescription medications are obtained from the pharmacy. Respondents were asked how they had received their most recent prescription. The current reporting is focused on community-dwelling respondents because individuals in long-term care settings would typically have their medications provided to them onsite. Nearly 97% of community-dwelling survey respondents answered this question. A small proportion (2.3%) of respondents checked more than one response and are omitted from the present tabulation. For the remaining 92,043 community-dwelling respondents who provided a single valid answer, the response frequencies are graphed on the next page.

72.6%

11.0%4.9% 5.1% 6.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%


% of Respondents

Days of Activity Limitation

5.2% of Respondents Reported 30 Days of LimitationMean Number of Days with Limitation = 3.7

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HOW THE PRESCRIPTION MEDICATION MOST RECENTLY FILLED WAS OBTAINED FROM THE PHARMACY

(N=92,043 RESPONSES, COMMUNITY-DWELLING ONLY)*

Nearly two thirds (63.4%) of community-dwelling respondents indicated that they had picked up their most recent prescription at the pharmacy themselves. The next most frequent means of obtaining the medication was having a friend or family member (other than a spouse) pick up the medication (18.7%), followed by home delivery (9.1%) and pickup by the respondent’s spouse (6.3%).

Transportation Access Transportation access is increasingly recognized as an important contributor to the health and well-being of older adults, particularly for the subset of elderly who do not drive. Without access to reliable transportation, some elderly face difficulties in obtaining necessary health care or in conducting everyday activities. To improve the Program’s understanding about PACE/PACENET cardholders’ transportation needs, the 2017-18 Survey on Health and Well-Being included two questions about potential transportation difficulties and transportation assistance.

63.4%

18.7%

9.1%

6.3%

2.5%

0% 10% 20% 30% 40% 50% 60% 70%

Cardholder picked up

Another family member or friend picked up

Mail order or pharmacy delivery

Spouse picked up

Not applicable (no recent Rxs)

% of Respondents

*Excludes 4,528 responses from cardholders identified as residing in a long‐term care setting based on either PACE’s data or their response to the survey question. An additional 2,246 responses were excluded because the respondent checked more than one response choice.

107

Respondents were first asked how frequently in the past year they had experienced limitations in specific activities due to a lack of transportation. They were then asked how frequently in the past year they had received transportation assistance from various sources. The current tabulation focuses on community-dwelling respondents, with responses summarized below.

HOW FREQUENTLY LACK OF TRANSPORTATION LIMITED ACTIVITIES IN PAST YEAR (N=93,053 RESPONSES, COMMUNITY-DWELLING ONLY)

Activities which were most frequently reported to have been limited due to transportation access were social outings (30.5% of respondents reported any limitation) and routine errands such as shopping or banking (28.6% reported any limitation). Other activities appeared to be less affected by a lack of transportation. Examples include going to medical or dental appointments (18.5% reported any limitation) or other appointments such as going to the barber or hairdresser (20.4% reported any limitation).

Ever: 23.0%

Ever: 28.6%

Ever: 18.5%

Ever: 20.4%

Ever: 25.3%

Ever: 30.5%

Never: 77.0%

Never: 71.4%

Never: 81.5%

Never: 79.6%

Never: 74.7%

Never: 69.5%

0% 20% 40% 60% 80% 100%

Going to the pharmacy to pick up a prescription

Routine errands like grocery, shopping, banking

Going to medical or dental appointments

Other appointments (e.g., hairdresser, barber)

Attending church or religious services

Social outings (e.g., visiting friends, restaurants)

% of Respondents

Often Sometimes Never

Ever: 5.2%

How Often Were The Following Activities Limited?

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When data from the multiple activity items were combined, more than a third of respondents (40.4%) had limitations for at least one activity due to a lack of transportation during the past year, and 16.8% experienced such difficulty frequently for at least one type of activity. These results indicate that substantial numbers of PACE/PACENET elderly report that their activities are limited at least some of the time due to a lack of transportation.

In addition to asking respondents how often their activities were limited, the 2017-18 survey also asked about the types of transportation assistance that cardholders had received during the past year. A summary of the responses is presented below.

HOW FREQUENTLY TRANSPORTATION HELP WAS RECEIVED IN PAST YEAR (N= 93,907 RESPONSES, COMMUNITY-DWELLING ONLY)

The transportation assistance source reported most frequently by community-dwelling respondents was help from their children or other relatives, with over half (56.8%) of respondents indicating that they had received such help either sometimes or often in the past year. The second most frequent source of transportation assistance was a friend or

56.8%

27.5%

10.8%

7.3%

6.9%

7.1%

Never: 43.2%

Never: 72.5%

Never: 89.2%

Never: 92.7%

Never: 93.1%

Never: 92.9%

0% 20% 40% 60% 80% 100%

% of Respondents

Often Sometimes NeverHow Frequently Help Was Received From:

Cardholder’s children or other relatives

Cardholder’s friends or neighbors

Public transportation with fixedroutes, like buses

Public transportation van service

Ride arranged by Area Agency on Aging, church, or another organization

Private ride services the cardholder paid for, like taxis

109

neighbor, with 27.5% of respondents reporting that they had received any help from friends or neighbors during the past year. Public transit, public van transport services, organization-provided rides, and private ride services like taxis were used considerably less frequently, with any reported use ranging from 6.9% to 10.8% of respondents.

As expected, cardholders who reported transportation-associated activity limitations were more likely than other respondents to have used some form of transportation assistance in the past year. Nearly 94% of cardholders who reported transportation-associated limitations indicated that they had received any transportation assistance, compared with 69% of persons with no transportation-associated limitations. Analyses of the transportation data are still in progress, but these preliminary results suggest that while many community-dwelling respondents have access to some form of transportation assistance, the assistance available may not be sufficient to meet their needs. The information collected through the Survey on Health and Well-Being will be used to conduct further analysis on the patterns of transportation difficulties and assistance available to PACE/PACENET cardholders. Gaining a better understanding of the transportation needs of the PACE/PACENET population may help the Pennsylvania Department of Aging to target outreach on transportation assistance to older Pennsylvanians. Satisfaction with PACE/PACENET The final topic included in the 2017-18 survey was satisfaction with PACE/PACENET. The satisfaction questions included a set of eight items that asked about satisfaction with specific program aspects, as well as a global summary rating of the respondent’s satisfaction with the drug coverage offered by PACE/PACENET. For the question set addressing satisfaction with specific program aspects, cardholders were presented with a series of statements accompanied by the following response choices: strongly agree, somewhat agree, somewhat disagree, strongly disagree, and “does not apply to me.” The frequencies of responses to the eight satisfaction questions are displayed graphically in two figures on the following page. The first figure presents all responses, including the choice of “does not apply to me.” Satisfaction levels were high for all questions, with the combined percentage of persons agreeing (either strongly or somewhat) to each statement ranging from 76.1% to 95.3%. These agreement levels are conservative because respondents who selected the answer “does not apply to me” remain in the denominator. The question most affected by the “does not apply to me” dilution was the item “my monthly premium is affordable,” for which 15.0% of respondents chose the “does not apply” response. The second figure presents the distribution of satisfaction responses when responses of “does not apply to me” are omitted. For all eight questions, the most frequently-selected category was “strongly agree.” Total agreement levels (combining the strongly agree and somewhat agree categories) range from 84.9% (PACE/PACENET covers all prescribed medicines) to 97.9% (PACE/PACENET is convenient to use).

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0% 20% 40% 60% 80% 100%

Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree Does Not Apply to Me

84.6% Agree

87.6% Agree

76.1% Agree

79.7% Agree

86.1% Agree

0% 20% 40% 60% 80% 100%

Strongly Agree Somewhat Agree Somewhat Disagree Strongly Disagree

89.5% Agree

90.6% Agree

89.5% Agree

84.9% Agree

92.6% Agree

PACE/PACENET is convenient to use

I understand how PACE/PACENET works

PACE/PACENET has good customer service

My total out‐of‐pocket costs are reasonable

My copays are affordable

My monthly premium is affordable

PACE/PACENET covers all my prescribed medicines

The combination of PACE/PACENET with Medicare Part D works well for me

97.9% Agree

91.4% Agree

96.7% Agree

% of Respondents

% of Respondents

LEVEL OF AGREEMENT WITH PACE/PACENET SATISFACTION QUESTIONS (INCLUDING RESPONSES OF “DOES NOT APPLY TO ME”)

LEVEL OF AGREEMENT WITH PACE/PACENET SATISFACTION QUESTIONS

(EXCLUDING RESPONSES OF “DOES NOT APPLY TO ME”)

PACE/PACENET is convenient to use

I understand how PACE/PACENET works

PACE/PACENET has good customer service

My total out‐of‐pocket costs are reasonable

My co‐pays are affordable

My monthly premium is affordable

PACE/PACENET covers all my prescribed medicines

The combination of PACE/PACENET with Medicare Part D works well for me

95.3% Agree

89.4% Agree

90.7% Agree

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For the global satisfaction question, respondents were asked to indicate how satisfied they were with their current prescription drug coverage from PACE/PACENET, with choices including extremely, quite a bit, moderately, somewhat, and not at all. Results are shown below.

GLOBAL SATISFACTION WITH PACE/PACENET DRUG COVERAGE (“OVERALL, HOW SATISFIED ARE YOU WITH YOUR CURRENT PRESCRIPTION DRUG COVERAGE FROM PACE/PACENET?”)

Overall responses reflect a high degree of satisfaction with PACE/PACENET. For the global satisfaction question, 78.7% of respondents indicated that they were either “extremely” or “quite a bit” satisfied with their prescription coverage from PACE/PACENET, and only 1.3% indicated that they were “not at all” satisfied. When the responses to the PACE/PACENET satisfaction are stratified by current program (PACE vs. PACENET), some differences are apparent. Among PACE cardholders, 48.9% indicated that they were extremely satisfied with their current PACE coverage, and 35.9% indicated that they were quite a bit satisfied (a total of 84.8% were either extremely or quite a bit satisfied). Among PACENET cardholders, 36.8% indicated that they were extremely satisfied and 38.5% were quite a bit satisfied (75.3% were either extremely or quite a bit satisfied) with their PACENET drug coverage.

41.1%37.6%

14.5%

5.6%

1.3%0%

10%

20%

30%

40%

50%

Extremely Quite a bit Moderately Somewhat Not at all

% of R

espo

nden

ts

Degree of Satisfaction

112

GLOBAL SATISFACTION WITH PACE/PACENET DRUG COVERAGE, BY PROGRAM (“OVERALL, HOW SATISFIED ARE YOU WITH YOUR CURRENT PRESCRIPTION DRUG COVERAGE FROM PACE/PACENET?”)

These results are consistent with prior survey findings suggesting that the different benefit structures of PACE and PACENET are associated with varying levels of satisfaction, but that, overall, cardholders in both programs express high degrees of satisfaction with the drug coverage that PACE/PACENET provides. In summary, the 2017-18 survey provides an important overview of PACE/PACENET cardholders’ satisfaction with the program, as well as insight into the health and transportation challenges experienced by the enrolled population. The information presented in this report is a high level descriptive summary of the most recent survey data collected through the survey initiative. Ongoing in-depth review and analysis of the survey data will help the Program to understand the needs of cardholders, identify areas for potential new initiatives, and evaluate the impact of the PACE and PACENET. __________ References 1. Healthy People 2020 [Internet]. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion [Accessed 3/21/2019]. https://www.healthypeople.gov/2020/topics-objectives/topic/health-related-quality-of-life-well-being

48.9%

35.9%

10.9%

3.5%0.9%

36.8% 38.5%

16.4%

6.7%

1.6%0%

10%

20%

30%

40%

50%

Extremely Quite a bit Moderately Somewhat Not at all

% of R

espo

nden

ts

Degree of Satisfaction

PACE PACENET

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The PACE Application Center 2018 Report

Overview Since 2006, the PACE Application Center for the Pennsylvania Department of Aging has conducted data-driven outreach and application assistance to connect older Pennsylvanians with public benefit programs to help cover the cost of prescriptions, shelter and food. The Application Center provides services

to locate eligible persons and submit PACE applications on their behalf to enroll persons in the Medicare Part D Extra Help Low-Income Subsidy (LIS) to assist older Pennsylvanians in accessing other benefit programs including the

Supplemental Nutrition Assistance Program (SNAP), Property Tax/Rent Rebate(PTRR), Low-Income Home Energy Assistance Program (LIHEAP), MedicareSavings Programs (MSP), and Medicaid coverage.

The PACE Application Center uses multiple sources of federal, state, private and public data to conduct outreach. Since the Center began working with PACE, outreach efforts have resulted in over 223,000 applications for the PACE and PACENET programs, and 112,000 applications for LIS. In addition, the Center has submitted over 152,000 other benefit applications on behalf of Pennsylvania’s seniors. In total, seniors received approximately $1 billion in benefits to help them afford their prescriptions, age in place, and live with dignity.

Outreach and Applications Submitted in 2018 Through mail, telephone and community-based outreach, the PACE Application Center assisted more than 21,000 senior households in applying for at least one benefit, delivering an estimated $77 million in benefits in 2018.

2018 OUTREACH AND APPLICATION ASSISTANCE TOTAL PACE/PACENET OUTREACH 421,272UNIQUE PACE/PACENET OUTREACH 185,488TOTAL LIS OUTREACH 39,457UNIQUE LIS OUTREACH 21,851

PACE/PACENET APPLICATIONS SUBMITTED 12,413RESPONSES TO PACE AND LIS OUTREACH 18,627LIS APPLICATIONS SUBMITTED 7,718SNAP APPLICATIONS SUBMITTED 6,731PTRR APPLICATIONS SUBMITTED 1,348LIHEAP APPLICATIONS SUBMITTED 199MSP APPLICATIONS SUBMITTED 1,334MEDICAID APPLICATIONS SUBMITTED 761HOUSEHOLDS WITH AT LEAST ONE BENEFIT APPLICATION SUBMITTED 21,443ESTIMATED ANNUAL BENEFIT VALUE $77.4 million

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Medicare Extra Help Low Income Subsidy (LIS) Auto Apply Pilot In 2019, the PACE Application Center successfully continued the LIS Auto Apply project. Through this pilot, PACE provides the Center with a list of the lowest income PACE enrollees not currently enrolled in LIS. Using existing systems, the Center created a program that submits applications directly to the Social Security Administration. This low-cost, high enrollment form of submission allows the Center to reach non-responder clients who are most likely eligible for valuable prescription benefits. The PACE Application Center submitted 2,728 applications on behalf of auto apply clients and are currently waiting enrollment information.

In-Person Expansions In 2019, the PACE Application Center will explore philanthropic funding opportunities to help expand great work being done through in-person centers such as PASSi. This model provides intensive assistance and allows the PACE Application Center to reach clients that would otherwise not be served by traditional outreach models. In addition to expanding our work in Pittsburgh, the PACE Application Center will expand work in Philadelphia serving Asian-American seniors by partnering with SEAMAAC. This partnership will serve new languages and new locations by having a center located in South Philadelphia.

2019 Initiatives For 2019, the Center anticipates conducting new outreach efforts and expanding its messaging about available services. The Center will:

receive and conduct mail and telephone PACE outreach to refreshed lists providedby SNAP, PTRR, LIHEAP, MSP, the Pennsylvania Department of Transportation,Medicaid for dual eligible re-deemed status, health insurance companies, andPennsylvania Department of Aging

receive and conduct mail and telephone outreach to PACE and PACENETenrollees for LIS and for SNAP

explore partnership opportunities with managed care organizations and otherhealth insurance companies

seek additional lists for outreach from valuable partnerships with community-basedorganizations

continue to successfully implement the Medicare Extra Help (LIS) Auto Applyproject

expand partnerships in the Pittsburgh area to increase PACE presence expand Medicare Extra Help Auto Apply project to include redeemed lists

AVAILABLE DATA SOURCES FOR OUTREACH NEW NAMES AVAILABLE FOR PACE OUTREACH 47,389 NEW NAMES AVAILABLE FOR LIS OUTREACH 7,828

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University of Pennsylvania and PACE/PACENET Behavioral Health Lab Program 2018 Report

Overview Depression, anxiety, and dementia are prevalent in later life and lead to significant morbidity and disability, thereby contributing to increased medical services utilization, nursing home utilization, and mortality. Despite advances in the assessment and treatment of behavioral health disorders among older adults, under-treatment of such disorders remains a major public health concern. Less than 20% of patients treated for major depression are seen monthly for the first three months, and they often do not achieve remission. Several factors pose barriers to successful treatment outcomes, such as limited provider resources for conducting frequent monitoring, the presence of multiple mental health conditions, patients’ lack of acceptance of treatment, low medication adherence, and logistic considerations such as transportation, daily schedules, lack of availability of providers, and finances. To address these barriers, care management strategies have been developed and shown to substantially address many of these challenges to successful treatment through the provision of collaborative care within primary care. One such evidence-based, algorithm driven program is the University of Pennsylvania’s Behavioral Health Lab (BHL) program. The BHL program has two main arms:

SUpporting Seniors receiving Treatment And INtervention (SUSTAIN) project that targets cardholders with depression or anxiety problems

Caregiver Resources, Education, and SupporT (CREST) project that targets caregivers of cardholders with dementing illnesses.

These two programs have been shown to be effective in identifying community-dwelling older persons at risk of poor health outcomes, including nursing home admissions, and in supporting these individuals and their caregivers to manage their mental health care. These programs are well suited to help reduce or delay the onset and progression of functional limitations, as well as to provide information about and access to community resources that enable independent living for longer periods of time. Assessments PACE/PACENET enrollees receive evidenced-based care management that includes counseling, support, education and advice about pharmacological treatment as well as referral to available community resources based on needs. The BHL program delivers to prescribers written patient monitoring and feedback about medication response, tolerability and safety, and offers telephone consultation to them. Family caregivers may participate in evidenced-based support that focuses on improving their caregiving skills through focused problem solving and education offered at their convenience.

116

2018 SUSTAIN Outreach Update In 2018, SUSTAIN completed:

464 initial assessments for cardholders new to SUSTAIN 1974 follow-up assessments

209 cardholders received care management services with behavioral health providers (BHP) over the course of 6 months.

190 cardholders received symptom and medication monitoring services 21 cardholders worked with BHPs and received referrals to community

mental health services

Of those eligible for follow-up services: 33% reported “no to low” symptoms at baseline 30% reported “moderate” symptoms at baseline 37% reported “high” symptoms at baseline

2018 CREST Outreach Update In 2014, CREST began caregiver outreach and telehealth education specifically for caregivers of cardholders with Alzheimer’s disease and related dementias. Caregivers receive care management services in combination with education and support. Additionally, SUSTAIN services are offered to cardholders who do not screen positive for cognitive impairment. In 2018, CREST completed:

154 initial assessments 69 caregivers received education and resource materials

o 68 caregivers worked directly with a BHP for care management and education services

o 1 caregiver did not work with a BHP but agreed to a 3-month follow-up assessment

39 cardholders failed the initial memory screening and did not identify a caregiver, or the caregiver chose to not engage in follow-up services

46 cardholders completed an initial assessment and passed the memory screening

o 24 cardholders were eligible for follow-up services and participated in either care management services with a BHP or medication monitoring, depending on severity of symptoms

o 22 cardholders were ineligible for services due to the absence of depression or anxiety symptoms; however, they did receive resource materials

2018 Update on Support for Cardholders Receiving High Dose Opioids In May of 2018, The University of Pennsylvania-PACE began outreach and telehealth education for PACE/PACENET cardholders prescribed opioid medications at high doses (total morphine equivalent per day of 120 mg/day or greater). Similar to the services offered in SUSTAIN, this project aims to provide cardholders with an innovative approach to managing chronic pain and addressing the unmet psychosocial needs that contribute

117

to the cycle of chronic pain. Cardholders receive care management services that focus on education about the safety risks associated with high dose opioids and alternative behavioral pain management strategies. BHPs provide both cardholders and their providers with support and feedback when the provider initiates and/or continues a drug taper to reduce the cardholder’s opioid intake and lower their risk for adverse events. In 2018, the Support for Cardholders Receiving High Dose Opioids completed:

70 initial assessments 323 follow-up contacts

63 cardholders received care management services with BHPs 7 cardholders were unable to participate in telehealth services however,

BHPs provided support and education to a relative/friend involved in their healthcare

Of those eligible for follow-up services: 80.9% reported symptoms of both chronic pain and depression/anxiety 19.1% reported symptoms of chronic pain. 62.3% reported their provider had initiated a dose reduction of their opioid

medication Sample Outcomes The graphs below depict pre- and post-data of those who completed follow-up services as part of the BHL program in 2018. The graphs show the differences in depression (PHQ) and anxiety (GAD) symptoms from the initial assessment to the last follow-up assessment.

0

2

4

6

8

10

12

INITIAL ASSESSMENT LAST ASSESSMENT

RESULTS FROM PATIENT HEALTH QUESTIONNAIRE PHQ‐9

(n=116)

0

2

4

6

8

INITIAL ASSESSMENT LAST ASSESSMENT

RESULTS FROM GENERALIZED ANXIEY DISORDER SCREENER

GAD‐7(n=116)

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The graph below illustrates that cardholders’ satisfaction with these telephone-based services is high.

Initiatives for 2019

1. Continued support for cardholders prescribed psychotropic medications The program will continue to sample 40 cardholders per week prescribed psychotropic medications and enroll participants into the care management and medication monitoring programs. Current data show more success in engaging rural cardholders compared to urban cardholders. The focus will be on rural cardholders and those at higher risk for mental health problems.

2. Direct-to-consumer marketing campaign

In addition to random sampling to enroll individuals, the program will continue a direct-to-consumer marketing campaign of those individuals prescribed psychotropic medications and not enrolled in our direct outreach. This will enable a comparison of different methods of direct-to-consumer marketing compared to aggressive outreach.

3. CREST program

The BHL will continue the sampling for CREST enrollees by 10 cardholders per week with a focus on those in rural counties. A direct-to-consumer marketing plan for the caregivers of those cardholders on cognitive enhancing pharmaceutical agents will be developed.

4. High dose opioid pilot project In 2018, the program began outreach to engage cardholders identified as having prescriptions for opioid medications at high doses, above total morphine equivalent per day of 120 mg/day. The program will continue to provide services and support for this at-risk group. Enrolled cardholders receive care management services aimed at helping to manage their chronic pain and other health conditions that may be contributing to pain symptoms with a focus on ensuring effective and safe use

0%

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EXCELLENT GOOD FAIR POOR

PROGRAM SATISFACTION

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of medications. In 2019, the program will perform initial analyses on the pilot group to guide further program improvements.

Publications, Presentations, and Awards

1. Factors associated with long-term benzodiazepine use among older adults. Gerlach LB, Maust DT, Leong SH, Mavandadi S, Oslin DW. JAMA Intern Med. 2018 Nov 1;178(11):1560-1562.

2. Telephone-based management of chronic pain in older adults in an integrated care program. Helstrom A, Haratz J, Chen S, Benson A, Streim J, Oslin D. Int J Geriatr Psychiatry. 2018 May;33(5):779-785.

3. Improving access to collaborative behavioral health care for rural-dwelling older adults. Psychiatr Serv. Gerlach LB, Mavandadi S, Maust DT, Streim JE, Oslin DW. 2018 Jan 1;69(1):117-120.

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The PACE Academic Detailing Program 2018

Overview The PACE Program provides funding and support to Alosa Health for the delivery of an academic detailing service to primary care clinicians who care for PACE beneficiaries. Academic detailing is outreach education for health care professionals to improve clinical decision making. Rather than promote products, educators provide comprehensive summaries of the body of evidence on a specific topic to help clinicians prescribe the safest, most effective medications for their patients. The information is compiled from comparative effectiveness research that compares the effectiveness, benefits, and harms of different medical treatment options. This provides a convenient and efficient way for primary care providers to stay current on the latest medical findings about the health issues they most commonly treat. The model uses trained clinical educators who meet one-on-one with physicians, nurse practitioners, and physician assistants at their practice locations to discuss the most recent clinical data on a particular primary care topic. This report reflects activity during 2018.

THERAPEUTIC AREA MODULE TITLE RELEASED

Depression Managing Depression in Older Patients: A Guide to the Most Current Evidence

Nov. 2018

Hypertension Don’t Let the Pressure Get to You: An Update on the Changing Recommendations for Treating Hypertension

Jul. 2018

Acute Pain Managing Acute Pain in the Elderly May 2018

Chronic Pain Managing Chronic Pain in the Elderly Dec. 2017

COPD Helping Patients with COPD Breathe Easier Jul. 2017

Elder Abuse Caring for Vulnerable Elders Apr. 2017

LDL-Lowering Therapy Managing Lipids to Prevent Cardiovascular Events: Integrating the Current Guidelines into Practice

Jul. 2016

Type 2 Diabetes Managing Type 2 Diabetes: A Spoonful of Medicine Helps the Sugar Go Down, But There is More to It Than That

Mar. 2016

Heart Failure Heart Failure: Managing Risk and Improving Patient Outcomes

Nov. 2015

Timely Education In response to the impact of the overuse of opioids, the program updated and relaunched Managing Chronic Pain in the Elderly in December 2017 and followed this module with Managing Acute Pain in the Elderly. Visits to prescribers on these topics went beyond

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regularly scheduled visits through an expansion using federal grant money secured by Pennsylvania under the 21st Century Cures Act to address the opioid epidemic. The expansion targeted high priority counties identified by the Pennsylvania Department of Health. Evaluation Both qualitative and quantitative data are helpful to assess the impact of the program on prescribers and to improve the program’s design for the primary care setting.

Clinician participants complete post-visit surveys after each educational session to measure knowledge, as well as to assess how the program impacts prescribing for their older patients.

Alosa conducts drug utilization analyses using PACE claims information. Nine clinical educators record feedback from the participants after each academic

detailing visit, capturing the clinicians’ impressions on the relevance of the current module to their practice and their perceived utility of the module in helping to improve patient care.

Alosa reports the number of prescribers educated on each topic by provider type (physician, nurse practitioner, or physician assistant).

Post-Visit Surveys Participant surveys began in 2013 and have continued for subsequent topics. For each module, the providers rate topic-specific statements and broader statements on the benefit to their patients. Clinicians strongly agree when asked if the program should continue and if they receive useful resources to use in caring for their older patients. Below are ratings for two modules. Rating results are available for other modules.

RATINGS FOR CHRONIC PAIN (DECEMBER 2017) Please rate how strongly you agree or disagree with the following statements. 5 = Strongly Agree; 3 = Neutral; 1 = Strongly Disagree

AVERAGE

RESPONSE (N=321)

5 4 3 2 1 The PACE academic detailer provided me with a useful way to think about managing chronic pain, focusing on function and maximizing non-opioid therapies. 4.96

The PACE academic detailer offered up-to-date, evidence-based information on non-drug and drug approaches for managing four chronic pain conditions. 4.97

The PACE academic detailer presented steps to maximize patient safety in cases when opioids may be needed such as prescribing naloxone and avoiding the co-prescribing of benzodiazepines.

4.95

The PACE academic detailer gave me useful tools to screen for and identify patients with opioid use disorder for referral to treatment. 4.92

PACE academic detailers provide current, non-commercial, evidence-based information that enables me to improve patient care. 4.95

The PACE Academic Detailing Program has impacted the way I make clinical decisions in caring for my older patients. 4.87

Information provided by the PACE Academic Detailing Program benefits the well-being of my patients. 4.94

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RATINGS FOR ACUTE PAIN (MAY 2018) Please rate how strongly you agree or disagree with the following statements. 5 = Strongly Agree; 3 = Neutral; 1 = Strongly Disagree

AVERAGE

RESPONSE (N=154)

5 4 3 2 1 The PACE academic detailer discussed the evidence that acute pain is self-limiting and usually resolves rapidly, even without intervention. 4.92

The PACE academic detailer offered up-to-date, evidence-based information on non-drug and drug approaches for managing acute pain conditions. 4.92

The PACE academic detailer provided evidence that older patients are at higher risk of complications from prescription opioids. 4.94

The PACE academic detailer presented principles to maximize patient safety in cases when opioids may be needed, such as continuing non-opioid treatments and avoiding the co-prescribing of benzodiazepines.

4.92

IDIS and PACE academic detailers provide current, non-commercial, evidence-based information that enables me to improve patient care. 4.90

The PACE Academic Detailing Program has impacted the way I make clinical decisions in caring for my older patients. 4.86

Information provided by the PACE Academic Detailing Program benefits the well being of my patients. 4.90

Qualitative Feedback At the end of each educational session, the academic detailer records specifics on how the messages were received by the prescriber. This provides valuable insight on the program, and helps the clinical educator reflect on how they presented the message so that they can engage in continuous quality improvement. Below are comments from clinicians participating in the program as noted by the clinical educators. Feedback on other modules is available from the PACE Program. Managing Chronic Pain in the Elderly Prescriber struggles with how much to wean off at a time; I went straight to the algorithm which he found supportive and helpful. Provider shared that this subject has been very difficult because of all the “don’t dos”; really appreciated finally getting some support into what we can do to better handle chronic pain; the struggle is getting the patients on board. Managing Acute Pain in the Elderly Prescriber very engaged; we reviewed various acute pain types and the evidence-based therapies available, both pharmacological and non-pharmacological; he had questions about topical therapies, such as topical NSAIDs/lidocaine. Don’t Let the Pressure Get to You (Hypertension) Found a review of BP measuring techniques, BP goals, and medication selection very helpful; we discussed using materials to educate staff; he said he was considering hanging BP measuring instruction sheets for staff reference and reminder.

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Familiar with the 2017 ACC/AHA guidelines and in agreement; provider likes rest, relax card and will put them in the exam room; will use the patient materials and brochure; also, will now repeat BP check during visit. Review of topic as physician mentioned he has patients taking their BPs at home; he appreciated the tear off pads to help educate patients on taking their BPs correctly; he has them bring BP machines and then he reviews their readings at the next office appointment; lifestyle mods are again encouraged as well; all of this is done prior to starting a med for hypertension; he thanked me for the patient ed materials. Visit Metrics The tables below show the total number of educational visits by provider type and by topic. As the primary target for the program, physicians continue to represent the majority of prescribers taking part in the program. However, nurse practitioners and physician assistants are visited as well.

EDUCATIONAL VISITS PRESCRIBER TYPE 2018 Physician 2,209Physician Assistant 324Nurse Practitioner 648Total 3,181

0 200 400 600 800 1,000 1,200

Chronic Pain (DEC 2017)

Acute Pain (MAY 2018)

Hypertension (JUL 2018)

COPD (JUL 2017)

Elder Abuse (APR 2017)

Depression (NOV 2018)

Congestive Heart Failure (NOV 2015)

Lipid-lowering Therapy (JUL 2016)

Diabetes (MAR 2016)

VISITS IN 2018 BY TOPIC (n = 3,023)

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APPENDIX B

The PACE/PACENET Medical Exception Process

125

THE PACE/PACENET MEDICAL EXCEPTION PROCESS

BACKGROUND:

Act 134-96, the State Lottery Law, requires publication and dissemination of the medical exception process used by the Department of Aging for the Pharmaceutical Assistance Contract for the Elderly (PACE) and for the Pharmaceutical Assistance Contract for the Elderly Needs Enhancement Tier (PACENET). Specifically, the legislation addresses the medical exception process with regard to generic substitution when an A-rated therapeutically equivalent medication is available. The law further requires that the Department of Aging distribute the medical exception process to providers and recipients in the Program.

THE MEDICAL EXCEPTION PROCESS:

Through the online claims processing system, the PACE/PACENET Program provides prospective therapeutic review of prescriptions before the pharmacist dispenses the medication to the cardholder. The review checks for potential drug interactions, duplicative therapies, over-utilization, under-utilization and other misutilization. The Department of Aging, of course, recognizes the possibility of exceptional circumstances in connection with the application of therapeutic criteria and reimbursement edits. A medical exception will be considered by the Program when the cardholder’s physician indicates the diagnosis, medical rationale, anticipated therapeutic outcomes, the expected length of exception therapy, and the last trial at alternative therapy.

Act 134-96 requires a pharmacist to dispense the A-rated, therapeutically equivalent, generic drug to the cardholder if they have a prescription for a multi-source brand product. If a cardholder seeks an exception to this mandate, a pharmacist may request a short term medical exception at the time of dispensing by calling 1-800-835-4080. The PACE Program may grant a 30-day medical exception if requested. Immediately following approval of the exception, the Program sends a follow-up letter to the cardholder’s prescribing physician. This letter serves as notice that the Program granted a temporary medical exception to the mandatory substitution requirement. The letter seeks the therapeutic rationale for continuing the medical exception. The Program allows 30 days for the return of the written medical exception request from the prescriber. If the Program does not receive written documentation, the short term medical exception will expire. If the prescriber does respond to the letter and provides appropriate information, the Program may grant a longer medical exception period. The cardholder may continue to obtain the brand medication without paying the extra cost of a generic differential.

The Program may refer a request to a physician consultant or to a therapeutics committee for special review and consideration. The cardholder will receive a short term medical exception until completion of the review process.

If the Program denies a request for a medical exception to the mandatory generic requirement, the cardholder may opt to continue using the brand multi-source product and, then, pay the generic differential. If this occurs, the pharmacist must collect the copay for the brand name product plus 70 percent of the average wholesale price of the brand name product from the cardholder.

Please direct questions regarding the implementation of the medical exception process to 1-800-835-4080 or in writing to:

Mr. Thomas M. Snedden Director, Bureau of Pharmaceutical Assistance Pennsylvania Department of Aging 555 Walnut Street, 5th Floor Harrisburg, PA 17101-1919

Source: Pennsylvania Bulletin, Vol. 26, No. 52, December 28, 1996; address change December 8, 1997.

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APPENDIX C

American Hospital Formulary Service (AHFS) Classifications for Therapeutic Classes

Used in Report

127

AMERICAN HOSPITAL FORMULARY SERVICE (AHFS) CLASSIFICATIONS FOR THERAPEUTIC CLASSES USED IN REPORT

The American Hospital Formulary Service (AHFS) provides a universal standard of drug classification. Listed below are the AHFS classifications corresponding to the drug classes reported in the tables and figures of this report.

Name of Therapeutic Class AHFS Classification Anti-infective agents 08

Quinolones 08:12.18 Cephalosporins 08:12.06

Antineoplastic agents 10

Autonomic drugs 12 Anticholinergics 12:08

Adrenergic agents 12:12

Blood formation and coagulation agents 20

Cardiovascular drugs 24 Cardiac drugs 24:04 or any below

Angiotensin receptor blockers 24:32.08 ACE inhibitors 24:32.04 Cardiac glycosides 24:04.08 Antiarrhythmic agents 24:04.04 Beta blockers 24:24 Calcium channel blockers 24:28

Lipid-lowering agents 24:06 Hypotensive agents 24:08, 20 Vasodilating agents 24:12

Analgesics/antipyretics 28:08 NSAID's/COX-2 Inhibitors 28:08.04 Opiate agonists 28:08.08 Opiate partial agonists 28:08.12

Psychotropic drugs 28:12,16, 20, 24, 28 Anxiolytics, sedatives, hypnotics 28:24 Antidepressants 28:16.04 Antipsychotic agents 28:16.08

Replacement solutions 40:12

Diuretics 40:28, 24:32.20, 52:40.12 Loop diuretics 40:28.08

Thiazide diuretics 40:28.20, 24 Potassium-sparing diuretics 40:28.16, 24:32.20

Respiratory tract agents 48

Eye, ear, nose and throat preparations 52

Gastrointestinal agents 56 H2-receptor antagonists (H2RA's) 56:28.12 Proton pump inhibitors 56:28.36

Miscellaneous anti-ulcer agents 56:28.28, 56:28.32

Hormones and synthetic substances 68 Adrenals and comb. 68:04 Estrogens and comb. 68:16.04 and selected other products Antidiabetic agents (including insulin) 68:20 Thyroid and antithyroid agents 68:36

Drugs for osteoporosis multiple classes (68:16.12, 68:24, 92:24)

Theophylline and related smooth muscle relaxants 86:16

SOURCE: AHFS Drug Information 128

APPENDIX D

PACE/PACENET Prospective Drug Utilization Review Criteria

Updated March 2019

129

Initial Dose For a first prescription of a given drug, the prescribed daily dose of medication exceeds PACE's safety threshold for initial use.

Maximum Dose The prescribed daily dose of medication exceeds PACE's safety threshold for non-initial use.

Quantity Limit The quantity of units prescribed (e.g., pills, tablets) within a specified time interval exceeds PACE's safety limit.

Duration of Therapy The total duration of time for which the cardholder has continuously used the medication exceeds PACE's safety limit.

Duplicate Therapy Two or more drugs with the same therapeutic effect have been prescribed concurrently, and the combination is duplicative rather than synergistic.

Drug-Drug Two or more drugs for which concurrent use is contraindicated have been prescribed.

Diagnosis Required PACE reviews diagnostic information provided by the prescriber to ensure that the drug that has been prescribed is safe and effective for the intended use, based on FDA and compendia supported guidelines.

Step Therapy For some conditions, accepted clinical guidelines recommend that certain medications should be used as the first line of treatment. Other medications in the step therapy protocol may be substituted or added later, if needed.

Medical Exception Some medications require additional clinical review by PACE pharmacists to ensure that the prescribed medication is appropriate.

PACE Prospective Drug Utilization Review Criteria Types

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AHFS Category Therapeutic Class Name

Starting Page

AHFS Category Therapeutic Class Name

Starting Page

04 Antihistamine Drugs 132 28:36.16 Dopamine Precursors 14908 Anti-Infective Agents 132 28:36.20 Dopamine Receptor Agonists 14910 Antineoplastic Agents 133 28:36.32 Monoamine Oxidase B Inhibitors 14912:04 Parasympathomimetic (Cholinergic Agents) 136 28:40 Fibromyalgia Agents 14912:08 Anticholinergic Agents 136 28:56 Vesicular Monoamine Transport2 Inhibitors 14912:12 Sympathomimetic (Adrenergic) Agents 137 28:92 Central Nervous System Agents, Misc. 14912:16 Sympatholytic Adrenergic Blocking Agents 137 40:10 Ammonia Detoxicants 14912:20 Skeletal Muscle Relaxants 137 40:18 Ion-Removing Agents 14912:92 Autonomic Drugs, Miscellaneous 138 40:20 Caloric Agents 14920:04.04 Iron Preparations 138 40:28 Diuretics 15020:12.04 Anticoagulants 138 40:40 Uricosuric Agents 15020:12.14 Platelet-Reducing Agents 138 44 Enzymes 15020:12.18 Platelet-Aggregation Inhibitors 138 48 Respiratory Tract Agents 15020:16 Hematopoietic Agents 138 52 Eye, Ear, Nose and Throat (EENT) Preps. 15120:28.16 Hemostatics 139 56:04 Antacids and Adsorbents 15224:04.04 Antiarrhythmic Agents 139 56:08 Antidiarrhea Agents 15224:04.08 Cardiotonic Agents 139 56:12 Cathartics and Laxatives 15224:04.92 Cardiac Drugs, Miscellaneous 139 56:22 Antiemetics 15224:06 Antilipemic Agents 139 56:28.12 Histamine H2-Antagonists 152

24:12.08 Nitrates and Nitrites 140 56:28.28 Prostaglandins 15224:12.12 Phosphodiesterase Type 5 Inhibitors 140 56:28.32 Protectants 15324:12.92 Vasodilating Agents, Miscellaneous 140 56:28.36 Proton Pump Inhibitors 15324:24 Beta-Adrenergic Blocking Agents 140 56:32:00 Prokinetic Agents 15324:28 Calcium-Channel Blocking Agents 141 56:36 Anti-Inflammatory Agents (GI Drugs) 15324:32.04 Angiotensin-Converting Enzyme Inhibitors 141 56:92 GI Drugs, Miscellaneous 15324:32.08 Angiotensin II Receptor Antagonists 141 64 Heavy Metal Antagonists 15424:32.40 Renin Inhibitors 142 68:04 Adrenals 15426:12 Gene Therapy 142 68:08 Androgens 15428:04.92 General Anesthetics, Miscellaneous 142 68:16 Estrogens and Antiestrogens 15428:08.04 Nonsteroidal Anti-Inflammatory Agents 142 68:18 Gonadotropins and Antigonadotropins 15428:08.08 Opiate Agonists 143 68:20 Antidiabetic Agents 15428:08.12 Opiate Partial Agonists 144 68:24 Parathyroid and Antiparathyroid Agents 15528:08.92 Analgesics and Antipyretics, Misc. 144 68:28 Pituitary 15628:10 Opiate Antagonists 144 68:29 Somatostatin Agonists and Antagonists 15628:12.08 Benzodiazepines (Anticonvulsants) 144 68:40 Leptins 15628:12.92 Anticonvulsants, Miscellaneous 144 68:44 Renin-Angiotensin-Aldosterone Syst (RAAS) 15628:16.04 Antidepressants 145 80:12 Vaccines 15628:16.08 Antipsychotic Agents 146 84 Skin and Mucous Membrane Agents 15628:20.04 Amphetamines 147 86 Smooth Muscle Relaxants 15728:20.08 Anorexigenic Agents 147 88 Vitamins 15828:20.32 Respiratory and CNS Stimulants 147 92:12 Antidotes 15828:20.80 Wakefulness-Promoting Agents 147 92:20 Immunomodulatory Agents 15828:20.92 Anorexigenic Agents and Stimulants, Misc. 147 92:24 Bone Resorption Inhibitors 15828:24.04 Barbiturates (Anxiolytic, Sedative/Hyp) 147 92:32 Complement Inhibitors 15828:24.08 Benzodiazepines (Anxiolytic, Sedative/Hyp) 148 92:36 Disease-Modifying Antirheumatic Agents 15928:24.92 Anxiolytics, Sedatives, and Hypnotics, Misc. 148 92:44 Immunosuppressive Agents 15928:32.28 Selective Serotonin Agonists 148 92:92 Other Miscellaneous Therapeutic Agents 159

Therapeutic Classes for Prospective Drug Utilization Review

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capt

opur

ine

Purix

an

Met

hotre

xate

Ras

uvo

Mid

osta

urin

Ryd

apt

Mito

myc

inM

utam

ycin

Ner

atin

ibN

erly

nx

Nira

parib

Zeju

la

Obi

nutu

zum

abG

azyv

a

Osi

mer

tinib

Tagr

isso

Palb

ocic

libIb

ranc

e

Pano

bino

stat

Fary

dak

Pazo

pani

bVo

trien

t

Plic

amyc

in---

Pom

alid

omid

ePo

mal

yst

Pona

tinib

Iclu

sig

Pral

atre

xate

Folo

tyn

135

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eR

amuc

irum

abC

yram

za

Reg

oraf

enib

Stiv

arga

Rib

ocic

libKi

sqal

i

Ruc

apar

ibR

ubra

ca

Rux

oliti

nib

Jaka

fi

Siltu

xim

abSy

lvan

t

Soni

degi

bO

dom

zo

Sora

feni

bN

exav

ar

Tem

ozol

omid

eTe

mod

ar

Tem

siro

limus

Toris

el

Tisa

genl

ecle

ucel

Kym

riah

Tram

etin

ibM

ekin

ist

Trifl

urid

ine

Lons

urf

Vand

etan

ibC

apre

lsa

Vem

uraf

enib

Zelb

oraf

Vene

tocl

axVe

ncle

xta

Vorin

osta

tZo

linza

Ziv-

aflib

erce

ptZa

ltrap

Don

epez

ilAr

icep

t

Gal

anta

min

eR

azad

yne

Pilo

carp

ine

Sala

gen

Riv

astig

min

eEx

elon

Aclid

iniu

mTu

dorz

a Pr

essa

ir

Gly

copy

rrola

teBe

vesp

i Aer

osph

ere

AH

FS C

lass

12:

04 -

Para

sym

path

omim

etic

(Cho

liner

gic

Age

nts)

AH

FS C

lass

12:

08 -

Ant

icho

liner

gic

Age

nts

136

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eIp

ratro

pium

Com

bive

nt R

espi

mat

Rev

efen

acin

Yupe

lri

Tiot

ropi

umSp

iriva

Um

eclid

iniu

mAn

oro

Ellip

ta

Albu

tero

lVe

ntol

in H

FA

Arfo

rmot

erol

Brov

ana

Dro

xido

paN

orth

era

Ephe

drin

e---

Epin

ephr

ine

Epip

en 2

-Pak

Form

oter

olPe

rforo

mis

t

Inda

cate

rol

Arca

pta

Neo

hale

r

Met

apro

tere

nol

---

Olo

date

rol

Striv

erdi

Res

pim

at

Rac

epin

ephr

ine

---

Salm

eter

olSe

reve

nt D

isku

s

Terb

utal

ine

---

Dih

ydro

ergo

tam

ine

Mig

rana

l

Met

hyse

rgid

e---

Phen

oxyb

enza

min

eD

iben

zylin

e

Bacl

ofen

Lior

esal

Car

isop

rodo

lSo

ma

Chl

orzo

xazo

neLo

rzon

e

Cyc

lobe

nzap

rine

Amrix

AH

FS C

lass

12:

12 -

Sym

path

omim

etic

(Adr

ener

gic)

Age

nts

AH

FS C

lass

12:

16 -

Sym

path

olyt

ic A

dren

ergi

c B

lock

ing

Age

nts

AH

FS C

lass

12:

20 -

Skel

etal

Mus

cle

Rel

axan

ts

137

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eD

antro

lene

Dan

trium

Met

axal

one

Skel

axin

Met

hoca

rbam

olR

obax

in-7

50

Orp

hena

drin

eN

orfle

x

Tiza

nidi

neZa

nafle

x

Vare

nicl

ine

Cha

ntix

Ferri

c ca

rbox

ymal

tose

Inje

ctaf

er

Betri

xaba

nBe

vyxx

a

Dal

tepa

rin,p

orci

neFr

agm

in

Edox

aban

Sava

ysa

Enox

apar

inLo

veno

x

Tinz

apar

in,p

orci

neIn

nohe

p

Anag

relid

eAg

rylin

Cilo

staz

olPl

etal

Clo

pido

grel

Plav

ix

Pras

ugre

lEf

fient

Ticl

opid

ine

Ticl

id

Eltro

mbo

pag

Prom

acta

Epoe

tin b

eta

Mirc

era

Pler

ixaf

orM

ozob

il

AH

FS C

lass

20:

12.1

4 - P

late

let-R

educ

ing

Age

nts

AH

FS C

lass

20:

12.1

8 - P

late

let-A

ggre

gatio

n In

hibi

tors

AH

FS C

lass

20:

16 -

Hem

atop

oiet

ic A

gent

s

AH

FS C

lass

12:

92 -

Aut

onom

ic D

rugs

, Mis

cella

neou

s

AH

FS C

lass

20:

04.0

4 - I

ron

Prep

arat

ions

AH

FS C

lass

20:

12.0

4 - A

ntic

oagu

lant

s

138

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eR

omip

lost

imN

plat

e

Tbo-

filgr

astim

Gra

nix

Fact

or IX

Reb

inyn

Fact

or X

IIIC

orifa

ct

Tran

exam

ic a

cid

Lyst

eda

Qui

nidi

ne---

Dig

oxin

Lano

xin

Milr

inon

e---

Ivab

radi

neC

orla

nor

Aliro

cum

abPr

alue

nt

Ator

vast

atin

Lipi

tor

Evol

ocum

abR

epat

ha

Ezet

imib

eZe

tia

Fluv

asta

tinLe

scol

XL

Lom

itapi

deJu

xtap

id

Lova

stat

inAl

topr

ev

Mip

omer

sen

Kyna

mro

Pita

vast

atin

Liva

lo

Prav

asta

tinPr

avac

hol

Ros

uvas

tatin

Cre

stor

Sim

vast

atin

Zoco

r

AH

FS C

lass

24:

04.9

2 - C

ardi

ac D

rugs

, Mis

cella

neou

s

AH

FS C

lass

24:

06 -

Ant

ilipe

mic

Age

nts

AH

FS C

lass

20:

28.1

6 - H

emos

tatic

s

AH

FS C

lass

24:

04.0

4 - A

ntia

rrhy

thm

ic A

gent

s

AH

FS C

lass

24:

04.0

8 - C

ardi

oton

ic A

gent

s

139

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Amyl

nitr

ite---

Isos

orbi

deIs

ordi

l

Nitr

ogly

cerin

Nitr

osta

t

Sild

enaf

ilVi

agra

Tada

lafil

Cia

lis

Vard

enaf

ilLe

vitra

Alpr

osta

dil

Mus

e

Isox

supr

ine

---

Aceb

utol

olSe

ctra

l

Aten

olol

Teno

rmin

Beta

xolo

lKe

rlone

Car

teol

olC

artro

l

Car

vedi

lol

Cor

eg C

R

Labe

talo

lTr

anda

te

Met

opro

lol

Topr

ol X

L

Nad

olol

Cor

gard

Neb

ivol

olBy

stol

ic

Penb

utol

olLe

vato

l

Pind

olol

Visk

en

Prop

rano

lol

Inno

pran

XL

Sota

lol

Beta

pace

Tim

olol

Bloc

adre

n

AH

FS C

lass

24:

12.0

8 - N

itrat

es a

nd N

itrite

s

AH

FS C

lass

24:

12.1

2 - P

hosp

hodi

este

rase

Typ

e 5

Inhi

bito

rs

AH

FS C

lass

24:

12.9

2 - V

asod

ilatin

g A

gent

s, M

isce

llane

ous

AH

FS C

lass

24:

24 -

Bet

a-A

dren

ergi

c B

lock

ing

Age

nts

140

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Amlo

dipi

neAz

or

Bepr

idil

Vasc

or

Dilt

iaze

mC

ardi

zem

LA

Felo

dipi

nePl

endi

l

Isra

dipi

neD

ynac

irc C

R

Nic

ardi

pine

Car

dene

SR

Nife

dipi

nePr

ocar

dia

XL

Nim

odip

ine

Nym

aliz

e

Nis

oldi

pine

Sula

r

Vera

pam

ilC

alan

SR

Bena

zepr

ilLo

tens

in

Cap

topr

ilC

apot

en

Enal

april

atVa

sote

c

Fosi

nopr

ilM

onop

ril

Lisi

nopr

ilZe

stril

Moe

xipr

ilU

niva

sc

Perin

dopr

ilAc

eon

Qui

napr

ilAc

cupr

il

Ram

ipril

Alta

ce

Can

desa

rtan

Atac

and

Epro

sarta

nTe

vete

n

Irbes

arta

nAv

apro

Losa

rtan

Coz

aar

AH

FS C

lass

24:

28 -

Cal

cium

-Cha

nnel

Blo

ckin

g A

gent

s

AH

FS C

lass

24:

32.0

4 - A

ngio

tens

in-C

onve

rtin

g En

zym

e In

hibi

tors

AH

FS C

lass

24:

32.0

8 - A

ngio

tens

in II

Rec

epto

r Ant

agon

ists

141

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eO

lmes

arta

nBe

nica

r

Sacu

bitri

lEn

trest

o

Telm

isar

tan

Mic

ardi

s

Vals

arta

nD

iova

n

Alis

kire

nTe

ktur

na

Vore

tigen

e ne

parv

ovec

-rzyl

Luxt

urna

Keta

min

eKe

tala

r

Brom

fena

cD

urac

t

Buta

lbita

lFi

orin

al

Cel

ecox

ibC

eleb

rex

Dic

lofe

nac

Volta

ren

Difl

unis

alD

olob

id

Etod

olac

Lodi

ne X

L

Feno

prof

enN

alfo

n

Flur

bipr

ofen

Ansa

id

Indo

met

haci

nIn

doci

n SR

Keto

prof

enO

ruva

il

Keto

rola

cTo

rado

l

Mec

lofe

nam

ic a

cid

Mec

lom

en

Mef

enam

ic a

cid

Pons

tel

Mel

oxic

amM

obic

Nab

umet

one

Rel

afen

AH

FS C

lass

28:

08.0

4 - N

onst

eroi

dal A

nti-I

nfla

mm

ator

y A

gent

s

AH

FS C

lass

24:

32.4

0 - R

enin

Inhi

bito

rs

AH

FS C

lass

26:

12 -

Gen

e Th

erap

y

AH

FS C

lass

28:

04.9

2 - G

ener

al A

nest

hetic

s, M

isce

llane

ous

142

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eO

xapr

ozin

Day

pro

Piro

xica

mFe

lden

e

Salic

ylat

es---

Sals

alat

e---

Sulin

dac

Clin

oril

Tolm

etin

Tole

ctin

DS

Vald

ecox

ibBe

xtra

Alfe

ntan

ilAl

fent

a

Benz

hydr

ocod

one

---

Cod

eine

Fior

inal

With

Cod

eine

#3

Dez

ocin

eD

alga

n

Dih

ydro

code

ine

---

Fent

anyl

Dur

ages

ic

Hyd

roco

done

Hys

ingl

a ER

Hyd

rom

orph

one

Exal

go

Ibup

rofe

nC

ombu

nox

Levo

met

hady

lO

rlaam

Levo

rpha

nol

Levo

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mor

an

Mep

erid

ine

Dem

erol

Met

hado

ne---

Mor

phin

eEm

beda

Opi

umB

& O

Sup

pret

tes

Oxy

codo

neO

xyco

ntin

Oxy

mor

phon

eO

pana

ER

Rem

ifent

anil

Ulti

va

AH

FS C

lass

28:

08.0

8 - O

piat

e A

goni

sts

143

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eSu

fent

anil

Sufe

nta

Tape

ntad

olN

ucyn

ta E

R

Tram

adol

Ultr

am

Bupr

enor

phin

eBu

trans

Buto

rpha

nol

Stad

ol N

S

Nal

buph

ine

Nub

ain

Pent

azoc

ine

Talw

in

Buta

lbita

lFi

oric

et

Gab

apen

tinG

ralis

e

Isom

ethe

pten

eN

odol

or

Preg

abal

inLy

rica

CR

Zico

notid

ePr

ialt

Nal

oxon

eN

arca

n

Clo

baza

mO

nfi

Clo

naze

pam

Klon

opin

Lam

otrig

ine

Lam

icta

l

Oxc

arba

zepi

neTr

ilept

al

Pera

mpa

nel

Fyco

mpa

Tiag

abin

eG

abitr

il

Topi

ram

ate

Topa

max

AH

FS C

lass

28:

12.9

2 - A

ntic

onvu

lsan

ts, M

isce

llane

ous

AH

FS C

lass

28:

08.1

2 - O

piat

e Pa

rtia

l Ago

nist

s

AH

FS C

lass

28:

08.9

2 - A

nalg

esic

s an

d A

ntip

yret

ics,

Mis

c.

AH

FS C

lass

28:

10 -

Opi

ate

Ant

agon

ists

AH

FS C

lass

28:

12.0

8 - B

enzo

diaz

epin

es (A

ntic

onvu

lsan

ts)

144

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Amitr

ipty

line

---

Amox

apin

eAs

endi

n

Bupr

opio

nW

ellb

utrin

XL

Cita

lopr

amC

elex

a

Clo

mip

ram

ine

Anaf

rani

l

Des

ipra

min

eN

orpr

amin

Des

venl

afax

ine

Pris

tiq

Dox

epin

Sile

nor

Dul

oxet

ine

Cym

balta

Esci

talo

pram

Lexa

pro

Fluo

xetin

ePr

ozac

Fluv

oxam

ine

Luvo

x C

R

Imip

ram

ine

Tofra

nil

Isoc

arbo

xazi

dM

arpl

an

Map

rotil

ine

Ludi

omil

Mirt

azap

ine

Rem

eron

Nef

azod

one

Serz

one

Nor

tript

ylin

ePa

mel

or

Ola

nzap

ine

Sym

byax

Paro

xetin

ePa

xil

Perp

hena

zine

Tria

vil 4

-50

Phen

elzi

neN

ardi

l

Prot

ripty

line

Viva

ctil

Sertr

alin

eZo

loft

Tran

ylcy

prom

ine

Parn

ate

AH

FS C

lass

28:

16.0

4 - A

ntid

epre

ssan

ts

145

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eTr

azod

one

Ole

ptro

ER

Trim

ipra

min

eSu

rmon

til

Venl

afax

ine

Effe

xor X

R

Vila

zodo

neVi

ibry

d

Vorti

oxet

ine

Trin

tellix

Arip

ipra

zole

Abilif

y

Asen

apin

eSa

phris

Brex

pipr

azol

eR

exul

ti

Car

ipra

zine

Vray

lar

Chl

orpr

omaz

ine

Thor

azin

e

Clo

zapi

neC

loza

ril

Flup

hena

zine

Prol

ixin

Hal

oper

idol

Hal

dol

Ilope

ridon

eFa

napt

Loxa

pine

Loxi

tane

Lura

sido

neLa

tuda

Mes

orid

azin

eSe

rent

il

Ola

nzap

ine

Zypr

exa

Palip

erid

one

Inve

ga S

uste

nna

Perp

hena

zine

Trila

fon

Pim

avan

serin

Nup

lazi

d

Que

tiapi

neSe

roqu

el X

R

Ris

perid

one

Ris

perd

al C

onst

a

Thio

ridaz

ine

Mel

laril

-S

Thio

thix

ene

Nav

ane

AH

FS C

lass

28:

16.0

8 - A

ntip

sych

otic

Age

nts

146

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eTr

ifluo

pera

zine

---

Zipr

asid

one

Geo

don

Amph

etam

ine

Adze

nys

XR-O

DT

Benz

phet

amin

eR

egim

ex

Dex

troam

phet

amin

eAd

dera

ll XR

Lisd

exam

feta

min

eVy

vans

e

Met

ham

phet

amin

eD

esox

yn G

radu

met

Die

thyl

prop

ion

Tepa

nil

Lorc

aser

inBe

lviq

Nal

trexo

neC

ontra

ve

Phen

dim

etra

zine

Prel

u-2

Phen

term

ine

Qsy

mia

Dex

met

hylp

heni

date

Foca

lin X

R

Met

hylp

heni

date

Rita

lin L

A

Arm

odaf

inil

Nuv

igil

Mod

afin

ilPr

ovig

il

Sibu

tram

ine

Mer

idia

Amob

arbi

tal

Amyt

al

Buta

barb

ital

Butis

ol

Seco

barb

ital

Seco

nal

AH

FS C

lass

28:

20.8

0 - W

akef

ulne

ss-P

rom

otin

g A

gent

s

AH

FS C

lass

28:

20.9

2 - A

nore

xige

nic

Age

nts

and

Stim

ulan

ts, M

isc.

AH

FS C

lass

28:

24.0

4 - B

arbi

tura

tes

(Anx

ioly

tic, S

edat

ive/

Hyp

notic

)

AH

FS C

lass

28:

20.0

4 - A

mph

etam

ines

AH

FS C

lass

28:

20.0

8 - A

nore

xige

nic

Age

nts

AH

FS C

lass

28:

20.3

2 - R

espi

rato

ry a

nd C

NS

Stim

ulan

ts

147

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Alpr

azol

amXa

nax

Chl

ordi

azep

oxid

eLi

briu

m

Clo

raze

pic

acid

Tran

xene

T-T

ab

Dia

zepa

mVa

lium

Esta

zola

mPr

osom

Flur

azep

amD

alm

ane

Hal

azep

amPa

xipa

m

Lora

zepa

mAt

ivan

Oxa

zepa

mSe

rax

Qua

zepa

mD

oral

Tem

azep

amR

esto

ril

Tria

zola

mH

alci

on

Chl

oral

hyd

rate

---

Eszo

picl

one

Lune

sta

Ram

elte

onR

ozer

em

Tasi

mel

teon

Het

lioz

Zale

plon

Sona

ta

Zolp

idem

Ambi

en

Alm

otrip

tan

Axer

t

Elet

ripta

nR

elpa

x

Frov

atrip

tan

Frov

a

Nar

atrip

tan

Amer

ge

Riz

atrip

tan

Max

alt M

LT

AH

FS C

lass

28:

24.0

8 - B

enzo

diaz

epin

es (A

nxio

lytic

, Sed

ativ

e/H

ypno

tic)

AH

FS C

lass

28:

24.9

2 - A

nxio

lytic

s, S

edat

ives

, and

Hyp

notic

s, M

isc.

AH

FS C

lass

28:

32.2

8 - S

elec

tive

Sero

toni

n A

goni

sts

148

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eSu

mat

ripta

nIm

itrex

Zolm

itrip

tan

Zom

ig

Car

bido

paR

ytar

y

Brom

ocrip

tine

Parlo

del

Ras

agilin

eAz

ilect

Safin

amid

eXa

dago

Sele

gilin

eZe

lapa

r

Miln

acip

ran

Save

lla

Deu

tetra

bena

zine

Aust

edo

Tetra

bena

zine

Xena

zine

Valb

enaz

ine

Ingr

ezza

Atom

oxet

ine

Stra

ttera

Dex

trom

etho

rpha

nN

uede

xta

Mem

antin

eN

amen

da X

R

Gly

cero

l phe

nylb

utyr

ate

Rav

icti

Seve

lam

erR

enve

la

Amin

o ac

ids

3.5

%Tr

avas

ol W

ith E

lect

roly

tes

AH

FS C

lass

40:

10 -

Am

mon

ia D

etox

ican

ts

AH

FS C

lass

40:

18 -

Ion-

Rem

ovin

g A

gent

s

AH

FS C

lass

40:

20 -

Cal

oric

Age

nts

AH

FS C

lass

28:

36.1

6 - D

opam

ine

Prec

urso

rs

AH

FS C

lass

28:

36.2

0 - D

opam

ine

Rec

epto

r Ago

nist

s

AH

FS C

lass

28:

36.3

2 - M

onoa

min

e O

xida

se B

Inhi

bito

rs

AH

FS C

lass

28:

40 -

Fibr

omya

lgia

Age

nts

AH

FS C

lass

28:

56 -

Vesi

cula

r Mon

oam

ine

Tran

spor

t2 In

hibi

tor

AH

FS C

lass

28:

92 -

Cen

tral

Ner

vous

Sys

tem

Age

nts,

Mis

c.

149

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Tolv

apta

nSa

msc

a

Lesi

nura

dD

uzal

lo

Agal

sida

se b

eta

Fabr

azym

e

Cer

lipon

ase

alfa

Brin

eura

Col

lage

nase

Clo

st. H

ist.

Xiaf

lex

Elos

ulfa

se a

lfaVi

miz

im

Talig

luce

rase

alfa

Elel

yso

Vest

roni

dase

alfa

-vjb

kM

epse

vii

Alph

a-1-

prot

eina

se in

hibi

tor

Zem

aira

Ambr

isen

tan

Leta

iris

Becl

omet

haso

neQ

var

Benr

aliz

umab

Fase

nra

Bose

ntan

Trac

leer

Bude

soni

deSy

mbi

cort

Cic

leso

nide

Alve

sco

Cod

eine

Tuzi

stra

XR

Dex

amet

haso

ne---

Epop

rost

enol

Flol

an

Flun

isol

ide

Aero

span

Flut

icas

one

Adva

ir D

isku

s

Flut

icas

one

furo

ate

Breo

Ellip

ta

Gua

ifene

sin

---

AH

FS C

lass

48

- Res

pira

tory

Tra

ct A

gent

s

AH

FS C

lass

40:

28 -

Diu

retic

s

AH

FS C

lass

40:

40 -

Uric

osur

ic A

gent

s

AH

FS C

lass

44

- Enz

ymes

150

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

eIlo

pros

tVe

ntav

is

Ivac

afto

rKa

lyde

co

Mac

itent

anO

psum

it

Mep

oliz

umab

Nuc

ala

Mom

etas

one

furo

ate

Dul

era

Nin

teda

nib

Ofe

v

Om

aliz

umab

Xola

ir

Pirfe

nido

neEs

brie

t

Prom

etha

zine

Phen

erga

n W

/Cod

eine

Pseu

doep

hedr

ine

---

Rio

cigu

atAd

empa

s

Rof

lum

ilast

Dal

iresp

Sele

xipa

gU

ptra

vi

Trep

rost

inil

Ore

nitra

m E

R

Tria

mci

nolo

neAz

mac

ort

Aflib

erce

ptEy

lea

Car

teol

olO

cupr

ess

Coc

aine

HC

l---

Dic

lofe

nac

Volta

ren

Dox

ycyc

line

Perio

stat

Flut

icas

one

Flon

ase

Keto

rola

cAc

ular

LS

Mom

etas

one

furo

ate

Nas

onex

Ocr

ipla

smin

Jetre

a

Pega

ptan

ibM

acug

en

AH

FS C

lass

52

- Eye

, Ear

, Nos

e an

d Th

roat

(EEN

T) P

reps

.

151

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Cal

cium

car

bona

te---

Mag

nesi

um---

Cro

fele

mer

Myt

esi

Opi

um---

Telo

trist

at e

thyl

Xerm

elo

Pico

sulfu

ric a

cid

Cle

npiq

Sodi

um s

ulfa

teSu

prep

Apre

pita

ntEm

end

Dox

ylam

ine

Dic

legi

s

Dro

nabi

nol

Mar

inol

Mec

lizin

e---

Ond

anse

tron

Zupl

enz

Palo

nose

tron

Alox

i

Rol

apita

ntVa

rubi

Cim

etid

ine

Taga

met

Fam

otid

ine

Pepc

id

Niz

atid

ine

Axid

Ran

itidi

neZa

ntac

Mis

opro

stol

Cyt

otec

AH

FS C

lass

56:

28.1

2 - H

ista

min

e H

2-Ant

agon

ists

AH

FS C

lass

56:

28.2

8 - P

rost

agla

ndin

s

AH

FS C

lass

56:

04 -

Ant

acid

s an

d A

dsor

bent

s

AH

FS C

lass

56:

08 -

Ant

idia

rrhe

a A

gent

s

AH

FS C

lass

56:

12 -

Cat

hart

ics

and

Laxa

tives

AH

FS C

lass

56:

22 -

Ant

iem

etic

s

152

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

rese

ntat

ive

Bra

nd N

ame

Initi

alD

ose

Max

imum

Dos

eQ

uant

ityLi

mit

Dur

atio

nof

The

rapy

Dup

licat

eTh

erap

yD

rug-

Dru

gD

iagn

osis

Req

uire

dSt

ep

Ther

apy

Oth

erM

edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

Gen

eric

Nam

e

Sucr

alfa

teC

araf

ate

Dex

lans

opra

zole

Dex

ilant

Esom

epra

zole

Nex

ium

Lans

opra

zole

Prev

acid

Om

epra

zole

Prilo

sec

Pant

opra

zole

Prot

onix

Rab

epra

zole

Acip

hex

Met

oclo

pram

ide

Reg

lan

Alos

etro

nLo

trone

x

Alvi

mop

anEn

tere

g

Cho

lic a

cid

Cho

lbam

Elux

adol

ine

Vibe

rzi

Glu

tam

ine

---

Lina

clot

ide

Linz

ess

Met

hyln

altre

xone

Rel

isto

r

Nal

dem

edin

eSy

mpr

oic

Nal

oxeg

olM

ovan

tik

Obe

ticho

lic a

cid

Oca

liva

Orli

stat

Xeni

cal

Plec

anat

ide

Trul

ance

Tedu

glut

ide

Gat

tex

AH

FS C

lass

56:

92 -

GI D

rugs

, Mis

cella

neou

s

AH

FS C

lass

56:

28.3

2 - P

rote

ctan

ts

AH

FS C

lass

56:

28.3

6 - P

roto

n Pu

mp

Inhi

bito

rs

AH

FS C

lass

56:

32 -

Prok

inet

ic A

gent

s

AH

FS C

lass

56:

36 -

Ant

i-Inf

lam

mat

ory

Age

nts

(GI D

rugs

)

153

PAC

E/PA

CEN

ET P

rosp

ectiv

e D

rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

lass

and

Dru

g

Rep

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ep

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edic

alEx

cept

ion

AH

FS T

hera

peut

ic C

lass

and

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Def

eras

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Def

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e

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atid

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etta

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lass

68:

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Ant

idia

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Age

nts

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lass

64

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vy M

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agon

ists

AH

FS C

lass

68:

04 -

Adr

enal

s

AH

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lass

68:

08 -

And

roge

ns

AH

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lass

68:

16 -

Estr

ogen

s an

d A

ntie

stro

gens

AH

FS C

lass

68:

18 -

Gon

adot

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ns a

nd A

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154

PAC

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rosp

ectiv

e D

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Util

izat

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Rev

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eria

By

AH

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ic C

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g

Rep

rese

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Bra

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mit

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nof

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Dup

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gD

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osis

Req

uire

dSt

ep

Ther

apy

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erM

edic

alEx

cept

ion

AH

FS T

hera

peut

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lass

and

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Nam

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limep

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Sem

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Nat

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68:

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and

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Age

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rosp

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rug

Util

izat

ion

Rev

iew

Crit

eria

By

AH

FS T

hera

peut

ic C

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and

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g

Rep

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Bra

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mit

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nof

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edic

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and

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eFo

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Des

mop

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Flex

pro

Lanr

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Oct

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tin L

ar D

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Met

rele

ptin

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lept

Angi

oten

sin

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an p

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mav

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vacc

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qua

driv

alen

tG

arda

sil

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ingo

cocc

al v

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,C,Y

an

d W

-13

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lovi

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pler

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Ago

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d A

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AH

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lass

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Lept

ins

AH

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lass

68:

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Ren

in-A

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RA

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156

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rosp

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Rev

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By

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ic C

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and

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g

Rep

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Bra

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mit

Dur

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nof

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Ther

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edic

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and

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abor

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Cos

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n

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inaf

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Lam

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At

Tret

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n---

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umab

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ara

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ophy

lline

---

Dyp

hyllin

e---

Gua

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sin

---

AH

FS C

lass

86

- Sm

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Mus

cle

Rel

axan

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157

PAC

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ET P

rosp

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Rev

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By

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Dur

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cid

Rec

last

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92:

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92:

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plem

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nhib

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92:

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Imm

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gent

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158

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rosp

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Rev

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Crit

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By

AH

FS T

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peut

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and

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g

Rep

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Dur

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and

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ara

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tem

ra

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citin

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ljanz

Belim

umab

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ysta

Dac

lizum

abZe

napa

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limus

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botu

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a

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abot

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lass

92:

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ease

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ifyin

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nts

AH

FS C

lass

92:

44 -

Imm

unos

uppr

essi

ve A

gent

s

AH

FS C

lass

92:

92 -

Oth

er M

isce

llane

ous

Ther

apeu

tic A

gent

s

159

APPENDIX E

State Funded Pharmacy Programs Utilizing the PACE Program Platform

January – December 2018

160

STA

TE F

UN

DED

PH

AR

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CY

PRO

GR

AM

S U

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YES

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PHAR

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SPEC

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MAC

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SPIN

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PRO

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14,0

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YES

YES

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DEP

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684

YES

YES

YES

YES

DEP

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2,07

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YE

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YES

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DEP

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(TO

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49

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YE

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(BEN

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PP

1,00

3 YE

S YE

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1 I

nclu

des

exch

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of e

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pay

men

t inf

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ith p

artn

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nd n

on-p

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plan

s; v

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catio

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pre

miu

m in

voic

es; a

nd, m

anag

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t of c

ardh

olde

r dru

g co

vera

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appe

als

and

prio

r aut

horiz

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ns w

ith P

art D

pla

ns

Upd

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Mar

ch 2

019

162

SEC

TIO

N B

: C

LAIM

S A

DJU

DIC

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AN

D P

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VID

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UPP

OR

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18

ANN

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PHAR

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PHAR

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OR

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AUD

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M

ANAG

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RM

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MAI

NTE

NAN

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PAC

E 1,

979,

788

$46,

592,

754

YES

YES

YES

YES

YES

YES

PAC

ENET

3,

987,

513

$99,

204,

797

YES

YES

YES

YES

YES

YES

AN

CIL

LAR

Y R

x B

ENEF

IT P

RO

GR

AM

S

CR

DP

57,8

49

$2,5

63,9

61

YES

YES

YES

YES

YES

YES

SPB

P1

227,

472

$80,

146,

886

YES

YES

YES

YES

YES

SPB

P2

7,00

4 $6

41,7

72

YES

YES

YES

YES

YES

CF

39

$7,0

30

YES

YES

YES

YES

SB

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YES

YES

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Upd

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Mar

ch 2

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164

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Upd

ated

Mar

ch 2

019

166

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PHARMACEUTICAL ASSISTANCE CONTRACT FOR THE ELDERLY … · 2019-06-18 · PHARMACEUTICAL ASSISTANCE...

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