Clinical Pharmacy Services helps upgrade MassHealth Drug List
CPS MassHealth Drug List Coordinator Deanna Joubert and CPS Clinical Consultant Pharmacist Mark Tesell
Commonwealth Medicine’s Clinical Pharmacy Services (CPS) division has helped upgrade the online MassHealth Drug List into a searchable database, allowing health care providers to improve patient care by more efficiently prescribing drugs for patients who are members of MassHealth, the state’s Medicaid program. The list, an index of drugs covered by MassHealth that details any prior authorization requirements or quantity limits, was formerly provided on the Massachusetts Executive Office of Health and Human Services website in the same manner as its printed version: as an alphabetical list of brand name and generic prescription drugs, and therapeutic class tables. Now, health care providers can use the versatile search function to search not only for a single drug, but also for a class of drugs for a specific disease, which appears in a table. “There are also different ways to search for and sort drugs, which were not available in the past,” said Mark Tesell, PharmD, BCPS, clinical consultant pharmacist at CPS who, along with Deanna Joubert, PharmD, CPS MassHealth Drug List coordinator, collaborated with both MassHealth and a third-party developer on the development and testing of the online database, which launched on Jan. 5. “These improvements make it easier for providers to find the drug and prior authorization information they need, which will help lead to improved patient care.”
A collaborative effort Managing the technical aspects of the conversion of the MassHealth Drug List to a searchable database was a team led by Gilles Charest, a Pharmacy Online Processing System (POPS) technical analyst for the Office of Clinical Affairs (OCA). Part of CWM’s Center for Health Policy and Research, OCA has managed MassHealth’s pharmacy benefit program since 2001, working to ensure MassHealth subscribers receive pharmacy benefits for medications that are medically necessary, medically appropriate, cost-effective and in compliance with federal and state Medicaid regulations. Through this partnership, OCA has produced millions of dollars in savings for the state through innovative cost control programs, including drug utilization review, program benefit design and quality improvement measures. POPS is a software system that provides real-time submission and approval of MassHealth pharmacy claims.
Like many health care insurance plans, MassHealth requires a prior authorization before certain drugs can be prescribed to its members as a way of containing costs. For example, because of its high price, a brand-name drug may require prior authorization whereas its less-expensive generic counterpart may not. “If a generic drug is a good alternative, we would like that to be the first step in therapy, given the same safety and efficacy,” said Vincent Palumbo, MBA, RPh, pharmacy program director of the Drug Utilization Review unit for CPS, which operates a call center that handles approximately 7,000 prior authorization requests and 8,000 phone inquiries on behalf of MassHealth each month. If a provider wants to prescribe a drug that requires a prior authorization, documentation explaining the choice must be provided. “There are thousands of rules in place pertaining to prior authorizations,” said Palumbo. “The searchable online Drug List now supplies a list of the criteria that must be provided when a prior authorization request is submitted, which makes the process more transparent.” CPS also supports MassHealth’s pharmacy department on decisions pertaining to prior authorizations, cost containment and therapeutic rationale.Although there are considerable improvements to the functionality of the online Drug List, which was created in the early 2000s, its look and feel is similar to its previous incarnation. “Maintaining a level of familiarity was important to the process,” said Joubert. “Since providers are used to seeing the list a certain way, having the upgraded product be recognizable makes transitioning to the new functionality easier.” In addition to listing brand name, generic and over-the-counter drugs and detailing any prior authorization criteria, the online database also provides the forms needed to obtain those prior authorizations. “We wanted to make everything as accessible as possible for providers,” said Tesell who, with Joubert, are managing and updating the database as new drugs come to market. “That way, they can get the drugs they feel are appropriate for their patients, and do so with as few road blocks as possible, all while working within the requirements established by the MassHealth Pharmacy Program.” About Clinical Pharmacy Services Part of UMass Medical School’s Commonwealth Medicine division, Clinical Pharmacy Services (CPS) offers comprehensive prescription drug management services to state and federal agencies, pharmacy benefit managers, managed care organizations and correctional health programs. First established in 1999 to provide drug utilization review services for Massachusetts Medicaid, CPS has become an industry leader in both service delivery and consultancy. For more information, visit www.umassmed.edu/cps. About Commonwealth Medicine Commonwealth Medicine (CWM) is the public, nonprofit health care consulting and service organization founded by UMass Medical School (UMMS). Government agencies, nonprofits and managed care organizations benefit from CWM’s expertise in clinical service delivery, health care financing strategies, policy management and quality improvement. CWM programs have helped Massachusetts—and many other state, international and local health care agencies—increase the value of health care expenditures while improving access and delivery of care to at-risk and uninsured populations. CWM programs were developed, in part, as a way for UMMS faculty and staff to have a direct and profound impact on the communities of Massachusetts, and now provide critical opportunities for UMMS faculty and students to serve the community. For more information, visit www.umassmed.edu/commed.