RODNEY DUNIGAN CareSource offers several different medications and therapies to help members through withdrawal from addiction, once they're ready to begin treatment We do not require opioids as a treatment for any condition to avoid costs. CareSource manages health care coverage and costs for 1.3 million Ohioans who receive state and federally funded Medicaid. We do not dictate medications prescribed by physicians for their patients, Through prior authorization and identification of alternative remedies we ensure our members receive the medication they need to help them through their treatment process, Medications ike Zohydro ER- intended to reduce abuse are still under review and have been categorized by the FDA as, “abuse deterrent” not abuse-proof CareSource has chosen not to include this medication on our lst of acceptable prescriptions. Our goal is to ensure coverage for medications in all classes as medically necessary. There are some medications where we require prior authorization and we cover the lowest cost alternatives when there is evidence of effectiveness, equivalent or better. CareSource Fran Robinson Manager Media Relations A CareSourceRODNEY DUNIGAN hope we are not too late in responding to your inquiry. Here is our response. Please let me know if you have any questions. Because of privacy restrictions, we are unable to comment relative to specific cases. Broadly speaking, all opioids, including medications like Butrans, present a risk of addiction. Medical Mutual’s team of doctors and pharmacists establish our policies on opioids for pain management using widely accepted medical evidence. I’s standard practice, when studies are conducted and new information becomes available, for us to update our policies as appropriate. If strong evidence of an apioid-class pain medication having a reduced risk of addiction is brought forward, Medical Mutual will address a change in coverage. We may still require safeguards such as prior authorization or step therapy to ensure our members receive high-quality care while managing healthcare costs. At any time, if a doctor feels strongly that his/her patient should be taking a specific medication, we encourage that doctor to contact Medical Mutual to request a peer review. Tiffini Bloniarz Manager, Communications Medical Mutual of OhioRODNEY DUNIGAN Molina takes these claims very seriously. As you can imagine, every patient's case is different with many varying factors to consider, and if the providers want to contact Molina directly about their patients to escalate their concern, we would be happy to look into specific cases. Feel free to send along their names and phone numbers and we will have someone get back to them right away. Have you reached out to the Ohio Department of Medicaid on this issue? | ask because Molina (and all Medicaid managed care plans) follows the guidelines outlined by ODM with the goal of addressing the opioid epidemic and improving health outcomes for Medicaid beneficia You can find more information in the attached memo from ODM or you can reach out to OOM directly. With all that context, here is a statement from Molina: Molina Healthcare is committed to helping reduce the number of cases of opioid addiction. We are carefully following the guidelines developed by the Ohio Department of Medicaid and we will continue to work closely with our provider network to support any members battling addiction. Additionally, Molina has launched a national pain safety initiative as a comprehensive approach to address the needs of members with acute and chronic pain. These measures follow the CDC guidelines on the use of opioids for chronic pain and will result in decreasing the number of members who end up on chronic opioid therapy. Furthermore, the initiative expands non-narcotic options for use in pain management, expands access to care for addictive disorders and improves the risk profile of members who suffer from chronic pain and require opioids. it also aligns systems between the pharmacy, behavioral health and physical medicine di more optimally care for these members.Ohio Preferred Drug List (PDL) Changes ee P&T Meeting Date: July 12, 2017 Department of Medicaid oy Changes Effective Date: October 1, 2017 Berbera A Sears, Dost CHANGES IN CRITERIA Draycote Cry RTs aelaeit cel ‘Opioid Prescribing Limits for Acute Pain: + Maximum 7-day supply on prescriptions for new patients + Maximum cumulative 14-day supply in a 45-day period ‘+ Maximum of 60 MED per prescription ‘+ New patients are defined as having less than a 90-day supply of opioids in the previous 120 days Additional Criteria for Exceeding Short Acting Opioid New Start Criteria: + Exemptions for certain conditions: active cancer treatment, palliative care, end-of-lifeyhospice care, sickle cell, severe burn, traumatic crushing of tissue, amputation, major orthopedic surgery Attestation that patient is not opioid naive © For example, if patient is newly eligible for Medicaid and no prior claims are available for review © For example, if patient was on a higher dose in the hospital Non-pharmacologic treatments and/or non-opioid analgesics ineffective or contraindicated Diagnosis code required Benefits and risks of opioid therapy have been discussed with patient (attestation) Prescriber has checked OARRS (attestation) Length of authorization: UP TO 90 days, depending on the indication (could be more restrictive) Analgesic Agents: Opioids All Long-Acting Opioids Require Prior Authorization: * Initial request (90 day approval) © Catastrophic injury or cancer pain does not require additional documentation ©. Allother causes of pain: * Documented treatment plan including risk assessment, substance abuse history, concurrent therapies + OARRS checked within 7 days prior to initiating long-acting therapy Documentation of pain and function scores at each visit Baseline urine drug test and plan for random urine screens Opioid contract required Documented failure of both non-opioid pharmacologic and non-pharmacologic treatments * History of short-acting opioids for >/= 60 days + Cumulative dose 100 MED requires pain specialist or anesthesiologist consultation Endocrine Agents: Diabetes + Non-preferred medications require a therapeutic failure to at least Adjunctive Therapy two preferred medications Topical Agents: Immunomodulators + Protopic® 0.1% and Dupixent® are indicated in adults only. + Additional Criteria for Dupilumab (Dupixent®) + Indicated for moderate to severe atopic dermatitis if © Patient has minimum body surface area (BSA) involvement of at least 10% © Presoribed by or in consultation with a dermatologist or allergisvimmunologist Topical Agents: ©. Patient is 18 years of age or older Immunomodulators © Patient has had inadequate response or contraindication to two of the following: topical corticosteroids, topical calcineurin inhibitors [e.g. Elidel®], or topical PDE-4 inhibitors (e.g. Eucrisa™) + Initial authorization is limited to 16 weeks with re-authorization of up to 1 year granted following demonstration of improvement in patient condition with therapy (e.g. reduced BSA affected) NEW PREFERRED DRUGS eee ean Citas ee Us) Breas rekee cy Infectious Disease Agents Mavyret™ Antivirals ~ Hepatitis C Agents Date of Notice: 09/01/2017 Page 2 of3Ohi oO Preferred Drug List (PDL) Changes see P&T Meeting Date: July 12, 2017 Decetment of Mediceld, PDL Changes Effective Date: October 1, 2017 Borbora Sears, DAE aa ele] tae ec) ior NRT = GG cry Extended Release Morphine Products ‘Morphine Sulfate ER tablet Riayat) ITAA oe ait asain Uc} Ree a aes pes Reel ears aussie) Extended Release Morphine Products Arymo™ ER Vyvanse® chewable Central Nervous System (CNS) Agents: Attention Deficit Hyperactivity Disorder Agents Endocrine Agents: Diabetes Adjunctive Therapy | Xultophy® Endocrine Agents: Diabetes Oral Hypoglycemics Synjardy® XR Gastrointestinal Agents: Iritable Bowel Trulance™ ‘Syndrome (IBS) / Selected Gi Respiratory Agents: Beta-Adrenergic Agonists Utibron™ Nechaler® Inhaled, Long Acting Respiratory Agents: Chronic Obstructive Pulmonary | Seebri™ Neohaler® Disease Topical Agents: Immunomodulators Eucrisa™ Topical Agents: Immunomodulators Dupixent® Anti-Inflammatory Interleukin Receptor ‘Antagonist For additional details, the Preferred Drug List (PDL) and clinical criteria can be found at: http://pharmacy. medicaid ohio.gov/drug-coverage Date of Notice: 09/01/2017 Page 3 ofRODNEY DUNIGAN The opioid epidemic was caused by a perfect storm of several factors. Because the nature of the problem is so complex, the solutions must be mult-faceted as well. AS noted in the information below, Aetna is focused on three pilars prevention (including responsible prescribing and more comprehensive pain treatment approaches), intervention {including using data to identify those with opioid abuse disorder) and suppor (including increased access to evidence- based treatments such as medication assisted therapy). Encouraging appropriate prescribing isa large part of our work 1, Aetna does cover abuse-deterrent formulations of opioids. In fact, we have gone a step further and executed value-based contracts with multiple manufacturers of these formulations in order to encourage their appropriate use. 2. Far from encouraging the use of fentanyl, we require doctors to go through a precertification process before prescribing this very potent drug in order to ensure that there isn't a better alternative Aetna just fled @ lawsuit against Insys acousing them of ‘wrongfully inducing healthcare benefit payors like Aetna into paying for expensive, lethally dangerous, addictive, and entirely inappropriate prescriptions for Subsys (a fentanyi opioid medication).” The full complaint is attached here 4, Last month, we announced a collaboration with Pacira, a NJ-based pharmaceutical company and the American Association of Oral and Maxillofacial Surgeons to provide an alternative to opioids for our dental members following wisdom tooth extraction. By providing safer alternatives for pain control, fewer opioids are prescribed, ‘and we avoid the risk of misuse and diversion of unused pills. Here is the link to the full announcement - 9s /ialobenewswire,com/news-rel 17/09/13/1120237/0/en/Pacira-Pharmaceuticals-Aetna-and-the- American-Association-of- Oral-and-Waxilofacial-Surgeons-Join-Together-in-a-Proaram-to-Reduce-Opioid- Exposure-for-Patients-Undergoing-Wisdor-Too.ntm! Aetna has a number of different initiatives intended to address opioid addiction and use among our members. For example, we recently ended the preautharization requirements on all buprenorphine products used to treat opioid ‘addiction for our commercial members. Ending the requirement for buprenorphine will Increase access to treatment of an addiction. Our goal with many of our initiatives is to prevent addiction, but ifit happens, we also want to be an advocate to helo with treatment (here are some details on this recent policy change - hitps.//news.aetva.com/2017/03/streamlining-to- help-treat-opio\d-adsiction)) ‘We work collaboratively with our members’ health care providers to determine at which level of care treatment could reasonably and appropriately be provided. Our intent is for our members to receive the support they need on an ‘ongoing and consistent basis, helping them make the necessary changes to address their disease of addiction. In addition, as part of Aetna's three-pronged strategy of prevention, intervention and support to address the opioid epidemic, the company is working to increase the percentage of members with chronic pain treated by an evidence-based multimodal approach by 50 percent by 2022