PENNSYLVANIA PACE’s HALCION PROSPECTIVE DUR HAS CUT CLAIMS BY 95%

Executive Summary

PENNSYLVANIA PACE's HALCION PROSPECTIVE DUR HAS CUT CLAIMS BY 95% in the first two months of operation. The prospective drug utilization review program specifically instructs pharmacies that reimbursement is prohibited if prescriptions exceed the dosage or treatment duration specified in Upjohn's labeling. In 1991, the program averaged about 5,500 claims monthly for the benzodiazepine. In February and March of this year, claims fell below 300. Pennsylvania's Pharmaceutical Assistance Contract for the Elderly provides outpatient drug coverage for low-income elderly who do not qualify for Medicaid. Halcion (triazolam) was chosen as the first product for the ProDUR program in part because of the publicity surrounding the product's withdrawal by British authorities in October. PACE is planning to expand ProDUR to the entire benzodiazepine/hypnotic class once manufacturers comply with FDA's request to relabel the products to emphasize short-term therapy ("The Pink Sheet" Dec. 16, 1991, T&G-1). The ProDUR program permits no pharmacy override of the prescription limits but does allow physicians to appeal the restrictions on a case-by-case basis. PACE has received about 500 appeal letters and approved about 25, with all of the approvals provided to patients with terminal cancer, state officials said. The program is also putting together a ProDUR advisory board to consist of five physicians, five pharmacists, a social worker and a PACE enrollee. PACE plans to expand ProDUR to include all H[2]-receptor antagonists and nonsteroidal anti- inflammatory drugs beginning July 1. While PACE officials said ProDUR is a quality of care rather than cost-containment initiative, they estimate that one-year savings on the high-volume H[2] and NSAID products could reach $18 mil. as a result of coupling drug utilization review with payment denials. PACE has been considering payment limits for H[2] products for some time, after finding evidence of mismedication and long-term use of acute doses ("The Pink Sheet" Sept. 16, 1991, p. 15).