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					State of WASHINGTON Medicaid Drug Utilization Review (DUR) Annual Report
for Federal Fiscal Year 2006
(October 1, 2005 to September 30, 2006)

Presented to: Center for Medicare and Medicaid Services (CMS)
By:

STATE OF WASHINGTON DEPARTMENT OF SOCIAL & HEALTH SERVICES Health & Recovery Services Administration 626 8th Avenue SE P.O. Box 45506 Olympia, WA 98504-5506
Prepared by ACS Government Healthcare Solutions, PBM Group
Michelle Laster-Bradley, Ph.D., M.S., R.Ph.

Government Healthcare Solutions, PBM Group

Under the direction of the Washington Health & Recovery Services Administration and Approved by the Washington DUR Board Report Date: 04/13/2007

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

WASHINGTON STATE CMS ANNUAL DUR REPORT – FFY 2006 TABLE OF CONTENTS
I. II. CMS SURVEY TABLE 1 - Prospective DUR (ProDUR) Criteria 1.A. Prospective DUR Criteria – Detailed 1.B. Prior Authorization (PA) Criteria
1.B.1 1.B.2 1.C.1 1.C.2 Expedited PA Description Expedited PA Drug List & Criteria Therapeutic Consultation Service (4-brand name Rx limit) Limitations on Certain Drugs: Quantity & Duration

Page 3 7 8 9 10 11 12 12 13 20-22 23

1.C. Miscellaneous Prior Authorization Programs

1.D. Preferred Drug List (PDL) Program III. IV. TABLE 2 - Retrospective DUR (RetroDUR) Criteria Attachment 1 - Monitoring Compliance with OBRA ’90 ProDUR Requirements Attachment 2 - ProDUR Activity 2.1. Pharmacy Eligibles, Users, and Claims by Month 2.2. Response to P.O.S. DUR Alerts by Alert Type 2.3. Response to P.O.S. DUR Alerts by Therapeutic Category VI. Attachment 3 - RetroDUR Activity 3.1. 3.2. 3.3. 3.4 Top 40 Therapeutic Classes - # Claims & Amount Paid RetroDUR Criteria Definitions & Development Description Washington IBM Profiles Screened & Interventions Summary Physician, Pharmacy, and Patient Profiling 3.4.A. and 3.4.B Washington IBM & TAS Interventions Summary

24 25 26 28 29 - 59 60-69 61 62-65 66 67 68-69 70-83 71-80 81 82-83 84-87 88-92 88 89-90 91 92

V.

VII.

Attachment 4 - Summary of DUR Board Activities 4.1 4.2 4.3 DUR Board Meeting Minutes RetroDUR Criteria Changes & Additions DUR Criteria Descriptions

VIII. Attachment 5 - Policy on Use of Therapeutically Equivalent Generics IX. Attachment 6 6.1 6.2 6.3 6.4 Program Evaluations/ Cost Savings Estimates

ProDUR Program Savings Summary RetroDUR Program Savings Summary ProDUR & RetroDUR Savings Conclusions RetroDUR Program Detailed Savings

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

CMS SURVEY DRUG UTILIZATION REVIEW (DUR) ANNUAL REPORT FEDERAL FISCAL YEAR 2006 I. STATE CODE WA MEDICAID AGENCY STAFF PERSON RESPONSIBLE FOR DUR ANNUAL REPORT PREPARATION Name Street Address City/State/ZIP Area Code/Phone Number Siri Childs, Pharm D 626 8th Avenue SE (P.O. Box 45506) Olympia, WA 98504-5506 360-725-1564

II.

III.

PROSPECTIVE DUR 1. During Federal Fiscal Year 2006 prospective DUR was conducted: (check those applicable) a) b) X By individual pharmacies on-site. On-line through approved electronic drug claims management system. Combination of (a) and (b). States conducting prospective DUR on-site have included as ATTACHMENT 1 (check one): Results of a random sample of pharmacies within the State pertaining to their compliance with OBRA 1990 prospective DUR requirements. Results of State Board of Pharmacy monitoring of pharmacy compliance with OBRA 1990 prospective DUR requirements. Results of monitoring of prospective DUR conducted by State Medicaid agency or other entities. (b) States conducting prospective DUR on-line have included as ATTACHMENT 1 a report on State efforts to monitor pharmacy compliance with the oral counseling requirement. Yes X No

c) 2. (a)

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3.

States conducting prospective DUR on-site plans with regards to establishment of an ECM system. State: Has no plans to implement an ECM system with prospective DUR capability. Plans to have an operational ECM system with prospective DUR in FFY 2006 or later.

STATES PERFORMING PROSPECTIVE DUR ON-SITE SKIP QUESTIONS 4-8 4. States conducting prospective DUR through an operational on-line POS system provide the following information: a) Operational date 03/96 (MM/YY) on which on-line POS system began accepting drug claims for adjudication from providers. Operational date 03/96 (MM/YY) on which on-line POS system began conducting prospective DUR screening. Percentage of Medicaid prescriptions processed by ECM system (where applicable) in FFY 2006. 99.71% Identify ECM vendor. Affiliated Computer Services (ACS), Inc., (facility manager) (company, academic institution, other organization) 1) Was system developed in house? Yes 2) Is vendor Medicaid Fiscal agent? Yes e) No No X X

b)

c)

d)

Identify prospective DUR (source of criteria). ACS/HRSA & First Data Bank with review & approval of DUR Board (company, academic institution, other organization)

5.

With regard to prospective DUR criteria from the vendor identified in 4 (d) above, the DUR Board: (Check one) (a) (b) X Approved in FFY 2006 all criteria submitted by the vendor. Chose to approve selected criteria submitted by the vendor.

6.

States checking 5 (b) have provided DUR criteria data requested on enclosed Table 1. Yes X No State prospective DUR screening includes screens run before obtaining DUR Board approval of criteria. Yes No X States conducting prospective DUR using an ECM system have included ATTACHMENT 2. Yes X No

7.

8.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

IV.

RETROSPECTIVE DUR 1. Identify your retrospective DUR vendor during FFY 2006. Affiliated Computer Services (ACS),Inc. Government Solutions (company, academic institution or other organization) a) Is the retrospective DUR vendor also the Medicaid fiscal agent? Yes No X Is your current retrospective DUR vendor contract subject to rebid in FFY 2006? Yes X No

b)

If your vendor changed during FFY 2006, identify your new vendor. N/A (company, academic institution or other organization) c) Is this retrospective DUR vendor also the Medicaid fiscal agent? Yes No X Is this retrospective DUR vendor also the developer/supplier of your retrospective DUR criteria? Yes No X

d)

2.

If your answer to question 1(c) or 1(d) above is no, identify the developer/supplier of your retrospective DUR criteria. (2a) Medical Assistance Administration with assistance of DUR Board (company, academic institution, or other organization) (2b) (company, academic institution, or other organization)

3.

Did DUR Board approve all retrospective DUR criteria supplied by the criteria source identified in questions 1(c) and 2 above? Yes No X States performing retrospective DUR have provided DUR Board approved criteria data requested on enclosed hardcopy Table 2. Yes X No States conducting retrospective DUR have included ATTACHMENT 3. Yes X No

4.

5.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

V.

DUR BOARD ACTIVITY 1. States have included a brief description of DUR Board activities during 2006 as ATTACHMENT 4. Yes X No FFY

2.

States have included a brief description of policies used to encourage the use of therapeutically equivalent generic drugs as ATTACHMENT 5. Yes X No

VI.

PROGRAM EVALUATION/COST SAVINGS 1. Did your State conduct a DUR program evaluation/cost savings estimate in FFY 2006? Yes X No Did you use Guidelines for Estimating the Impact of Medicaid DUR as the basis for developing your program evaluation/cost savings estimate? Yes X No Who conducted your program evaluation/cost savings estimate? Program Evaluation Estimates: Medical Assistance Administration (company, academic institution, or other organization) ProDUR Cost Savings Estimates: ACS, Inc. Government Solutions IBM RetroDUR Cost Savings Estimates: ACS, Inc. (company, academic institution, or other organization) 4. States have provided as ATTACHMENT 6 the program evaluations/cost savings estimates. Yes X No

2.

3.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

TABLE 1.

PROSPECTIVE DUR CRITERIA
Approval Process

FOR EACH PROBLEM TYPE BELOW, LIST (DRUGS/ DRUG CATEGORY/ DISEASE COMBINATIONS) FOR WHICH DUR BOARD CONDUCTED IN-DEPTH REVIEWS. PLEASE INDICATE WITH AN ASTERISK (*) THOSE FOR WHICH CRITERIA WERE ADOPTED.

INAPPROPRIATE DOSE
1. 2. 3. * Attention Deficit Hyperactive Disorder (ADHD) High Dose Therapy 1. 2. 3.

THERAPEUTIC DUPLICATION
* TD 2 Generation Anti-Depressants, specifically SSRI’s and SNRIs
nd

DRUG ALLERGY INTERACTION
1. 2. 3.

INAPPROPRIATE DURATION
1. 2. 3. 1. 2. 3.

DRUG/ DRUG INTERACTIONS
1. 2. 3.

DRUG DISEASE CONTRAINDICATION

OTHER OVERUSE
1. 2. 3.

(specify) 1. 2. 3.

OTHER EARLY REFILL

(specify) 1. 2. 3.

OTHER Drug-Age Contraindication (specify)
*Attention Deficit Hyperactive Disorder (ADHD) Therapy for patients <5 yrs old *Identified Sedative/Hypnotics use in patients < 18 years of age

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Table 1.A. Prospective DUR Criteria (Edits) - Detailed
Health & Recovery Services Administration (HRSA) provides a system-facilitated Prospective Drug Use Review screening as a part of the point-of-sale (POS) system. ProDUR edits post and claims are rejected when potential drug therapy problems are identified. Some ProDUR edits can be immediately overridden by dispensing pharmacists, some ProDUR edits require prior authorization approval to be overridden and dispensed, some edits require an expedited prior authorization by dispensing pharmacists, and some ProDUR edits are subject to quantity or duration limits. The following table outlines potential ProDUR edits (also called the HRSA-recognized NCPDP DUR Reason for Service Codes used by the state of Washington Medicaid program. NCPDP DUR Reason for Service Codes (formerly known as DUR Conflict Codes) used by HRSA in the WA Medicaid Program
ProDUR CONFLICT TYPE DD ER HD ID LD MX PA PG TD DESCRIPTION DRUG-DRUG INTERACTIONS EARLY REFILL HIGH DOSE ALERT INGREDIENT DUPLICATION LOW DOSE ALERT EXCESSIVE DURATION DRUG-AGE PRECAUTION DRUG-GENDER ALERT THERAPEUTIC DUPLICATION

Once pharmacists have conducted their professional review, HRSA-recognized NCPDP DUR Professional Service and Result of Service codes can be used to override the Pro-DUR edits.

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Table 1.B. Prior Authorization (PA) Criteria
HRSA pharmacists, medical consultants, and the drug utilization review team evaluate drugs to determine authorization status on the drug file. HRSA may consult with an evidencebased practice center, the Drug Use Review (DUR) Board, and/or participating HRSA providers in this evaluation. HRSA requires pharmacists to obtain prior authorization for many drug products and items before providing them to the client. HRSA reviews authorization requests for medical necessity. The requested service or item must be covered within the scope of the client's program. Exception: In emergency situations, pharmacists may fill prescription drugs that require authorizationwithout an authorization number. Justification for the emergency fill must be provided to HRSA no later than 72 hours after the fill date (excluding weekends and Washington State holidays). HRSA’s current list of drugs that do and do not require prior authorization can be found at the following link, as well as a PDL list for Washington state Medicaid. Go to the link: http://maa.dshs.wa.gov/pharmacy

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Table 1.B.1. Expedited PA Description

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Table 1.B.2. Expedited PA Guidelines & Drug List

The Expedited PA Drug List can be found at the following link, beginning on page 65: http://fortress.wa.gov/dshs/maa/download/BillingInstructions/Prescription Drug Program/Prescription_Drug_Program_BI.pdf

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Table 1.C. Miscellaneous Prior Authorization Programs
Table 1.C.1 Therapeutic Consultation Service (4-brand name Rx limit)

Therapeutic Consultation Service (TCS)
[ Refer to WAC 388-530-1260]

Overview of TCS
HRSA provides a complete drug profile review for each client when a drug claim for that client triggers a TCS consultation. The purpose of TCS is to facilitate the appropriate and costeffective use of prescription drugs. HRSA-designated clinical pharmacists review profiles in consultation with the prescriber or the prescriber’s designee by telephone. A TCS review occurs when a drug claim exceeds the four-brand-name-prescriptions-percalendar-month limit. Exception: Nonpreferred drugs do not count against the limit when an endorsing practitioner indicates dispense as written (DAW). However, if a nonendorsing practitioner indicates DAW for a nonpreferred drug, the nonpreferred drug counts against the limit and requires prior authorization, regardless of the DAW indication. When a pharmacy provider submits a claim that exceeds the four-brand-name-prescriptionsper-calendar-month limit for a client, HRSA generates a Point-of-Sale (POS) computer alert to notify the pharmacy provider that a TCS review is required. The computer alert provides a tollfree telephone number (866) 246-8504 to the pharmacy for the prescriber or prescriber’s designee to call.

Drugs excluded from the four brand name prescription per calendar month review
Drugs exluded from the four brand name prescription per calendar month review: • Antidepressants • Antipsychotics • Anticonvulsants • Chemotherapy drugs • Contraceptives • HIV medications • Immunosuppressants • Hypoglycemia rescue agents • Generic drugs • Drugs on the Washington Preferred Drug List (PDL)

(Revised March 2005) (#Memo 05-09 MAA)

- F.1 -

Therapeutic Consultation Service

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Table 1.C.2

Limitations on Certain Drugs: Quantity & Duration

The Health & Recovery Services Administration (HRSA) has set the following limits on certain drugs based on FDA approved indications and recommended limitations. Physicians and pharmacists should monitor the use of these drugs and counsel patients when the limits are exceeded. Prior authorization is required if these limits are exceeded.
Drug Abilify Abilify Abilify Abilify Aciphex Adderall-05/06 Adderall-05/06 Adderall-05/06 Adderall-05/06 Adderall-05/06 Adderall-05/06 Adderall-05/06 Adderall XR-05/06 Adderall XR-05/06 Adderall XR-05/06 Adderall XR-05/06 Adderall XR-05/06 Adderall XR-05/06 Allegra Allegra Allegra Allegra Allegra D Ambien Ambien Ambien CR Ambien CR Amerge Amerge Amphetamine Salts-05/06 Amphetamine Salts-05/06 Amphetamine Salts-05/06 Amphetamine Salts-05/06 Amphetamine Salts-05/06 Amphetamine Salts-05/06 Amphetamine Salts-05/06 Androgel Androderm Description Quantity 10 mg tab 15 mg tab 20 mg tab 20 mg tab 20 mg 1 5 mg tab 7.5 mg tab 10 mg tab 12.5 mg tab 15 mg tab 20 mg tab 30 mg tab 5 mg tab 10 mg tab 15 mg tab 20 mg tab 25 mg tab 30 mg tab 30 mg tab 60 mg cap 60 mg tab 180 mg tab tab 5 mg tab 10 mg tab 6.25 mg tab 12.5 mg tab 1 mg tab 2.5 mg tab 5 mg tab 7.5 mg tab 10 mg tab 12.5 mg tab 15 mg tab 20 mg tab 30 mg tab 1% gel 2.5 mg /24hr patch 2 2 2 1 2 2 1 Duration Age/sex 6 & older 6 & older 6 & older 6 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older Other

Day 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day as a single daily dose 60mg per day as a single daily dose 60mg per day as a single daily dose 60mg per day as a single daily dose 60mg per day as a single daily dose 60mg per day as a single daily dose Day Day Day Day Day Day Day

18 & older 18 & older 18 & older 18 & older

10 in 30 days 10 in 30 days 10 in 30 days 10 in 30 days

9 9

Month Month 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day 60mg per day

5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older Male patients only Male patients only

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-- continued -- Table 1.C.2 Limitations on Certain Drugs: Quantity & Duration
Drug Androderm Arava Avinza Avinza Avinza Avinza Axert Axert Azelex Bactroban (cream) Bactroban (ointment) Bactroban Nasal Bextra Bextra Description Quantity 5 mg /24hr patch 10 mg tab 1 30 mg 1 60 mg 1 90 mg 1 120 mg 1 6.25 mg tab 12 12.5 mg tab 12 20% cream 2% cream 30 units 2% ointment 22 units 2% ointment 30 units 10 mg tab 20 mg tab 1 2 Duration Age/sex Male patients only Other

Day Day Day Day Day Month Month 12 & older 6 Months=180 days 4 Months=120 days 6 Months=180 days Day Day

18 & older 18 & older

See EPA criteria Maximum 7 days treatment per calendar month. See EPA

Butorphanol Campral Celebrex Celebrex Celebrex Centany Clarinex Claritin Claritin Claritin Claritin D Claritin D Clobex Shampoo(Clobetasol) Clobetasol Clobetasol Clozapine Clozapine Clozaril Clozaril Concerta Concerta Concerta Concerta Contraceptives

spray 333mg tab

10

100 mg cap 4 200 mg cap 2.200 400mg cap 2 2% ointment 22 units 5 mg tab syrup 10 mg redi-tab 10 mg tab 12 hr tab 24 hr tab 0.05% Shampoo 1 10 1 1 2 1 118 ml

Month 1 year of therapy in lifetime Day Day Day 4 Months=120 days Day Day Day Day Day Day 17 Days

0.05% (cream, 100 units 14 Days gel, ointment) 0.05% (solution 14 Days & lotion) 25 mg tab 100 mg tab 25 mg tab 100 mg tab 18 mg tab 120 mg per day as a single daily dose 27 mg tab 120 mg per day as a single daily dose 36 mg tab 120 mg per day as a single daily dose 54 mg tab 120 mg per day as a single daily dose All forms

50gm per week & maximum of 14 day supply 50ml per week & maximum of 14 day supply 17 & older 17 & older 17 & older 17 & older 5 & older 5 & older 5 & older 5 & older 10 & older

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-- continued -- Table 1.C.2 Limitations on Certain Drugs: Quantity & Duration
Drug

Copegus Crestor Crestor Crestor Crestor Cymbalta Cymbalta Cymbalta Dexedrine Dexedrine Spansule-05/06 Dexedrine Spansule-05/06 Dexedrine Spansule-05/06 Diastat Acudial-10/06 Diastat Acudial-10/06 Doral Dextroamphetamine-05/06 Dextroamphetamine-05/06 Dextrostat-05/06 Dextrostat-05/06 Doral Enbrel Estazolam Estazolam Felbatol Felbatol Felbatol Flouride Flumist Fluoride preparations Flurazepam Flurazepam Focalin-05/06 Focalin-05/06 Focalin XR-05/06

Description Quantity Duration 200mg tab 5mg 8 Day 10 mg 4 Day 20 mg 2 Day 40 mg 1 Day 20 mg 3 Day 30 mg 2 Day 60 mg 1 Day 5 mg 60mg per day 5 mg 60mg per day 10 mg 60mg per day 15 mg 60mg per day 10-15-20mg 5 kits per month 5-7.5-10mg 5 kits per month 7.5 mg 5 mg 60mg per day 10 mg 60mg per day 5 mg 60mg per day 10 mg 60mg per day 15 mg 25 mg kit 8 28 days 1 mg 2 mg 600 mg/5ml susp 45 Day 400mg tab 14 Day 600 mg tab 9 Day Nasal vaccine

Age/sex 18 & older

Other

5 & older 5 & older 5 & older 5 & older

18 & older 5 & older 5 & older 5 & older 5 & older 18 & older 18 & older 18 & older

15 mg 30 mg 2.5 mg tab 5 mg tab 5mg

Focalin XR-05/06

10mg

Focalin XR-05/06

20mg

Frova Geodon Geodon Geodon Geodon Halobetasol Humira

2.5 mg tab 20 mg cap 40 mg cap 60 mg cap 80 mg cap .05% - all forms (cream & ointmnt) 40 mg/0.8ml syr

20 & younger Ages 5-50 21 years & under 18 & older 18 & older 60mg per day 5 & older 60mg per day 5 & older 60mg per day as 5 & older a single daily dose 60mg per day as 5 & older a single daily dose 60mg per day as 5 & older a single daily dose 9 Month 6 & older 6 & older 6 & older 6 & older 100 units 14 Days 50gm per week & max of 14 day supply 1 Week

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-- continued -- Table 1.C.2 Limitations on Certain Drugs: Quantity & Duration
Drug Imitrex Imitrex Imitrex Imitrex Imitrex Imitrex Imitrex Infergen Infergen Infergen Infergen Kadian Kadian Kadian Kadian Kadian Kineret Lariam Loratadine Loratadine Lunesta Lunesta Lunesta Loratadine-D Maxalt Maxalt Maxalt MLT Maxalt MLT Metadate CD-05/06 Metadate CD-05/06 Metadate CD-05/06 Metadate CD-05/06 Metadate CD-05/06 Metadate CD-05/06 Metadate ER-05/06 Metadate ER-05/06 Methylin-05/06 Methylin-05/06 Methylin-05/06 Methylin ER-05/06 Methylin ER-05/06 Methylphenidate-05/06 Methylphenidate-05/06 Methylphenidate-05/06 Description Quantity syringe 4 units vial 4 units 5 mg spray 12 20 mg spray 12 25 mg tab 9 50 mg tab 9 100 mg tab 9 15mcg/0.5ml syringe 15mcg/0.5ml vial 9mcg/0.3ml syringe 9mcg/0.3ml vial 20 mg cap 2 30 mg cap 2 50 mg cap 2 60 mg cap 2 100 mg cap 2 100 mg/0.67ml syr 1 250mg tablet 5 10 10mg tab 1 24hr tab 1 1 mg tab 10 2 mg tab 10 3 mg tab 10 24hr tab 1 5 mg tab 12 10 mg tab 12 5 mg tab 12 10 mg tab 12 10 mg cap 20 mg cap 30 mg cap 40 mg cap 50 mg cap 60 mg cap 10 mg tab 20 mg tab 5 mg tab 10 mg tab 20 mg tab 10 mg tab 20 mg tab 5 mg tab 10 mg tab 20 mg tab Duration Month Month Month Month Month Month Month Age/sex Other

18 & older 18 & older 18 & older 18 & older Day Day Day Day Day Day Prescription 6 months Day Day 30 days 30 days 30 days Day Month Month Month Month 120mg per day as a single daily dose 120mg per day as a single daily dose 120mg per day as a single daily dose 120mg per day as a single daily dose 120mg per day as a single daily dose 120mg per day as a single daily dose 120mg per day 120mg per day 120mg per day 120mg per day 120mg per day 120mg per day 120mg per day 120mg per day 120mg per day 120mg per day

18 & older 18 & older 18 & older

5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older

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-- continued -- Table 1.C.2 Limitations on Certain Drugs: Quantity & Duration
Drug Migranal Mupirocin Naltrexone Namenda Namenda Namenda Nexium Nexium OxyContin OxyContin OxyContin OxyContin OxyContin PEG-Intron PEG-Intron PEG-Intron PEG-Intron Pegasys Pegasys Prenatal vitamins Prevacid Prevacid Prevacid Prilosec Prilosec Prilosec Prilosec Protonix Protonix Pulmozyme Rebetol Rebetol Relpax Relpax Revia Risperdal Risperdal Risperdal Risperdal Risperdal Risperdal Risperdal Description Quantity Duration nasal spray (any form) 6 21 Day period 2% ointment 22 units 4 months=120 days 50 mg tab 12 weeks lifetime limit 5 mg tab 2 Day 10 mg tab 2 Day 5/10mg titration pack 2 Day 20 mg cap 1 Day 40 mg cap 1 Day 10mg tab 2 Day 20 mg tab 2 Day 40 mg tab 2 Day 80 mg tab 2 Day 160 mg tab 2 Day 120 mcg kit 150 mcg kit 50 mcg kit 80 mcg kit 180mcg/mil vial Convenience pack Age/sex Other

18 & older 18 & older 18 & older 18 & older 18 & older 18 & older 10-40, pregnant female

15 mg cap 30 mg cap 15 mg susp 2 mg cap 10 mg cap 20 mg OTC 40 mg cap 20 mg cap 40 mg cap 1 mg/ml ampule 200mg cap 40mg/ml sol 20mg tab 40mg tab 50mg tab 2 mg M-tab 0.25 mg tab 0.5 M-tab 0.5 mg tab 1 mg M-tab 1 mg tab 1 mg/ml solution

1 1 1 1 1 2 1 1 1

Day Day Day Day Day Day Day Day 5 & older 18 & older 18 & older

6 6

Month Month 12 weeks 6 & older 6 & older 6 & older 6 & older 6 & older 6 & older 6 & older

Single course of treatment in lifetime

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-- continued -- Table 1.C.2 Limitations on Certain Drugs: Quantity & Duration
Drug Risperdal Risperdal Risperdal Consta-03/06 Risperdal Consta-03/06 Risperdal Consta-03/06 Ritalin -05/06 Ritalin -05/06 Ritalin -05/06 Ritalin LA-05/06 Ritalin LA-05/06 Ritalin LA-05/06 Ritalin LA-05/06 Ritalin SR-05/06 Rozerem Seroquel Seroquel Seroquel Seroquel Sonata Sonata Stadol NS Strattera-05/06 Strattera-05/06 Strattera-05/06 Strattera-05/06 Strattera-05/06 Strattera-05/06 Strattera-05/06 Description Quantity Duration 2 mg M-tab 3 mg tab 25mg 1 unit/syringe in 14 days 37.5mg 1 unit/syringe in 14 days 50mg 1 unit/syringe in 14 days 5 mg tab 120 mg per day 10 mg tab 120 mg per day 20 mg tab 120 mg per day 10 mg cap 120 mg per day as a single daily dose 20 mg cap 120 mg per day as a single daily dose 30 mg cap 120 mg per day as a single daily dose 40 mg cap 120 mg per day as a single daily dose 20 mg tab 120 mg per day 8 mg tab 25 mg tab 100 mg tab 200 mg tab 300 mg tab 5 mg cap 2 Day 10 mg cap 1 Day spray 10 Month 10 mg cap 120mg per day as a single daily dose 18 mg cap 120mg per day as a single daily dose 25 mg cap 120mg per day as a single daily dose 40 mg cap 120mg per day as a single daily dose 60 mg cap 120mg per day as a single daily dose 80 mg cap 120mg per day as a single daily dose 100 mg cap 120mg per day as a single daily dose Age/sex 6 & older 6 & older Other

5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 18 & older 6 & older 6 & older 6 & older 6 & older 18 & older 18 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older 5 & older

10 in 30 days

10 in 30 days 10 in 30 days

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-- continued -- Table 1.C.2 Limitations on Certain Drugs: Quantity & Duration
Drug Suboxone Suboxone Synagis Synagis Temazepam Temazepam Tretinoin Tretinoin Tretinoin Tretinoin Tretinoin Tretinoin Triazolam Triazolam Vicuprofen Description Quantity 2 mg tab 14 days 8 mg tab 14 days 50 mg 100 mg 15 mg 30 mg .03% ointment .1% ointment .01% gel .025% cream .05% solution .1% cream .125 mg tab .25 mg tab 200/7.5 tab 5 Duration Claim Claim Age/sex Other 6 month maximum 6 month maximum

Under 1 Under 1 18 & older 18 & older 25 & younger 25 & younger 25 & younger 25 & younger 25 & younger 25 & younger 18 & older 18 & older Day Max of 10 days supply per claim Maximum of 20 days continuous therapy 18 & older 18 & older 18 & older 18 & older

Vioxx Vioxx Vioxx Vioxx Xifaxan Xopenex Xopenex Xopenex Xopenex Zelapar ODT-10/06 Zelnorm Zelnorm Zomig Zomig Zomig Zomig ZMT Zomig ZMT Zyprexa Zyprexa Zyprexa Zyprexa Zyprexa Zyprexa Zyrtec Zyrtec Zyrtec Zyrtec-D

syrup 12.5 mg tab 25 mg tab 50 mg 200 mg tab

10 2 1 1 9

Day Day Day Day Month

Maximum 5 days treatment Maximum 3 day supply in calendar month

0.31 mg/3 ml 0.63 mg/3 ml 1.25 mg/0.5 ml 1.25mg/3ml 1.25mg tab 2.5mg 2mg 6 6mg 2 Nasal spray 12 units 2.5 mg tab 9 5 mg tab 9 2.5 mg tab 9 5 mg tab 9 2.5 mg tab 5 mg tab 7.5 mg tab 10 mg tab 15 mg tab 20 mg tab syrup 10 5 mg tab 1 10 mg tab 1 tab 2

6 & older 6 & older 6 & older 6 & older Day Day Day Month Month Month Month Month 6 & older 6 & older 6 & older 6 & older 6 & older 6 & older Day Day Day Day

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Table 1.D. Preferred Drug List (PDL) Program

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

-- continued -- Table 1.D. Preferred Drug List (PDL) Program

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-- continued -- Table 1.D. Preferred Drug List (PDL) Program

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

TABLE 2.

RETROSPECTIVE DUR CRITERIA – FFY 2006 – WA STATE MEDICAID
Approval Process

FOR EACH PROBLEM TYPE BELOW, LIST (DRUGS/ DRUG CATEGORY/ DISEASE COMBINATIONS) FOR WHICH DUR BOARD CONDUCTED IN-DEPTH REVIEWS. PLEASE INDICATE WITH AN ASTERISK (*) THOSE FOR WHICH CRITERIA WERE ADOPTED.

INAPPROPRIATE DOSE
1. 2. 3. * Attention Deficit Hyperactive Disorder (ADHD) High Dose Therapy 1. 2. 3.

THERAPEUTIC DUPLICATION
Second Generation Antidepressants Attention Deficit Hyperactive Disorder (ADHD) Agents

DRUG ALLERGY INTERACTION
1. 2. 3.

INAPPROPRIATE DURATION
1. 2. 3. 1. 2. 3.

DRUG/ DRUG INTERACTIONS
Combination of Triptans and (SSRI or SNRI) causing Serotonin Syndrome 1. 2. 3.

DRUG DISEASE CONTRAINDICATION

OTHER PDL Implementations
1. 2. 3. Immune Modulators

(specify) 1. 2. 3.

OTHER Monitoring Polypharmacy
Narcotics Review Program

(specify) 1. 2. 3.

OTHER Drug-Age Contraindication (specify)
*Attention Deficit Hyperactive Disorder (ADHD) Therapy for patients <5 yrs old *Identified Sedative/Hypnotics use in patients < 18 years of age

Antiemetics, Atypical Antipsychotic Thiazolidiones, Nasal Corticosteroids, Second Generation Antidepressant

Dual Eligibles clients receiving 20 unique medications in 60 days by > 2 physicians

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ANNUAL DUR REPORT – WASHINGTON STATE FFY 2006 (October 1, 2005 – September 30, 2006)

ATTACHMENT 1. MONITORING PHARMACY COMPLIANCE WITH OBRA '90
(Online ProDUR and/ or Oral Counseling Requirements)

Online Prospective DUR (ProDUR) The State of Washington Medicaid does not require use of the electronic claims management point-of-sale (POS)/ProDUR system by The State of Washington Medicaid Pharmacy providers. Those who do use the system benefit from the ProDUR information available at the POS, but must take appropriate action before the claim will pay. ProDUR alerts require review by pharmacy providers and result in a payable claim , depending on action taken by the pharmacist upon posting of a given ProDUR alert. Some ProDUR alerts result in a stopped claim that will not pay unless prior authorization is obtained. States’ Efforts to Monitor ProDUR Oral Counseling Requirement The Washington State Board of Pharmacy has adopted the counseling requirements as set forth in the Omnibus Budget Reconciliation Act of 1990 (OBRA-90) and requires pharmacists in Washington State to counsel all patients or the patient’s agent or caregiver in all ambulatory care settings where patients receive prescriptions. The rules are explicit on the content of the counseling. It is recommended that the counseling is in person, but it can be done in writing with free access to a pharmacist by phone. Some counseling is documented in daily signature logs kept in retail pharmacies. The Washington State Board of Pharmacy is the controlling authority over the patient counseling regulations portion of OBRA ’90 for the Washington Medicaid program. The Board of Pharmacy inspects pharmacies and measures conformance with patient counseling requirements. The Washington State Board of Pharmacy periodically inspects all pharmacies licensed in Washington State and observes counseling by the pharmacists in their practice settings. The Health and Recovery Services Administration (HRSA) requires pharmacy providers to conform to all Washington State Board of Pharmacy rules. According to Andrew Mecca, Pharm.D., Pharmacist Consultant, Washington State Board of Pharmacy (ph: 360-236-4831), of the 116 complaints received during the FFY 2006 period, 4 were a result of (or included upon further investigation) a counseling infraction. During the same period of FFY 2006, a total of 823 inspections were conducted and 0 patient counseling infractions were found as part of the inspection.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 2: ProDUR Activity

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.1.

Pharmacy Eligibles, Users, and Claims by Month
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM CONSULTEC PRESCRIPTION DRUG CARD SERVICES CLAIMS PAYMENT SUMMARY CLAIMS PAID FROM 08/01/05 - 01/31/07

AS OF 01/31/07

GROUP:

7850

WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM
PARTICIPANT ---------------------ELIGIBLE UTILIZING 975,778 980,459 983,064 981,850 982,813 979,543 979,373 984,392 980,016 980,345 978,453 971,483 972,329 969,274 970,385 963,425 962,953 957,770 17,553,705 207,986 208,904 210,755 209,910 211,437 180,274 174,888 199,436 192,327 195,572 192,042 186,723 191,291 186,423 191,872 186,713 184,401 192,002 3,502,956 ELIG PARTICPNT -------------AVG AVG CLM PRESC AMT PD 1.17 1.13 1.14 1.15 1.19 0.69 0.65 0.96 0.89 0.98 0.94 0.90 0.94 0.87 0.91 0.88 0.85 1.00 0.96 64.84 61.98 62.43 64.29 64.54 38.40 32.64 37.78 33.44 36.25 35.65 34.01 35.80 34.04 36.31 34.87 34.74 38.74 43.42 UTIL PARTICPNT --------------AVG AVG CLM PRESC AMT PD 5.49 5.31 5.33 5.39 5.54 3.76 3.67 4.73 4.55 4.90 4.80 4.66 4.80 4.50 4.61 4.53 4.46 4.99 4.81 304.21 290.88 291.19 300.72 300.00 208.66 182.78 186.47 170.38 181.71 181.65 176.95 181.96 176.99 183.64 179.91 181.39 193.23 217.57

PAYMENT MONTH AUG, SEP, OCT, NOV, DEC, JAN, FEB, MAR, APR, MAY, JUN, JUL, AUG, SEP, OCT, NOV, DEC, JAN, 2005 2005 2005 2005 2005 2006 2006 2006 2006 2006 2006 2006 2006 2006 2006 2006 2006 2007

ELIGIBLE EMPLOYEES 975,778 980,459 983,064 981,850 982,813 979,543 979,373 984,392 980,016 980,345 978,453 971,483 972,329 969,274 970,385 963,425 962,953 957,770

PRESCRIPTIONS PAID 1,142,477 1,108,432 1,123,405 1,130,997 1,170,658 677,496 641,352 943,170 874,457 958,537 922,706 870,924 918,220 839,732 885,289 846,346 823,059 958,553 16,835,810

PAID BY CLIENT 63,271,488.17 60,765,490.96 61,369,472.02 63,125,041.93 63,430,669.27 37,615,517.84 31,965,204.46 37,188,421.70 32,769,274.01 35,537,856.94 34,883,693.35 33,040,550.47 34,807,963.93 32,994,327.99 35,236,237.92 33,592,325.91 33,449,295.61 37,100,035.76 762,142,868.24

AVERAGE PRESCRP PAID 55.38 54.82 54.63 55.81 54.18 55.52 49.84 39.43 37.47 37.08 37.81 37.94 37.91 39.29 39.80 39.69 40.64 38.70 45.27

TOTALS

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Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

– continued –
ATTACHMENT 2.1. -- continued – Pharmacy Eligibles, Users, and Claims by Month

AS OF 01/31/07

WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM CONSULTEC PRESCRIPTION DRUG CARD SERVICES CLAIMS PAYMENT SUMMARY CLAIMS PAID FROM 08/01/05 - 01/31/07

PAGE 2 RUN DATE 02/02/07

GROUP:

ALL GROUPS
PARTICIPANT ---------------------ELIGIBLE UTILIZING 975,778 980,459 983,064 981,850 982,813 979,543 979,373 984,392 980,016 980,345 978,453 971,483 972,329 969,274 970,385 963,425 962,953 957,770 35,107,410 207,986 208,904 210,755 209,910 211,437 180,274 174,888 199,436 192,327 195,572 192,042 186,723 191,291 186,423 191,872 186,713 184,401 192,002 7,005,912 AVERAGE PRESCRP PAID 55.38 54.82 54.63 55.81 54.18 55.52 49.84 39.43 37.47 37.08 37.81 37.94 37.91 39.29 39.80 39.69 40.64 38.70 15.57 ELIG PARTICPNT UTIL PARTICPNT -------------- -------------AVG AVG CLM AVG AVG CLM PRESC AMT PD PRESC AMT PD 1.17 1.13 1.14 1.15 1.19 0.69 0.65 0.96 0.89 0.98 0.94 0.90 0.94 0.87 0.91 0.88 0.85 1.00 0.96 64.84 61.98 62.43 64.29 64.54 38.40 32.64 37.78 33.44 36.25 35.65 34.01 35.80 34.04 36.31 34.87 34.74 38.74 14.93 5.49 5.31 5.33 5.39 5.54 3.76 3.67 4.73 4.55 4.90 4.80 4.66 4.80 4.50 4.61 4.53 4.46 4.99 4.81 304.21 290.88 291.19 300.72 300.00 208.66 182.78 186.47 170.38 181.71 181.65 176.95 181.96 176.99 183.64 179.91 181.39 193.23 74.83

PAYMENT MONTH AUG, SEP, OCT, NOV, DEC, JAN, FEB, MAR, APR, MAY, JUN, JUL, AUG, SEP, OCT, NOV, DEC, JAN, 2005 2005 2005 2005 2005 2006 2006 2006 2006 2006 2006 2006 2006 2006 2006 2006 2006 2007

ELIGIBLE EMPLOYEES 975,778 980,459 983,064 981,850 982,813 979,543 979,373 984,392 980,016 980,345 978,453 971,483 972,329 969,274 970,385 963,425 962,953 957,770

PRESCRIPTIONS PAID 1,142,477 1,108,432 1,123,405 1,130,997 1,170,658 677,496 641,352 943,170 874,457 958,537 922,706 870,924 918,220 839,732 885,289 846,346 823,059 958,553 33,671,620

PAID BY CLIENT 63,271,488.17 60,765,490.96 61,369,472.02 63,125,041.93 63,430,669.27 37,615,517.84 31,965,204.46 37,188,421.70 32,769,274.01 35,537,856.94 34,883,693.35 33,040,550.47 34,807,963.93 32,994,327.99 35,236,237.92 33,592,325.91 33,449,295.61 37,100,035.76 524,285,736.48

TOTALS

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.2 ProDUR ACTIVITY: RESPONSE TO P.O.S. DUR ALERTS BY ALERT TYPE

WASHINGTON MEDICAID
FEDERAL FISCAL YEAR 2006 (10/1/05 - 9/30/06)

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 ProDUR ACTIVITY: RESPONSE TO P.O.S. ALERTS BY THERAPEUTIC CATEGORY
FEDERAL FISCAL YEAR 2006 (10/1/05 - 9/30/06)
11/14/06 RXRQ4098-R001 RXRQ4098-R001 DRUG CONFLICT CODE: THERAPEUTIC CLASS CODE/NAME ORAL ANTICOAGULANTS, LIPOTROPICS NARCOTIC ANALGESICS ANTIDEPRESSANTS POTASSIUM REPLACEMEN DIURETICS, THIAZIDE ANTI-INFLAMMATORY AG THYROID HORMONES QUINOLONES BETA-ADRENERGIC AGEN HYPOTENSIVES SYMPATH BETA ADRENERGIC BLOC POTASSIUM SPARING DI SKELETAL MUSCLE RELA DIGITALIS GLYCOSIDES LOOP DIURETICS ANTICONVULSANTS MACROLIDES ANTIARRHYTHMICS CONTRACEPTIVES, ORAL INTESTINAL MOTILITY TETRACYCLINES SALICYLATE ANALGESIC PENICILLINS ANTI-MANIA DRUGS ANTIMETABOLITES CALCIUM CHANNEL BLOC IMMUNOSUPPRESSIVES PURINE INHIBITORS IRON REPLACEMENT ABSORBABLE SULFONAMI COUGH COLD PREPARATI ANTI-NARCOLEPSY/ANTI INSULINS INSULIN ENHANCER ANTIULCER PREPARATIO ANTIMIGRAINE PREPARA ANTI-ANXIETY DRUGS ANTIMALARIAL DRUGS ANTIFUNGAL AGENTS ANTIPARKINSONISM DRU ADRENERGIC AGENTS, A ANTIVIR,HIV,PROTEASE ANTI-PSYCHOTICS,PHEN THIAZIDE DIURETICS A ANTIHISTAMINES ALPHA-BETA ADRENERGI ANTI-EMETICS NIACIN PREPARATIONS ANTACIDS EXPECTORANTS ANTIVIRALS, HIV-SPEC XANTHINES ANTIDIARRHEALS CALCIUM REPLACEMENT SYMPATHOMIMETIC AGEN BARBITURATES ANAPHYLAX THERAPY AG ANALGESIC/ANTIPYRETI HEPARIN PREPARATIONS LAXATIVES AND CATHAR BETA-ADRENERGICS GLU PRENATAL VITAMIN PRE TOTAL MESSAGES 62,321 49,136 34,420 27,153 22,958 18,346 16,869 16,303 15,079 13,375 11,519 11,147 10,605 9,813 8,662 8,170 8,133 8,070 7,618 7,175 7,163 7,154 6,851 6,098 5,916 5,848 5,450 4,933 4,609 4,508 4,445 4,424 4,364 4,353 4,334 4,286 3,937 3,811 3,577 3,454 3,207 3,104 3,036 2,802 2,790 2,720 2,067 1,974 1,776 1,717 1,625 1,575 1,475 1,289 1,259 1,257 1,213 1,153 1,001 976 926 853 823 DRUG-DRUG INTERACTION DENIAL MESSAGES 1,147 128 261 297 353 12 3,455 41 98 702 290 8 48 147 41 1 1,558 70 60 163 341 23 58 17 155 25 0 20 154 4 36 26 47 366 7 536 140 747 2 36 78 31 10 13 10 30 89 55 0 3 7 2 10 1 1 0 2 0 34 12 6 24 137 OVERRIDDEN CLAIMS 2,010 2,976 28,724 0 1,597 322 16,591 1,642 764 2,222 3,583 2,791 398 2,017 354 2,306 21,815 976 118 1,059 376 376 1,384 5,968 1,980 219 1,496 835 171 716 390 0 11,461 2,222 489 223 344 28,998 239 516 817 9,500 151 262 939 0 618 955 51 310 173 0 91 200 887 71 214 30 1,490 327 3,295 492 205 TOTAL CLAIMS 107,540 497,998 1,250,585 13 150,301 48,876 525,789 231,563 76,702 336,282 77,870 349,306 38,897 231,387 47,533 203,186 767,967 106,483 11,436 145,545 52,845 43,614 232,002 198,494 49,974 15,394 227,566 20,998 25,079 89,754 70,132 256 123,138 199,513 88,458 12,470 54,098 378,799 48,556 50,279 54,408 96,892 10,999 17,972 173,287 268 43,565 78,047 3,697 45,569 23,571 0 11,041 37,420 92,745 19,557 17,447 6,800 138,003 14,944 306,981 75,439 76,588 PAID MESSAGES 61,174 49,008 34,159 26,856 22,605 18,334 13,414 16,262 14,981 12,673 11,229 11,139 10,557 9,666 8,621 8,169 6,575 8,000 7,558 7,012 6,822 7,131 6,793 6,081 5,761 5,823 5,450 4,913 4,455 4,504 4,409 4,398 4,317 3,987 4,327 3,750 3,797 3,064 3,575 3,418 3,129 3,073 3,026 2,789 2,780 2,690 1,978 1,919 1,776 1,714 1,618 1,573 1,465 1,288 1,258 1,257 1,211 1,153 967 964 920 829 686 WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CLASS CONSULTEC PRESCRIPTION DRUG CARD SERVICES PAGE 1

M9L M4E H3A H2J C1D R1L S2B P3A W1Q J5D A4B J7C R1H H6H A1A R1M H4B W1D A2A G8A J9A W1C H3D W1A H2M V1B A9A Z2E C7A C3B W2A B3K H2V C4G C4N D4E H3F H2F W4A W3B H6A J5B W5C H2G R1F Z2A J7A H6J C6N D4B B3J W5B A1B D6D C1F J5E H2D J5F H3E M9K D6S J5G C6F

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Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
DRUG CONFLICT CODE: DRUG-DRUG INTERACTION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME ORAL HYPOGLYCEMIC AG ORAL HYPOGLYCEMIC AG ANOREXIC AGENTS MAGNESIUM REPLACEMEN AMINOGLYCOSIDES NON-BARBITURATE, SED 1ST GEN ANTIHIST-DEC GASTRIC ACID SECRETI MISC ANTINEOPLASTICS TRICHOMONACIDES ANTITUBERCULAR ANTIB VITAMIN E PREPARATIO ANTITUBERCULAR AGENT PHOSPHATE REPLACEMEN MISCELLANEOUS MULTIV ANTIULCER H.PYLORI A NARC ANTITUSS-1ST GE HYPOTENSIVES MISCELL URINARY TRACT ANTISP HYPOTENSIVES ANGIOTE CONTRACEPTIVES, INJE NOSE PREPS ANTIINFLA CHOLINESTERASE INHIB VITAMIN K PREPARATIO BRONCHODIALATORS GLUCOCORTICOIDS ANTILEPROTICS MISCELLANEOUS FOOD S CARBONIC ANHYDRASE I ANTIPSYCHOTICS, NONHYPOTEN ANGIOTEN REC MONOAMINEOXIDASE (MA DECON-EXP NOSE PREPS VASOCONST NARCOTIC ANTAGONISTS CORONARY VASODILATOR PLATELET AGGREGATION URINARY PH MODIFIERS DRUGS TO TREAT IMPOT MIOTICS AND OTHER IN BELLADONNA ALKALOIDS ANTIDEPRESSANTS COMB VAGINAL ANTIFUNGALS MISC ANTIBACTERIAL C EYE VASOCONSTRITRS ( ESTROGEN/ANDROGEN CO ADRENERGIC VASOPRESS PITUITARY SUPPRESSIV ANTIPARKINSONISM DRU VITAMIN A DERIVATIVE ACNE AGENTS, SYSTEMI ANTIPRURITICS, TOPIC ENTERED BULK CHEMICALS ORAL ANTICOAGULANTS, ESTROGENIC AGENTS TOPICAL SULFONAMIDES ELECTROLYTE DEPLETER ANTIPSORIATIC AGENTS GRAM NEGATIVE BACILL TOPICAL/MUCOUS MEMBR CEPHALOSPORINS ANTIFUNGAL ANTIBIOTI HEPATITIS C TREATMEN ANTICHOLINERGICS, AN ZINC REPLACEMENT TOTAL MESSAGES 727 667 637 623 586 550 513 500 488 484 465 462 442 385 378 332 328 312 278 269 249 242 232 229 223 207 205 198 197 178 172 141 137 136 133 126 123 117 105 100 90 86 82 78 74 71 64 64 60 58 57 53 49 49 46 45 45 44 42 42 41 41 41 40 38 33 PAID MESSAGES 726 660 627 598 570 422 513 500 478 481 454 462 435 385 378 330 316 312 278 267 248 240 232 227 222 198 205 198 184 178 162 141 137 136 94 124 123 117 104 82 90 86 80 77 74 71 64 60 60 58 57 53 48 49 46 45 45 42 42 42 41 39 40 40 38 32 DENIAL MESSAGES 1 7 10 25 16 128 0 0 10 3 11 0 7 0 0 2 12 0 0 2 1 2 0 2 1 9 0 0 13 0 10 0 0 0 39 2 0 0 1 18 0 0 2 1 0 0 0 4 0 0 0 0 1 0 0 0 0 2 0 0 0 2 1 0 0 1 OVERRIDDEN TOTAL CLAIMS CLAIMS 1,578 138,365 1,336 171,858 0 1,030 536 12,521 34 2,627 8,477 200,107 313 17,195 8,310 695,874 44 7,636 297 21,769 222 2,595 196 15,932 2,101 6,090 10 1,399 57 14,586 7 1,270 51 4,892 19 5,997 770 76,201 2,336 378,145 56 6,654 409 111,558 364 39,965 35 1,614 437 52,394 1,542 182,512 19 2,428 0 2,305 39 2,591 0 0 1,535 150,295 3 31 65 11,816 2 2,090 75 1,279 601 84,959 603 84,919 69 3,953 29 3,498 388 62,808 72 12,205 0 0 279 18,245 13 3,436 2 1,210 0 627 10 1,203 16 1,357 415 45,059 24 7,391 12 1,235 11 1,516 91,277 3,140,038 47 2,668 0 0 569 89,574 95 8,117 263 19,933 6 636 0 116 32 5,851 0 0 572 18,340 209 10,972 58 15,346 8 2,625

C4K C4L J8A C1H W1F H2E Z2N D4K V1F W4E W1G C6E W2E C1P C6Z D4F B3Q A4Y R1A A4D G8C Q7P J1B C6K A1D P5A W4P C5F R1E H2L A4F H2H B4W Q7D H3T A7B M9P R1S F2A Q6G J2A H2K Q4F W2G Q6D G1B J5H P1F H6B L9B L1B L3P NOT U6W M9M G1A Q5S C1A L1A W7M L0B W1B W3A W5G J2D C3C

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
11/14/06 RXRQ4098-R001 WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CLASS CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: DRUG-DRUG INTERACTION FISCAL YEAR 10/1/05 - 9/30/06 TOTAL MESSAGES 32 29 26 25 25 23 23 21 20 20 20 18 18 16 16 15 15 15 13 13 12 11 11 11 10 10 10 9 9 9 9 8 8 8 8 7 5 5 4 4 3 3 3 3 3 3 3 2 2 2 2 2 2 1 1 1 1 1 1 PAID MESSAGES 32 28 26 25 16 23 23 21 20 20 20 18 18 16 16 15 11 15 13 13 12 11 11 11 10 10 10 9 9 9 9 8 8 8 8 7 5 5 4 4 3 3 3 3 3 3 3 1 2 2 2 2 2 1 1 1 1 1 1 DENIAL MESSAGES 0 1 0 0 9 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 OVERRIDDEN CLAIMS 22 11 59 87 7 407 0 169 131 0 116 6 98 15 3,201 0 306 4 311 2 318 3 12 47 253 368 1 43 71 0 224 43 145 112 31 88 0 104 368 158 91 50 2 3 37 9 4 2 7 32 178 118 3 0 341 21 0 5 21 PAGE 3

C4M J9B F1A B3T M9F W5A Z1E C6H C0D C6G H0A C5B H6C C0K Z2P P6A Q3S Q6C B4D C3M J2B B3X Q7A R5A C6B Q5W R1R B3R D8A J5A Q9B B4E G2A L6A M9S S2A C8A Q4W J7B W2F A4A B4C C3H J3A Q5B W7C X1C A7C B4Q D7L H0E P2B Q5A B4R B4S C1B D4H P1B Q3A

THERAPEUTIC CLASS CODE/NAME HYPOGLYC;ALPHA-GLUCO ANTISPASMODIC AGENTS ANDROGENIC AGENTS NON-NARC ANTITUSS-EX THROMBOLYTIC ENZYMES ANTIVIRALS ANTIOXIDANT AGENTS PEDIATRIC VITAMIN PR ANTIALCOHOLIC PREPAR GERIATRIC VITAMIN PR LOCAL ANESTHETICS PROTEIN REPLACEMENT ANTITUSSIVE, NON-NAR BICARBONATE PRODUCIN 1ST GEN ANTIHISTAMIN PINEAL HORMONE AGENT LAXATIVES, LOCAL/REC EYE VASOCONSTRICTRS( NARC ANTITUSS-1ST GE MISCELLANEOUS MINERA ANTICHOLINERGICS, QU 1STGEN ANTIHIST-DECO NOSE PREPS MISC RX O URINARY TRACT ANEST VITAMIN B PREPARATIO TOPICAL ANTIBIOTICS URICOSURIC AGENTS NONARC ANTITUSS-1G A PANCREATIC ENZYMES ADRENERGIC AGENTS, C BPH NON-NARC ANTITUS-1G PROGESTATIONAL AGENT IRRITANTS HEMORRHEOLOGIC AGENT COLCHICINE METALLIC POISON ANTI VAGINAL ANTIBIOTICS ALPHA ADRENERGIC BLO NITROFURAN DERIVATIV HYPOTENSIVES VASODIL NARC ANTITUSS-ANTICH IODINE REPLACEMENT GANGLIONIC STIMULANT TOPICAL ANTIBACTERIA INFLUENZA VIRUS VACC IUD PERIPHERAL VASODILAT NARC ANTITUS-DECON-E BILE SALT INHIBITORS AGENTS TO TREAT MULT ANTIDIURETIC AND VAS TOPICAL PREPARATIONS NON-NARC ANTITUSS-DE NARC ANTITUSS-EXP SODIUM REPLACEMENT ORAL MUCOSITIS/STOMA SOMATOSTATIC AGENTS RECTAL PREPARATIONS

TOTAL CLAIMS 2,459 337 5,287 21,855 150 37,861 365 15,507 3,470 801 11,807 557 17,329 775 220,971 209 12,947 841 28,015 340 4,036 109 2,344 12,317 25,827 54,077 1,158 6,886 11,159 29 35,622 7,660 14,247 17,983 4,299 9,852 328 6,740 42,759 32,601 9,443 3,363 292 3,998 3,332 7,114 488 146 1,188 5,042 7,841 8,302 1,104 268 40,630 5,080 61 315 13,394

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 31 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
11/14/06 RXRQ4098-R001 WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: DRUG-DRUG INTERACTION FISCAL YEAR 10/1/05 - 9/30/06 TOTAL MESSAGES 1 1 1 1 1 521,929 PAID MESSAGES 1 1 1 1 1 509,393 DENIAL MESSAGES 0 0 0 0 0 12,536 OVERRIDDEN CLAIMS 958 93 0 0 46 308,063 PAGE 4

Q5F Q6P U5B W4K Z2G

THERAPEUTIC CLASS CODE/NAME TOPICAL ANTIFUNGALS EYE ANTIINFLAMMATORY HERBAL DRUGS MISC ANTIPROTOZOAL D IMMUNOMODULATORS

TOTAL CLAIMS 116,702 17,150 174 327 1,945 15,442,991

DRUG-DRUG INTERACTION SUM

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 32 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EARLY REFILL FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME H4B H3A H2J H2F A4D J5D R1M D4K J7C D4E M4E C4G S2B P3A H6H A9A H2L C4K M9L C1D D6S C4L G1A H3D R1F Z2A P5A H2E A4B G8A A1A H2M H6B Z2Q A4F H2V A7B Z2P R1A H2G C3B H6A Q7P J5B J9A H3E R1L P4L Q5P M9P C4N Q5F D4B R1H Z4B Q6G W4A C1F J5G C6F A4A Z2E A1D H2D ANTICONVULSANTS NARCOTIC ANALGESICS ANTIDEPRESSANTS ANTI-ANXIETY DRUGS HYPOTENSIVES ANGIOTE BETA-ADRENERGIC AGEN LOOP DIURETICS GASTRIC ACID SECRETI BETA ADRENERGIC BLOC ANTIULCER PREPARATIO LIPOTROPICS INSULINS ANTI-INFLAMMATORY AG THYROID HORMONES SKELETAL MUSCLE RELA CALCIUM CHANNEL BLOC ANTIPSYCHOTICS, NONORAL HYPOGLYCEMIC AG ORAL ANTICOAGULANTS, POTASSIUM REPLACEMEN LAXATIVES AND CATHAR ORAL HYPOGLYCEMIC AG ESTROGENIC AGENTS SALICYLATE ANALGESIC THIAZIDE DIURETICS A ANTIHISTAMINES GLUCOCORTICOIDS NON-BARBITURATE, SED HYPOTENSIVES SYMPATH CONTRACEPTIVES, ORAL DIGITALIS GLYCOSIDES ANTI-MANIA DRUGS ANTIPARKINSONISM DRU 2ND GEN ANTIHISTAMIN HYPOTEN ANGIOTEN REC ANTI-NARCOLEPSY/ANTI CORONARY VASODILATOR 1ST GEN ANTIHISTAMIN URINARY TRACT ANTISP ANTI-PSYCHOTICS,PHEN IRON REPLACEMENT ANTIPARKINSONISM DRU NOSE PREPS ANTIINFLA ADRENERGIC AGENTS, A INTESTINAL MOTILITY ANALGESIC/ANTIPYRETI DIURETICS, THIAZIDE BONE RESORBTION SUPP TOPICAL ANTI FLAMMAT PLATELET AGGREGATION INSULIN ENHANCER TOPICAL ANTIFUNGALS ANTACIDS POTASSIUM SPARING DI LEUKOTRIENE RECEPTOR MIOTICS AND OTHER IN ANTIMALARIAL DRUGS CALCIUM REPLACEMENT BETA-ADRENERGICS GLU PRENATAL VITAMIN PRE HYPOTENSIVES VASODIL IMMUNOSUPPRESSIVES BRONCHODIALATORS BARBITURATES TOTAL MESSAGES 83,181 77,667 57,885 34,618 28,839 26,373 25,513 24,251 24,147 23,953 21,963 21,198 20,109 19,578 18,558 18,007 16,244 15,073 14,962 13,834 13,045 11,957 11,777 11,459 11,355 10,810 10,637 10,235 9,189 8,747 7,912 7,180 6,974 6,878 6,541 6,108 6,057 6,000 5,526 5,203 4,978 4,952 4,893 4,614 4,469 4,396 4,317 3,985 3,683 3,581 3,579 3,316 3,248 3,224 3,003 2,934 2,923 2,764 2,711 2,705 2,537 2,535 2,410 2,334 PAID MESSAGES 231 50,778 38,360 157 15,508 589 14,467 14,250 13,528 347 12,272 154 320 10,765 7,105 9,934 9,547 8,576 10,084 7,593 7,462 6,612 5,398 5,431 5,821 5,636 11 119 4,648 3,652 3,999 4,441 4,237 3,474 3,377 4,951 3,444 3,907 2,874 3,071 2,647 2,379 1,858 3,916 1,723 1,856 2,584 1,695 1,026 1,930 1,961 1,403 1,411 2,093 1,573 7 1,437 1,047 1,194 1,304 1,386 1,903 1,261 1,334 DENIAL MESSAGES 82,950 26,889 19,525 34,461 13,331 25,784 11,046 10,001 10,619 23,606 9,691 21,044 19,789 8,813 11,453 8,073 6,697 6,497 4,878 6,241 5,583 5,345 6,379 6,028 5,534 5,174 10,626 10,116 4,541 5,095 3,913 2,739 2,737 3,404 3,164 1,157 2,613 2,093 2,652 2,132 2,331 2,573 3,035 698 2,746 2,540 1,733 2,290 2,657 1,651 1,618 1,913 1,837 1,131 1,430 2,927 1,486 1,717 1,517 1,401 1,151 632 1,149 1,000 OVERRIDDEN CLAIMS 21,815 28,724 0 28,998 2,336 2,222 2,306 8,310 2,791 223 2,976 2,222 16,591 1,642 2,017 1,496 0 1,578 2,010 1,597 3,295 1,336 569 1,384 939 0 1,542 8,477 3,583 1,059 354 1,980 415 2,254 1,535 11,461 601 3,201 770 262 716 817 409 9,500 376 1,490 322 844 954 603 489 958 310 398 289 388 239 887 492 205 91 835 437 214 TOTAL CLAIMS 767,967 1,250,585 13 378,799 378,145 336,282 203,186 695,874 349,306 12,470 497,998 199,513 525,789 231,563 231,387 227,566 0 138,365 107,540 150,301 306,981 171,858 89,574 232,002 173,287 268 182,512 200,107 77,870 145,545 47,533 49,974 45,059 223,394 150,295 123,138 84,959 220,971 76,201 17,972 89,754 54,408 111,558 96,892 52,845 138,003 48,876 114,460 142,291 84,919 88,458 116,702 45,569 38,897 66,387 62,808 48,556 92,745 75,439 76,588 9,443 20,998 52,394 17,447 11/14/06 PAGE 5

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 33 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EARLY REFILL FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME C6M J7A W2A A1B J7B G2A C7A H6J Q9B J1B W5B D6D W1C H3F A2A V1B W3B C6C W5C B3J W5A Q5W C1A D9A Q6T W2F C6D B3K D2A C6E Q6P V1F P2B Q5H J2A W1A C1H C6L J2D M9S D8A A4Y S2A W1Q W1D L2A C6B D1D W3A L6A W5G W2E N1B Q5S H0E J5E M9K C6Z S2J V1E W1B V1A C6Q FOLIC ACID PREPARATI ALPHA-BETA ADRENERGI ABSORBABLE SULFONAMI XANTHINES ALPHA ADRENERGIC BLO PROGESTATIONAL AGENT PURINE INHIBITORS ANTI-EMETICS BPH CHOLINESTERASE INHIB ANTIVIRALS, HIV-SPEC ANTIDIARRHEALS TETRACYCLINES ANTIMIGRAINE PREPARA ANTIARRHYTHMICS ANTIMETABOLITES ANTIFUNGAL AGENTS VITAMIN C PREPARATIO ANTIVIR,HIV,PROTEASE EXPECTORANTS ANTIVIRALS TOPICAL ANTIBIOTICS ELECTROLYTE DEPLETER AMMONIA INHIBITORS ARTIFICIAL TEARS NITROFURAN DERIVATIV VITAMIN D PREPARATIO COUGH COLD PREPARATI FLUORIDE PREPARATION VITAMIN E PREPARATIO EYE ANTIINFLAMMATORY MISC ANTINEOPLASTICS ANTIDIURETIC AND VAS TOPICAL LOCAL ANESTH BELLADONNA ALKALOIDS PENICILLINS MAGNESIUM REPLACEMEN VITAMIN B12 PREPARAT ANTICHOLINERGICS, AN HEMORRHEOLOGIC AGENT PANCREATIC ENZYMES HYPOTENSIVES MISCELL COLCHICINE QUINOLONES MACROLIDES EMOLLIENTS VITAMIN B PREPARATIO DENTAL AIDS AND PREP ANTIFUNGAL ANTIBIOTI IRRITANTS HEPATITIS C TREATMEN ANTITUBERCULAR AGENT HEMATINICS, OTHER TOPICAL SULFONAMIDES AGENTS TO TREAT MULT SYMPATHOMIMETIC AGEN HEPARIN PREPARATIONS MISCELLANEOUS MULTIV TUMOR NECROSIS INHIB STEROID ANTINEOPLAST CEPHALOSPORINS ALKYLATING AGENTS VITAMIN B6 PREPARATI TOTAL MESSAGES 2,291 2,188 2,119 1,996 1,959 1,926 1,737 1,674 1,649 1,608 1,576 1,497 1,441 1,438 1,336 1,283 1,265 1,213 1,167 1,112 1,097 1,093 1,033 1,015 961 875 874 842 821 799 768 766 762 753 726 717 683 662 655 630 614 611 579 566 535 514 491 485 482 476 473 468 465 464 456 442 418 413 403 403 387 379 351 PAID MESSAGES 1,064 1,095 973 879 1,261 785 145 887 1,044 781 1,321 620 759 179 780 900 457 466 880 494 373 439 591 361 318 349 324 432 281 437 215 373 402 394 288 225 356 30 329 321 216 347 279 269 131 206 248 208 74 244 234 240 149 157 202 246 145 146 202 164 136 202 162 DENIAL MESSAGES 1,227 1,093 1,146 1,117 698 1,141 1,592 787 605 827 255 877 682 1,259 556 383 808 747 287 618 724 654 442 654 643 526 550 410 540 362 553 393 360 359 438 492 327 632 326 309 398 264 300 297 404 308 243 277 408 232 239 228 316 307 254 196 273 267 201 239 251 177 189 OVERRIDDEN CLAIMS 293 618 390 91 368 145 171 955 224 364 0 200 376 344 118 219 516 166 151 173 407 368 263 183 264 158 163 0 3,518 196 93 44 118 155 72 5,968 536 536 58 31 71 19 88 764 976 131 253 361 572 112 209 2,101 194 95 178 71 327 57 95 16 0 50 258 TOTAL CLAIMS 42,385 43,565 70,132 11,041 42,759 14,247 25,079 78,047 35,622 39,965 0 37,420 43,614 54,098 11,436 15,394 50,279 21,301 10,999 23,571 37,861 54,077 19,933 14,923 39,793 32,601 17,754 256 50,054 15,932 17,150 7,636 8,302 23,694 12,205 198,494 12,521 15,923 15,346 4,299 11,159 5,997 9,852 76,702 106,483 26,926 25,827 16,280 18,340 17,983 10,972 6,090 8,425 8,117 7,841 19,557 14,944 14,586 10,477 2,069 0 3,328 7,458 11/14/06 PAGE 6

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 34 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EARLY REFILL FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME P5S W8F B4S H2A C1B J2B C0D H0A Q6R P3L Q6W L5F J1A F1A D4N D7L Q4K Q3S L0B C6H Z2F B4D D7A R1E W4P R1S L5A H6C C3C L9B W2G P1F C6N C4M Z2G W1G P1A S2I Q3A B0A G1B Z2N G8C W8E U6H Q5B L5E W1F Q6I Q5R H3T Q7A C7D C5B U6N V1J C6K C5J Q8W Q6Y R5A MINERALOCORTICOIDS IRRIGANTS NARC ANTITUSS-EXP CENTRAL NERVOUS SYST SODIUM REPLACEMENT ANTICHOLINERGICS, QU ANTIALCOHOLIC PREPAR LOCAL ANESTHETICS EYE ANTIHISTAMINES ANTITHYROID PREPARAT EYE ANTIBIOTICS ANTIPSORIATICS AGENT PARASYMPATHETIC AGEN ANDROGENIC AGENTS ANTIFLATULENTS BILE SALT INHIBITORS VAGINAL ESTROGEN LAXATIVES, LOCAL/REC TOPICAL/MUCOUS MEMBR PEDIATRIC VITAMIN PR CHROMOLYN AND DERIVA NARC ANTITUSS-1ST GE BILE SALTS CARBONIC ANHYDRASE I ANTILEPROTICS URINARY PH MODIFIERS KERATOLYTICS ANTITUSSIVE, NON-NAR ZINC REPLACEMENT VITAMIN A DERIVATIVE MISC ANTIBACTERIAL C PITUITARY SUPPRESSIV NIACIN PREPARATIONS HYPOGLYC;ALPHA-GLUCO IMMUNOMODULATORS ANTITUBERCULAR ANTIB GROWTH HORMONES PYRIMIDINE SYNTH INH RECTAL PREPARATIONS GENERAL INHALATION A ESTROGEN/ANDROGEN CO 1ST GEN ANTIHIST-DEC CONTRACEPTIVES, INJE ANTISEPTICS, GENERAL SOLVENTS TOPICAL ANTIBACTERIA ANTISEBORRHEIC AGENT AMINOGLYCOSIDES EYE ANTIBIOTIC CORTI TOPICAL ANTIPARASITI NARCOTIC ANTAGONISTS NOSE PREPS MISC RX O METABOLIC DEFICIENCY PROTEIN REPLACEMENT VEHICLES ANTIANDROGENIC AGENT VITAMIN K PREPARATIO IV SOLUTIONS; DEXTRO EAR PREPS ANTIBIOTIC EYE PREPARATIONS, MI URINARY TRACT ANEST TOTAL MESSAGES 345 345 343 342 341 334 314 310 303 299 293 291 274 273 268 268 267 259 247 241 239 231 231 230 226 220 219 211 210 196 193 192 186 177 176 172 170 168 163 162 161 158 156 153 148 143 142 140 128 127 119 117 116 115 114 110 107 106 105 101 101 PAID MESSAGES 184 108 180 220 147 116 190 104 92 162 123 81 91 141 104 123 98 94 58 73 102 117 101 129 110 70 93 74 95 72 53 90 121 76 41 111 63 71 54 58 77 101 59 41 61 57 46 50 46 26 67 27 35 19 51 56 44 34 42 25 34 DENIAL MESSAGES 161 237 163 122 194 218 124 206 211 137 170 210 183 132 164 145 169 165 189 168 137 114 130 101 116 150 126 137 115 124 140 102 65 101 135 61 107 97 109 104 84 57 97 112 87 86 96 90 82 101 52 90 81 96 63 54 63 72 63 76 67 OVERRIDDEN CLAIMS 52 61 341 36 21 318 131 116 89 49 112 40 24 59 164 32 37 306 32 169 6 311 140 39 19 69 68 98 8 24 13 16 51 22 46 222 39 83 21 26 0 313 56 119 9 37 19 34 46 849 75 12 15 6 18 59 35 1 37 28 47 TOTAL CLAIMS 3,254 4,030 40,630 649 5,080 4,036 3,470 11,807 19,871 4,058 36,478 4,703 2,976 5,287 12,487 5,042 7,189 12,947 5,851 15,507 1,482 28,015 3,446 2,591 2,428 3,953 9,911 17,329 2,625 7,391 3,436 1,357 3,697 2,459 1,945 2,595 3,279 3,274 13,394 2,656 627 17,195 6,654 16,692 3,116 3,332 4,931 2,627 7,593 18,843 1,279 2,344 2,104 557 2,399 835 1,614 705 16,484 3,635 12,317 11/14/06 PAGE 7

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 35 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EARLY REFILL FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME NOSE PREPS ANTIHISTA LINCOSAMIDES ACNE AGENTS, TOPICAL ELECTROLYTE REPLACEM HYPERGLYCEMICS VAGINAL ANTIFUNGALS ADRENERGIC VASOPRESS MYDRIATICS MONOAMINEOXIDASE (MA URICOSURIC AGENTS TRICHOMONACIDES MUCOLYTICS PHOSPHATE REPLACEMEN DECON-EXP IV SOLUTIONS; DEXTRO NOSE PREPS VASOCONST NARC ANTITUSS-ANTICH ANTIDEPRESSANTS COMB URINARY TRACT ANALGE APPETITE STIMULANTS 2ND GEN ANTIHIST-DEC BICARBONATE PRODUCIN VANCOMYCIN AND DERIV HEPATITIS B TREATMEN ANTIPRURITICS, TOPIC TOPICAL PREPARATIONS NON-NARC ANTITUSS-EX MISCELLANEOUS FOOD S MISCELLANEOUS MINERA LEUKOCYTE STIMULANTS EYE SULFONAMIDES ACNE AGENTS, SYSTEMI HEMORRHOIDAL PREPARA EAR PREPS ANTIBIOTIC MISC ANTIPROTOZOAL D ANTIPSORIATIC AGENTS TOPICAL ANTIVIRALS ANTIPERSPIRANTS CONTRACEPTIVES, INTR NASAL MAST CELL STAB EAR PREPS MISC ANTII PERIPHERAL VASODILAT PROTECTIVES EYE PREPS, MISC (RX GASTRIC ENZYMES 1ST GN ANTIHIST-ANAL NARC ANTITUSS-1ST GE PHARMACEUTICAL ADJUV VITAMIN B1 PREPARATI NON-NARC ANTITUS-1G DIABETIC ULCER PREPA WATER PLATELET REDUCING AG SOMATOSTATIC AGENTS CHEMOTHERAPY ANTIDOT METALLIC POISON ANTI LUTEINIZING HORMONES EAR PREPS LOCAL ANES CREAM/OINTMENT BASES SUSPENDING AGENTS TOPICAL ANTINEOPLAST EAR PREPS EAR WAX RE ANTISERA VITAMIN A PREPARATIO TOTAL MESSAGES 97 94 91 88 86 85 82 82 81 81 79 77 77 76 73 73 68 67 67 66 66 64 60 57 56 56 55 51 50 48 47 45 45 44 44 43 39 37 35 33 31 30 29 29 27 26 25 25 23 20 20 19 19 19 17 16 16 16 16 16 15 15 14 13 PAID MESSAGES 61 28 41 11 23 36 46 16 40 47 33 25 42 36 5 34 39 33 27 28 37 35 15 32 21 13 38 20 11 27 7 18 19 24 27 25 14 8 24 21 22 7 7 8 10 11 14 2 8 10 4 8 12 8 5 10 6 9 9 4 3 11 2 4 DENIAL MESSAGES 36 66 50 77 63 49 36 66 41 34 46 52 35 40 68 39 29 34 40 38 29 29 45 25 35 43 17 31 39 21 40 27 26 20 17 18 25 29 11 12 9 23 22 21 17 15 11 23 15 10 16 11 7 11 12 6 10 7 7 12 12 4 12 9 OVERRIDDEN CLAIMS 26 1,161 17 30 19 279 10 13 3 1 297 84 10 65 4 2 50 0 13 15 48 15 66 13 11 3 87 0 2 13 13 12 2 268 0 6 67 4 40 2 5 2 1 10 0 9 51 0 2 43 1 4 3 5 0 0 0 71 4 0 0 28 1 1 TOTAL CLAIMS 3,519 23,214 4,242 5,298 3,886 18,245 1,203 2,745 31 1,158 21,769 2,706 1,399 11,816 859 2,090 3,363 0 1,111 1,299 5,611 775 3,840 1,532 1,516 1,104 21,855 2,305 340 1,550 5,312 1,235 1,906 5,736 327 636 4,753 1,117 1,890 504 1,483 146 1,677 1,501 309 1,211 4,892 1 1,258 7,660 499 763 334 315 431 328 0 6,390 210 262 409 3,305 561 112 11/14/06 PAGE 8

Q7E W1K L5H C1W M4G Q4F J5H Q6J H2H R1R W4E B3A C1P B4W C5K Q7D B4C H2K R5B C7E Z2O C0K W1J W5F L3P Q5A B3T C5F C3M N1C Q6S L1B Q3D Q8F W4K L1A Q5V L8B G9A Q7H Q8B A7C L3A Q6A D4G B5S B3Q U6A C6T B4E L0C C0B N1D P1B V1I C8A P1C Q8H U6F U7A Q5N Q8R W7K C6A

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 36 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EARLY REFILL FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME ANAPHYLAX THERAPY AG ADRENOCORTICOTROPHIC ANTIARTHRITICS AGTS ANTHELMINTICS IUD VASODILATORS MISCELL EYE ANTIVIRALS DECARBOXYLASE INHIBI OXIDIZING AGENTS EYE VASOCONSTRICTRS( EYE VASOCONSTRITRS ( THIENAMYCINS MISC ANTIBACTERIAL A MISCELLANEOUS SOLUTI ANTIHEMOPHILIC FACTO OINTMENT/CREAM BASES NONARC ANTITUSS-1G A ANTISPASMODIC AGENTS ASTRINGENTS ANTIVIRAL MONOCLONAL RECTAL/LOWER BOWEL P HEMORRHOID PREP, LOC IODINE REPLACEMENT ANTIULCER H.PYLORI A INTESTINAL ADSORBENT AMYOTROP LATERAL SCL MISCELLANEOUS TOPICA VIRAL VACCINES DRUGS TO TREAT IMPOT ANALGESICS ANESTHETI ANOREXIC AGENTS FOLLICLE STIMULATING VAGINAL ANTIBIOTICS POLYMYXIN AND DERIVA GRAM POSITIVE COCCI SYSTEMIC ENZYME INHI INOTROPIC DRUGS NARC ANTITUS-DECON-E GERIATRIC VITAMIN PR CONTRACEPTIVES, IMPL NOSE PREPS ANTIBIOTI ANTIBIOTICS OXABETA LACTAMS AMEBACIDES 1STGEN ANTIHIST-DECO INFANT FORMULA OXYTOCICS GENERAL ANESTHETICS, ALCOHOL TOPICAL HYPERPIGMENT ANTIFIBRINOLYTIC AGE ORAL ANTICOAGULANTS, METABOLIC FUNCTION D VAGINAL PREPARATIONS TOPICAL ANTIFUNGALS/ TOPICAL ANTIBIO/INFL NOSE PREPS MISC OTC GOLD SALTS NEUROMUSCULAR BLOCKI HERBAL DRUGS INFLUENZA VIRUS VACC MED SUPPLIES MISCELL TOTAL MESSAGES 13 13 13 13 12 11 11 10 10 8 8 8 8 7 7 7 6 6 6 6 5 5 4 4 4 4 4 4 3 3 3 3 3 3 3 3 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 919,448 PAID MESSAGES 6 6 11 7 10 4 6 5 1 2 2 1 3 6 1 5 5 4 1 4 1 0 2 4 1 3 0 2 0 0 3 0 1 0 0 3 0 1 0 2 0 0 1 0 0 0 1 0 1 0 1 1 1 0 0 0 1 0 0 1 1 0 381,864 DENIAL MESSAGES 7 7 2 6 2 7 5 5 9 6 6 7 5 1 6 2 1 2 5 2 4 5 2 0 3 1 4 2 3 3 0 3 2 3 3 0 2 1 2 0 2 2 1 2 1 1 0 1 0 1 0 0 0 1 1 1 0 1 1 0 0 1 537,584 OVERRIDDEN CLAIMS 30 3 0 13 4 0 2 7 0 4 2 48 0 0 18 0 43 11 4 4 2 1 2 7 0 3 3 0 29 0 0 0 104 0 8 0 0 7 0 0 0 2 2 0 3 0 16 0 0 0 7 0 0 0 0 0 0 2 0 0 9 0 231,882 TOTAL CLAIMS 6,800 78 825 1,825 488 4 352 235 183 841 1,210 753 0 68 522 352 6,886 337 273 2,993 197 184 292 1,270 72 210 624 884 3,498 45 1,030 22 6,740 75 1,285 141 16 1,188 801 0 406 3 71 16 109 50 2,304 64 0 24 153 0 0 11 0 218 3,028 75 105 174 7,114 1,320 13,462,903 11/14/06 PAGE 9

J5F P1E S2H W4L X1C A7E Q6V C7B W8D Q6C Q6D W1S W8J C5O M0E U6E B3R J9B L4A W5D Q3B Q3H C3H D4F D5P H6I L9A W7B F2A H3H J8A P0B Q4W W1N W7L Z2H A1C B4Q C6G G8B Q7W W1L W1P W4C B3X C5C G3A H2C H2T L9D M9D M9M P1U Q4A Q5G Q5X Q7Y S2C S7A U5B W7C Y0A

EARLY REFILL SUM

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 37 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: HIGH DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME H3A S2B D4K H3E D4E H2E H6H D6S H4B H6J H2F H2J B3K Z2P A9A D1D B4D H2V P3A Z2A G8A H2L D6D C6L P4L J5D J5B C1D B4S C4L P5A R1A H3D A7B A4B M9L A4F H3F Z2Q C4K W5C W1A W3A M9K A4D J5G C1H W1Q A1B A1D J5E G1A Q3S B3J R5A J7A Q8F M4E H6C H2G H6B Q5R B4E NARCOTIC ANALGESICS ANTI-INFLAMMATORY AG GASTRIC ACID SECRETI ANALGESIC/ANTIPYRETI ANTIULCER PREPARATIO NON-BARBITURATE, SED SKELETAL MUSCLE RELA LAXATIVES AND CATHAR ANTICONVULSANTS ANTI-EMETICS ANTI-ANXIETY DRUGS ANTIDEPRESSANTS COUGH COLD PREPARATI 1ST GEN ANTIHISTAMIN CALCIUM CHANNEL BLOC DENTAL AIDS AND PREP NARC ANTITUSS-1ST GE ANTI-NARCOLEPSY/ANTI THYROID HORMONES ANTIHISTAMINES CONTRACEPTIVES, ORAL ANTIPSYCHOTICS, NONANTIDIARRHEALS VITAMIN B12 PREPARAT BONE RESORBTION SUPP BETA-ADRENERGIC AGEN ADRENERGIC AGENTS, A POTASSIUM REPLACEMEN NARC ANTITUSS-EXP ORAL HYPOGLYCEMIC AG GLUCOCORTICOIDS URINARY TRACT ANTISP SALICYLATE ANALGESIC CORONARY VASODILATOR HYPOTENSIVES SYMPATH ORAL ANTICOAGULANTS, HYPOTEN ANGIOTEN REC ANTIMIGRAINE PREPARA 2ND GEN ANTIHISTAMIN ORAL HYPOGLYCEMIC AG ANTIVIR,HIV,PROTEASE PENICILLINS ANTIFUNGAL ANTIBIOTI HEPARIN PREPARATIONS HYPOTENSIVES ANGIOTE BETA-ADRENERGICS GLU MAGNESIUM REPLACEMEN QUINOLONES XANTHINES BRONCHODIALATORS SYMPATHOMIMETIC AGEN ESTROGENIC AGENTS LAXATIVES, LOCAL/REC EXPECTORANTS URINARY TRACT ANEST ALPHA-BETA ADRENERGI EAR PREPS ANTIBIOTIC LIPOTROPICS ANTITUSSIVE, NON-NAR ANTI-PSYCHOTICS,PHEN ANTIPARKINSONISM DRU TOPICAL ANTIPARASITI NON-NARC ANTITUS-1G TOTAL MESSAGES 209,925 25,021 24,930 23,649 17,088 13,361 12,815 11,794 11,495 11,304 10,977 10,662 10,199 8,893 8,411 7,443 7,418 6,389 6,258 6,222 6,116 5,915 5,769 5,495 5,391 5,234 4,876 4,807 4,400 4,078 3,898 3,760 3,506 3,384 3,316 3,214 3,139 3,008 3,001 2,776 2,774 2,541 2,536 2,421 2,403 2,318 2,204 2,189 2,172 2,156 2,152 2,139 2,113 1,990 1,944 1,867 1,854 1,765 1,729 1,663 1,634 1,575 1,523 PAID MESSAGES 187,279 21,114 21,663 22,108 12,277 9,674 11,239 10,780 8,648 9,738 7,912 9,313 9,614 8,199 7,622 6,436 7,012 5,480 5,412 4,807 4,599 5,337 5,523 783 4,549 4,138 4,181 3,841 4,223 3,788 2,605 3,252 3,004 2,931 2,328 2,656 2,832 2,567 1,077 2,382 2,671 2,100 2,003 796 2,091 1,914 1,639 1,568 2,071 1,821 2,091 1,364 1,495 1,799 1,857 1,606 882 1,527 1,652 1,277 1,367 1,212 1,466 DENIAL MESSAGES 22,646 3,907 3,267 1,541 4,811 3,687 1,576 1,014 2,847 1,566 3,065 1,349 585 694 789 1,007 406 909 846 1,415 1,517 578 246 4,712 842 1,096 695 966 177 290 1,293 508 502 453 988 558 307 441 1,924 394 103 441 533 1,625 312 404 565 621 101 335 61 775 618 191 87 261 972 238 77 386 267 363 57 OVERRIDDEN CLAIMS 28,724 16,591 8,310 1,490 223 8,477 2,017 3,295 21,815 955 28,998 0 0 3,201 1,496 361 311 11,461 1,642 0 1,059 0 200 536 844 2,222 9,500 1,597 341 1,336 1,542 770 1,384 601 3,583 2,010 1,535 344 2,254 1,578 151 5,968 572 327 2,336 492 536 764 91 437 71 569 306 173 47 618 268 2,976 98 262 415 849 43 TOTAL CLAIMS 1,250,585 525,789 695,874 138,003 12,470 200,107 231,387 306,981 767,967 78,047 378,799 13 256 220,971 227,566 16,280 28,015 123,138 231,563 268 145,545 0 37,420 15,923 114,460 336,282 96,892 150,301 40,630 171,858 182,512 76,201 232,002 84,959 77,870 107,540 150,295 54,098 223,394 138,365 10,999 198,494 18,340 14,944 378,145 75,439 12,521 76,702 11,041 52,394 19,557 89,574 12,947 23,571 12,317 43,565 5,736 497,998 17,329 17,972 45,059 18,843 7,660 11/14/06 PAGE 10

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 38 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: HIGH DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME Q6I C1A H6A W1D D4N C3B J9A J1B H0E M9P D7A C6H B3Q D9A J2B C4N W3B W7L B4C C1F Q6G W1B J7C B3T H3T A1A M9S Z2N Q5H R1M C6Z S2A W5A Z4B H2A J2A C6F B3R V1E P5S R5B W1K W5B N1B J2D D4B F1A H2M B3A W5G Q9B B4W W1G W2A R1E J3A A4A P2B S2J R1F W7C B4Q EYE ANTIBIOTIC CORTI ELECTROLYTE DEPLETER ANTIPARKINSONISM DRU MACROLIDES ANTIFLATULENTS IRON REPLACEMENT INTESTINAL MOTILITY CHOLINESTERASE INHIB AGENTS TO TREAT MULT PLATELET AGGREGATION BILE SALTS PEDIATRIC VITAMIN PR NARC ANTITUSS-1ST GE AMMONIA INHIBITORS ANTICHOLINERGICS, QU INSULIN ENHANCER ANTIFUNGAL AGENTS GRAM POSITIVE COCCI NARC ANTITUSS-ANTICH CALCIUM REPLACEMENT MIOTICS AND OTHER IN CEPHALOSPORINS BETA ADRENERGIC BLOC NON-NARC ANTITUSS-EX NARCOTIC ANTAGONISTS DIGITALIS GLYCOSIDES HEMORRHEOLOGIC AGENT 1ST GEN ANTIHIST-DEC TOPICAL LOCAL ANESTH LOOP DIURETICS MISCELLANEOUS MULTIV COLCHICINE ANTIVIRALS LEUKOTRIENE RECEPTOR CENTRAL NERVOUS SYST BELLADONNA ALKALOIDS PRENATAL VITAMIN PRE NONARC ANTITUSS-1G A STEROID ANTINEOPLAST MINERALOCORTICOIDS URINARY TRACT ANALGE LINCOSAMIDES ANTIVIRALS, HIV-SPEC HEMATINICS, OTHER ANTICHOLINERGICS, AN ANTACIDS ANDROGENIC AGENTS ANTI-MANIA DRUGS MUCOLYTICS HEPATITIS C TREATMEN BPH DECON-EXP ANTITUBERCULAR ANTIB ABSORBABLE SULFONAMI CARBONIC ANHYDRASE I GANGLIONIC STIMULANT HYPOTENSIVES VASODIL ANTIDIURETIC AND VAS NOT ENTERED TUMOR NECROSIS INHIB THIAZIDE DIURETICS A INFLUENZA VIRUS VACC NARC ANTITUS-DECON-E TOTAL MESSAGES 1,436 1,421 1,409 1,408 1,376 1,274 1,260 1,245 1,211 1,201 1,127 1,048 1,036 1,029 974 926 883 830 802 777 768 757 740 687 681 670 661 629 575 566 561 559 552 541 540 540 516 513 450 435 424 396 394 393 391 384 365 360 352 350 346 335 319 304 294 272 268 255 253 251 242 240 218 PAID MESSAGES 1,221 1,340 1,181 895 1,193 917 1,084 924 965 1,056 851 1,002 1,001 880 592 844 731 810 725 733 0 374 519 648 413 500 634 538 501 466 311 445 483 464 481 484 292 481 354 346 401 348 360 92 380 314 297 248 284 209 300 298 199 174 227 224 256 200 118 183 154 240 211 DENIAL MESSAGES 215 81 228 513 183 357 176 321 246 145 276 46 35 149 382 82 152 20 77 44 768 383 221 39 268 170 27 91 74 100 250 114 69 77 59 56 224 32 96 89 23 48 34 301 11 70 68 112 68 141 46 37 120 130 67 48 12 55 135 68 88 0 7 OVERRIDDEN CLAIMS 46 263 817 976 164 716 376 364 178 603 140 169 51 183 318 489 516 8 50 887 388 0 2,791 87 75 354 31 313 155 2,306 57 88 407 289 36 72 205 43 16 52 13 1,161 0 194 58 310 59 1,980 84 209 224 65 222 390 39 3 91 118 91,277 95 939 9 7 TOTAL CLAIMS 7,593 19,933 54,408 106,483 12,487 89,754 52,845 39,965 7,841 84,919 3,446 15,507 4,892 14,923 4,036 88,458 50,279 1,285 3,363 92,745 62,808 0 349,306 21,855 1,279 47,533 4,299 17,195 23,694 203,186 14,586 9,852 37,861 66,387 649 12,205 76,588 6,886 2,069 3,254 1,111 23,214 0 8,425 15,346 45,569 5,287 49,974 2,706 10,972 35,622 11,816 2,595 70,132 2,591 3,998 9,443 8,302 3,140,038 10,477 173,287 7,114 1,188 11/14/06 PAGE 11

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 39 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: HIGH DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME S2I Q4F V1F W2G A2A R1S C6B Q3A W1C J8A Z2G W4A C7A W2E V1B V1J H0A F2A Z2F J1A Z2O W4E C6M Z2E C1W R1H P1F W1J P3L Q6P W1S C6C G2A W2F H2D D7L R1L C4M C6T C7E A4Y C3M P1B C6D W1F D4F R1R D8A W4K M9F C0D C6K C1P Q4K A7C H2K C8A H2H W5F Q6J J7B P0A J5H PYRIMIDINE SYNTH INH VAGINAL ANTIFUNGALS MISC ANTINEOPLASTICS MISC ANTIBACTERIAL C ANTIARRHYTHMICS URINARY PH MODIFIERS VITAMIN B PREPARATIO RECTAL PREPARATIONS TETRACYCLINES ANOREXIC AGENTS IMMUNOMODULATORS ANTIMALARIAL DRUGS PURINE INHIBITORS ANTITUBERCULAR AGENT ANTIMETABOLITES ANTIANDROGENIC AGENT LOCAL ANESTHETICS DRUGS TO TREAT IMPOT CHROMOLYN AND DERIVA PARASYMPATHETIC AGEN 2ND GEN ANTIHIST-DEC TRICHOMONACIDES FOLIC ACID PREPARATI IMMUNOSUPPRESSIVES ELECTROLYTE REPLACEM POTASSIUM SPARING DI PITUITARY SUPPRESSIV VANCOMYCIN AND DERIV ANTITHYROID PREPARAT EYE ANTIINFLAMMATORY THIENAMYCINS VITAMIN C PREPARATIO PROGESTATIONAL AGENT NITROFURAN DERIVATIV BARBITURATES BILE SALT INHIBITORS DIURETICS, THIAZIDE HYPOGLYC;ALPHA-GLUCO VITAMIN B1 PREPARATI APPETITE STIMULANTS HYPOTENSIVES MISCELL MISCELLANEOUS MINERA SOMATOSTATIC AGENTS VITAMIN D PREPARATIO AMINOGLYCOSIDES ANTIULCER H.PYLORI A URICOSURIC AGENTS PANCREATIC ENZYMES MISC ANTIPROTOZOAL D THROMBOLYTIC ENZYMES ANTIALCOHOLIC PREPAR VITAMIN K PREPARATIO PHOSPHATE REPLACEMEN VAGINAL ESTROGEN PERIPHERAL VASODILAT ANTIDEPRESSANTS COMB METALLIC POISON ANTI MONOAMINEOXIDASE (MA HEPATITIS B TREATMEN MYDRIATICS ALPHA ADRENERGIC BLO FERTILITY PREPARATIO ADRENERGIC VASOPRESS TOTAL MESSAGES 211 203 203 201 195 194 190 189 186 182 177 173 167 165 164 158 157 154 151 150 148 146 139 138 137 137 131 131 130 130 124 116 115 107 106 100 91 90 90 86 85 80 71 66 60 59 57 56 56 54 52 50 45 45 41 40 39 36 36 34 32 30 27 PAID MESSAGES 116 63 47 117 174 163 162 164 98 155 91 121 157 108 73 50 120 95 147 143 144 94 93 112 127 119 89 14 114 0 55 96 84 58 68 80 55 84 47 77 76 74 61 52 51 54 51 0 49 29 32 14 45 8 40 37 39 35 29 0 29 27 26 DENIAL MESSAGES 95 140 156 84 21 31 28 25 88 27 86 52 10 57 91 108 37 59 4 7 4 52 46 26 10 18 42 117 16 130 69 20 31 49 38 20 36 6 43 9 9 6 10 14 9 5 6 56 7 25 20 36 0 37 1 3 0 1 7 34 3 3 1 OVERRIDDEN CLAIMS 83 279 44 13 118 69 253 21 376 0 46 239 171 2,101 219 59 116 29 6 24 48 297 293 835 30 398 16 66 49 93 48 166 145 158 214 32 322 22 2 15 19 2 5 163 34 7 1 71 0 7 131 35 10 37 2 0 0 3 13 13 368 0 10 TOTAL CLAIMS 3,274 18,245 7,636 3,436 11,436 3,953 25,827 13,394 43,614 1,030 1,945 48,556 25,079 6,090 15,394 835 11,807 3,498 1,482 2,976 5,611 21,769 42,385 20,998 5,298 38,897 1,357 3,840 4,058 17,150 753 21,301 14,247 32,601 17,447 5,042 48,876 2,459 1,258 1,299 5,997 340 315 17,754 2,627 1,270 1,158 11,159 327 150 3,470 1,614 1,399 7,189 146 0 328 31 1,532 2,745 42,759 183 1,203 11/14/06 PAGE 12

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 40 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: HIGH DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME FAT ABS DEC AGT VITAMIN A PREPARATIO EYE ANTIHISTAMINES HYPERTRICHOTIC AGNTS ANTISPASMODIC AGENTS SODIUM REPLACEMENT IODINE REPLACEMENT NIACIN PREPARATIONS EYE ANTIBIOTICS ANTIPSORIATIC AGENTS OXABETA LACTAMS ZINC REPLACEMENT METABOLIC DEFICIENCY ARTIFICIAL TEARS EXP COMBO OTHER ANTIPARASITICS FLUORIDE PREPARATION TOPICAL HYPERPIGMENT ANTHELMINTICS TOXIN PRODUCING BACT AMYOTROP LATERAL SCL VEHICLES MISCELLANEOUS FOOD S ADRENOCORTICOTROPHIC 1STGEN ANTIHIST-DECO HYPERGLYCEMICS VAGINAL ANTIBIOTICS GRAM NEGATIVE COCCI ANTIGENIC SKIN TESTS OXYTOCICS EYE PREPS, MISC (RX EYE VASOCONSTRICTRS( GOLD SALTS ALKYLATING AGENTS MISC ANTIINFECTIVES VIRAL VACCINES NON-NARC ANTITUSS-DE ESTROGEN/ANDROGEN CO CONTRACEPTIVES, INJE ANTILEPROTICS NARC ANTITUSS-1G AH1ST GN ANTIHIST-ANAL MISCELLANEOUS ANTIDO TOPICAL SULFONAMIDES DECON-NSAID,COX NONBICARBONATE PRODUCIN INTESTINAL ADSORBENT ANAPHYLAX THERAPY AG VAGINAL SULFONAMIDES EYE SULFONAMIDES EYE ANTIVIRALS EAR PREPS LOCAL ANES AMEBACIDES TOTAL MESSAGES 26 25 24 22 21 20 20 19 19 18 15 14 14 14 13 13 11 11 11 11 10 10 9 9 8 7 7 6 6 5 5 4 4 4 4 4 3 3 3 3 2 2 2 2 1 1 1 1 1 1 1 1 1 626,604 PAID MESSAGES 21 13 0 10 17 15 17 19 0 18 7 12 14 0 10 13 2 6 3 10 7 10 0 7 8 5 5 6 0 5 0 0 1 0 4 4 1 3 0 3 0 2 0 1 0 1 1 1 1 0 0 0 0 529,703 DENIAL MESSAGES 5 12 24 12 4 5 3 0 19 0 8 2 0 14 3 0 9 5 8 1 3 0 9 2 0 2 2 0 6 0 5 4 3 4 0 0 2 0 3 0 2 0 2 1 1 0 0 0 0 1 1 1 1 96,901 OVERRIDDEN CLAIMS 0 1 89 0 11 21 2 51 112 6 2 8 15 264 0 0 3,518 0 13 0 3 18 0 3 3 19 104 0 2 16 10 4 2 50 0 0 0 0 56 19 0 9 0 95 0 15 0 30 0 13 2 71 0 316,701 TOTAL CLAIMS 328 112 19,871 41 337 5,080 292 3,697 36,478 636 71 2,625 2,104 39,793 68 112 50,054 24 1,825 6 210 2,399 2,305 78 109 3,886 6,740 23 17 2,304 1,501 841 75 3,328 26 884 268 627 6,654 2,428 2 1,211 8 8,117 30 775 72 6,800 4 5,312 352 6,390 16 15,774,829 11/14/06 PAGE 13

D5A C6A Q6R L1C J9B C1B C3H C6N Q6W L1A W1P C3C C7D Q6T B4X W4M D2A L9D W4L W7N H6I U6N C5F P1E B3X M4G Q4W W7Q W7T G3A Q6A Q6C S2C V1A W2Y W7B B4R G1B G8C W4P B4H B5S C8E Q5S B5G C0K D5P J5F Q4S Q6S Q6V Q8H W4C

HIGH DOSE ALERT SUM

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 41 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: INGREDIENT DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME H3A D4K Z2P Z2Q Q5F H6J A1D B3K H6A R1A J5D H3F C6F H2E Z2N Z2A R1L B4S Q7E Q6T C6B Z2O B4D S2B B3J Q5W G8A A4F Q5P C1F B4W D6S J5G Q7P Q5R Q6I B3T H3E B3Q L2A Q4F Q6W D4F H3D B3R W1A A4Y D8A W2A B4E C1A A4D Q7A C6H Q5H Q9B B5S C3B Q3S W5G B4C D6D U6W NARCOTIC ANALGESICS GASTRIC ACID SECRETI 1ST GEN ANTIHISTAMIN 2ND GEN ANTIHISTAMIN TOPICAL ANTIFUNGALS ANTI-EMETICS BRONCHODIALATORS COUGH COLD PREPARATI ANTIPARKINSONISM DRU URINARY TRACT ANTISP BETA-ADRENERGIC AGEN ANTIMIGRAINE PREPARA PRENATAL VITAMIN PRE NON-BARBITURATE, SED 1ST GEN ANTIHIST-DEC ANTIHISTAMINES DIURETICS, THIAZIDE NARC ANTITUSS-EXP NOSE PREPS ANTIHISTA ARTIFICIAL TEARS VITAMIN B PREPARATIO 2ND GEN ANTIHIST-DEC NARC ANTITUSS-1ST GE ANTI-INFLAMMATORY AG EXPECTORANTS TOPICAL ANTIBIOTICS CONTRACEPTIVES, ORAL HYPOTEN ANGIOTEN REC TOPICAL ANTI FLAMMAT CALCIUM REPLACEMENT DECON-EXP LAXATIVES AND CATHAR BETA-ADRENERGICS GLU NOSE PREPS ANTIINFLA TOPICAL ANTIPARASITI EYE ANTIBIOTIC CORTI NON-NARC ANTITUSS-EX ANALGESIC/ANTIPYRETI NARC ANTITUSS-1ST GE EMOLLIENTS VAGINAL ANTIFUNGALS EYE ANTIBIOTICS ANTIULCER H.PYLORI A SALICYLATE ANALGESIC NONARC ANTITUSS-1G A PENICILLINS HYPOTENSIVES MISCELL PANCREATIC ENZYMES ABSORBABLE SULFONAMI NON-NARC ANTITUS-1G ELECTROLYTE DEPLETER HYPOTENSIVES ANGIOTE NOSE PREPS MISC RX O PEDIATRIC VITAMIN PR TOPICAL LOCAL ANESTH BPH 1ST GN ANTIHIST-ANAL IRON REPLACEMENT LAXATIVES, LOCAL/REC HEPATITIS C TREATMEN NARC ANTITUSS-ANTICH ANTIDIARRHEALS BULK CHEMICALS TOTAL MESSAGES 86,465 23,685 22,205 16,305 9,623 8,202 7,077 2,902 2,885 2,863 2,661 2,607 2,078 1,989 1,793 1,394 1,342 1,340 1,263 1,166 1,061 905 892 857 827 824 764 729 712 653 578 539 514 513 482 448 442 428 369 354 354 353 326 321 320 301 300 292 292 276 275 270 264 235 230 201 200 193 193 144 140 127 118 PAID MESSAGES 85,125 23,509 22,136 16,084 9,586 8,099 7,039 2,877 2,731 2,856 2,257 2,488 2,052 842 1,789 1,379 1,342 1,331 1,263 1,166 1,059 904 865 343 822 824 733 729 13 651 576 538 2 3 479 428 442 407 368 354 347 353 325 315 313 299 300 291 291 276 275 270 264 235 229 201 200 187 190 136 138 127 118 DENIAL MESSAGES 1,340 176 69 221 37 103 38 25 154 7 404 119 26 1,147 4 15 0 9 0 0 2 1 27 514 5 0 31 0 699 2 2 1 512 510 3 20 0 21 1 0 7 0 1 6 7 2 0 1 1 0 0 0 0 0 1 0 0 6 3 8 2 0 0 OVERRIDDEN CLAIMS 28,724 8,310 3,201 2,254 958 955 437 0 817 770 2,222 344 205 8,477 313 0 322 341 26 264 253 48 311 16,591 173 368 1,059 1,535 954 887 65 3,295 492 409 849 46 87 1,490 51 131 279 112 7 1,384 43 5,968 19 71 390 43 263 2,336 12 169 155 224 9 716 306 209 50 200 47 TOTAL CLAIMS 1,250,585 695,874 220,971 223,394 116,702 78,047 52,394 256 54,408 76,201 336,282 54,098 76,588 200,107 17,195 268 48,876 40,630 3,519 39,793 25,827 5,611 28,015 525,789 23,571 54,077 145,545 150,295 142,291 92,745 11,816 306,981 75,439 111,558 18,843 7,593 21,855 138,003 4,892 26,926 18,245 36,478 1,270 232,002 6,886 198,494 5,997 11,159 70,132 7,660 19,933 378,145 2,344 15,507 23,694 35,622 1,211 89,754 12,947 10,972 3,363 37,420 2,668 11/14/06 PAGE 14

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 42 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: INGREDIENT DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME Q4K D4B D7L Q5A Q8F D1D G1A Q6P M9P L0B Q8W C4K Q5S C4N Q3D Q6S B4Q L5H Q6R Q6Y C6M J2A W1J B3X Q6G R1S D4E L1B Q5V Q6D G8C L3A W2G J5H L5A Q3A J2B C1D H2K Q5B H0E W1Q W4P B4L R5A F2A Q7D C7D M4G W1S A4B C6Z J9B M4E B4R Q8B C6G D4G Q6J Q6V W5B W8H B3P VAGINAL ESTROGEN ANTACIDS BILE SALT INHIBITORS TOPICAL PREPARATIONS EAR PREPS ANTIBIOTIC DENTAL AIDS AND PREP ESTROGENIC AGENTS EYE ANTIINFLAMMATORY PLATELET AGGREGATION TOPICAL/MUCOUS MEMBR EAR PREPS ANTIBIOTIC ORAL HYPOGLYCEMIC AG TOPICAL SULFONAMIDES INSULIN ENHANCER HEMORRHOIDAL PREPARA EYE SULFONAMIDES NARC ANTITUS-DECON-E ACNE AGENTS, TOPICAL EYE ANTIHISTAMINES EYE PREPARATIONS, MI FOLIC ACID PREPARATI BELLADONNA ALKALOIDS VANCOMYCIN AND DERIV 1STGEN ANTIHIST-DECO MIOTICS AND OTHER IN URINARY PH MODIFIERS ANTIULCER PREPARATIO ACNE AGENTS, SYSTEMI TOPICAL ANTIVIRALS EYE VASOCONSTRITRS ( CONTRACEPTIVES, INJE PROTECTIVES MISC ANTIBACTERIAL C ADRENERGIC VASOPRESS KERATOLYTICS RECTAL PREPARATIONS ANTICHOLINERGICS, QU POTASSIUM REPLACEMEN ANTIDEPRESSANTS COMB TOPICAL ANTIBACTERIA AGENTS TO TREAT MULT QUINOLONES ANTILEPROTICS NON-NARC ANTITUSS-DE URINARY TRACT ANEST DRUGS TO TREAT IMPOT NOSE PREPS VASOCONST METABOLIC DEFICIENCY HYPERGLYCEMICS THIENAMYCINS HYPOTENSIVES SYMPATH MISCELLANEOUS MULTIV ANTISPASMODIC AGENTS LIPOTROPICS NON-NARC ANTITUSS-DE EAR PREPS MISC ANTII GERIATRIC VITAMIN PR GASTRIC ENZYMES MYDRIATICS EYE ANTIVIRALS ANTIVIRALS, HIV-SPEC MOUTHWASHES NONARC ANTITUS-1G AH TOTAL MESSAGES 103 101 95 90 90 89 88 78 77 73 68 67 66 63 62 62 58 55 53 51 46 44 39 36 35 33 28 28 27 27 26 26 26 25 22 22 21 20 20 20 18 17 17 16 15 14 14 12 12 12 11 10 10 10 9 9 8 7 7 7 7 7 6 PAID MESSAGES 103 101 95 90 53 87 88 39 77 73 68 67 66 63 60 61 55 55 52 51 46 44 39 36 13 32 10 28 27 27 26 26 26 25 22 4 21 20 20 20 18 17 17 16 15 7 14 12 12 12 11 10 10 10 9 9 8 7 7 7 7 7 6 DENIAL MESSAGES 0 0 0 0 37 2 0 39 0 0 0 0 0 0 2 1 3 0 1 0 0 0 0 0 22 1 18 0 0 0 0 0 0 0 0 18 0 0 0 0 0 0 0 0 0 7 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 OVERRIDDEN CLAIMS 37 310 32 3 268 361 569 93 603 32 37 1,578 95 489 2 13 7 17 89 28 293 72 66 3 388 69 223 12 67 2 56 1 13 10 68 21 318 1,597 0 37 178 764 19 1 47 29 2 15 19 48 3,583 57 11 2,976 0 5 0 0 13 2 0 0 0 TOTAL CLAIMS 7,189 45,569 5,042 1,104 5,736 16,280 89,574 17,150 84,919 5,851 16,484 138,365 8,117 88,458 1,906 5,312 1,188 4,242 19,871 3,635 42,385 12,205 3,840 109 62,808 3,953 12,470 1,235 4,753 1,210 6,654 1,677 3,436 1,203 9,911 13,394 4,036 150,301 0 3,332 7,841 76,702 2,428 737 12,317 3,498 2,090 2,104 3,886 753 77,870 14,586 337 497,998 268 1,483 801 309 2,745 352 0 63 48 11/14/06 PAGE 15

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 43 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: INGREDIENT DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME W1B W1K A4A Q5N C7E W5C H6H L9B Q3H Q5X Q8H B3O B4M B4X C5F H3H L5E Q7Y W1F W4E X1C H0A H4B J3A L1A M0E Q4W Q6C U6N W1G W5F W8F CEPHALOSPORINS LINCOSAMIDES HYPOTENSIVES VASODIL TOPICAL ANTINEOPLAST APPETITE STIMULANTS ANTIVIR,HIV,PROTEASE SKELETAL MUSCLE RELA VITAMIN A DERIVATIVE HEMORRHOID PREP, LOC TOPICAL ANTIBIO/INFL EAR PREPS LOCAL ANES 1ST GEN ANTIHIST-DEC NON-NARC ANTITUSS-DE EXP COMBO OTHER MISCELLANEOUS FOOD S ANALGESICS ANESTHETI ANTISEBORRHEIC AGENT NOSE PREPS MISC OTC AMINOGLYCOSIDES TRICHOMONACIDES IUD LOCAL ANESTHETICS ANTICONVULSANTS GANGLIONIC STIMULANT ANTIPSORIATIC AGENTS ANTIHEMOPHILIC FACTO VAGINAL ANTIBIOTICS EYE VASOCONSTRICTRS( VEHICLES ANTITUBERCULAR ANTIB HEPATITIS B TREATMEN IRRIGANTS TOTAL MESSAGES 6 6 5 5 4 4 3 3 3 3 3 2 2 2 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 220,852 PAID MESSAGES 6 6 5 5 4 4 3 3 3 2 3 2 2 1 2 2 2 2 2 2 2 1 1 1 1 1 1 1 1 1 1 1 214,409 DENIAL MESSAGES 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 6,443 OVERRIDDEN CLAIMS 0 1,161 91 0 15 151 2,017 24 1 0 71 0 0 0 0 0 19 0 34 297 4 116 21,815 3 6 18 104 4 18 222 13 61 143,059 TOTAL CLAIMS 0 23,214 9,443 409 1,299 10,999 231,387 7,391 184 218 6,390 17 48 68 2,305 45 4,931 3,028 2,627 21,769 488 11,807 767,967 3,998 636 522 6,740 841 2,399 2,595 1,532 4,030 9,469,210 11/14/06 PAGE 16

INGREDIENT DUPLICATION SUM

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 44 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: LOW DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME R1A H4B D4K Z2Q A9A R1M W5C H6H H2E J7B R1L C4N Z2P H0A A4D H2J H2F D4E Z2N A4B M9L B4S J9A H3A S2B S2J H6A B3T W5G F2A Q6I H2L C4L H3F Q6G J5F M4E D7L R1F H2M J7C Z4B G1A P5A J2B C4M B4D C6L C7D D1D A7B W2A W3B J5H H2G A1A J5G W1A P4L W3A W5A W1D URINARY TRACT ANTISP ANTICONVULSANTS GASTRIC ACID SECRETI 2ND GEN ANTIHISTAMIN CALCIUM CHANNEL BLOC LOOP DIURETICS ANTIVIR,HIV,PROTEASE SKELETAL MUSCLE RELA NON-BARBITURATE, SED ALPHA ADRENERGIC BLO DIURETICS, THIAZIDE INSULIN ENHANCER 1ST GEN ANTIHISTAMIN LOCAL ANESTHETICS HYPOTENSIVES ANGIOTE ANTIDEPRESSANTS ANTI-ANXIETY DRUGS ANTIULCER PREPARATIO 1ST GEN ANTIHIST-DEC HYPOTENSIVES SYMPATH ORAL ANTICOAGULANTS, NARC ANTITUSS-EXP INTESTINAL MOTILITY NARCOTIC ANALGESICS ANTI-INFLAMMATORY AG TUMOR NECROSIS INHIB ANTIPARKINSONISM DRU NON-NARC ANTITUSS-EX HEPATITIS C TREATMEN DRUGS TO TREAT IMPOT EYE ANTIBIOTIC CORTI ANTIPSYCHOTICS, NONORAL HYPOGLYCEMIC AG ANTIMIGRAINE PREPARA MIOTICS AND OTHER IN ANAPHYLAX THERAPY AG LIPOTROPICS BILE SALT INHIBITORS THIAZIDE DIURETICS A ANTI-MANIA DRUGS BETA ADRENERGIC BLOC LEUKOTRIENE RECEPTOR ESTROGENIC AGENTS GLUCOCORTICOIDS ANTICHOLINERGICS, QU HYPOGLYC;ALPHA-GLUCO NARC ANTITUSS-1ST GE VITAMIN B12 PREPARAT METABOLIC DEFICIENCY DENTAL AIDS AND PREP CORONARY VASODILATOR ABSORBABLE SULFONAMI NOT ENTERED ANTIFUNGAL AGENTS ADRENERGIC VASOPRESS ANTI-PSYCHOTICS,PHEN DIGITALIS GLYCOSIDES BETA-ADRENERGICS GLU PENICILLINS BONE RESORBTION SUPP ANTIFUNGAL ANTIBIOTI ANTIVIRALS MACROLIDES TOTAL MESSAGES 15,930 12,990 12,406 11,215 11,156 9,186 7,018 6,607 5,562 4,908 4,622 4,081 3,332 3,038 3,018 2,773 2,445 2,389 2,367 2,264 1,929 1,819 1,655 1,530 1,436 1,417 1,393 1,338 1,314 1,288 1,226 1,161 1,096 1,050 1,004 920 909 847 822 802 733 594 566 531 528 508 502 496 455 449 429 407 403 387 382 354 350 327 310 294 281 281 279 PAID MESSAGES 15,591 0 12,122 11,095 10,892 8,930 6,981 0 0 4,842 4,567 4,035 3,280 3,013 2,966 0 0 0 2,365 0 0 1,801 0 0 0 1,395 0 1,335 1,298 1,288 1,213 0 0 0 0 918 0 828 0 0 0 579 0 0 516 503 494 0 432 433 0 0 403 1 377 0 0 320 0 0 0 0 0 DENIAL MESSAGES 339 12,990 284 120 264 256 37 6,607 5,562 66 55 46 52 25 52 2,773 2,445 2,389 2 2,264 1,929 18 1,655 1,530 1,436 22 1,393 3 16 0 13 1,161 1,096 1,050 1,004 2 909 19 822 802 733 15 566 531 12 5 8 496 23 16 429 407 0 386 5 354 350 7 310 294 281 281 279 OVERRIDDEN CLAIMS 770 21,815 8,310 2,254 1,496 2,306 151 2,017 8,477 368 322 489 3,201 116 2,336 0 28,998 223 313 3,583 2,010 341 376 28,724 16,591 95 817 87 209 29 46 0 1,336 344 388 30 2,976 32 939 1,980 2,791 289 569 1,542 318 22 311 536 15 361 601 390 91,277 516 10 262 354 492 5,968 844 572 407 976 TOTAL CLAIMS 76,201 767,967 695,874 223,394 227,566 203,186 10,999 231,387 200,107 42,759 48,876 88,458 220,971 11,807 378,145 13 378,799 12,470 17,195 77,870 107,540 40,630 52,845 1,250,585 525,789 10,477 54,408 21,855 10,972 3,498 7,593 0 171,858 54,098 62,808 6,800 497,998 5,042 173,287 49,974 349,306 66,387 89,574 182,512 4,036 2,459 28,015 15,923 2,104 16,280 84,959 70,132 3,140,038 50,279 1,203 17,972 47,533 75,439 198,494 114,460 18,340 37,861 106,483 11/14/06 PAGE 17

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 45 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: LOW DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME J7A A1B H3D B3R Q6P Z2A J5D A2A H2V H0E Q9B C6K W2F G2A Z2E P3A C6D R1H W1Q A4F S2I M9P H6J C1D C4K N1D B3Q H6B G8A H3E W1B B3J D5A C1A B4Q G8C D6S A4A B4E J1A W2G M9S R5B C6Z V1B W5B D9A J1B W1C L1A Q6W U6N C7A Q6R D8A Q3S Q8F B3K B4C D6D N1B W1F W5F ALPHA-BETA ADRENERGI XANTHINES SALICYLATE ANALGESIC NONARC ANTITUSS-1G A EYE ANTIINFLAMMATORY ANTIHISTAMINES BETA-ADRENERGIC AGEN ANTIARRHYTHMICS ANTI-NARCOLEPSY/ANTI AGENTS TO TREAT MULT BPH VITAMIN K PREPARATIO NITROFURAN DERIVATIV PROGESTATIONAL AGENT IMMUNOSUPPRESSIVES THYROID HORMONES VITAMIN D PREPARATIO POTASSIUM SPARING DI QUINOLONES HYPOTEN ANGIOTEN REC PYRIMIDINE SYNTH INH PLATELET AGGREGATION ANTI-EMETICS POTASSIUM REPLACEMEN ORAL HYPOGLYCEMIC AG PLATELET REDUCING AG NARC ANTITUSS-1ST GE ANTIPARKINSONISM DRU CONTRACEPTIVES, ORAL ANALGESIC/ANTIPYRETI CEPHALOSPORINS EXPECTORANTS FAT ABS DEC AGT ELECTROLYTE DEPLETER NARC ANTITUS-DECON-E CONTRACEPTIVES, INJE LAXATIVES AND CATHAR HYPOTENSIVES VASODIL NON-NARC ANTITUS-1G PARASYMPATHETIC AGEN MISC ANTIBACTERIAL C HEMORRHEOLOGIC AGENT URINARY TRACT ANALGE MISCELLANEOUS MULTIV ANTIMETABOLITES ANTIVIRALS, HIV-SPEC AMMONIA INHIBITORS CHOLINESTERASE INHIB TETRACYCLINES ANTIPSORIATIC AGENTS EYE ANTIBIOTICS VEHICLES PURINE INHIBITORS EYE ANTIHISTAMINES PANCREATIC ENZYMES LAXATIVES, LOCAL/REC EAR PREPS ANTIBIOTIC COUGH COLD PREPARATI NARC ANTITUSS-ANTICH ANTIDIARRHEALS HEMATINICS, OTHER AMINOGLYCOSIDES HEPATITIS B TREATMEN TOTAL MESSAGES 271 266 265 253 253 240 239 235 233 221 212 204 198 197 194 180 179 170 169 165 164 162 158 153 150 148 145 142 128 111 101 89 79 74 70 70 69 68 68 68 68 66 66 58 55 55 52 51 51 49 49 49 44 44 43 43 38 37 37 37 37 36 35 PAID MESSAGES 0 0 0 253 0 0 0 0 0 217 209 196 0 0 0 0 0 0 0 0 161 0 0 0 0 145 143 0 0 0 0 0 79 0 70 0 0 0 67 0 0 0 66 56 0 0 0 0 0 48 0 48 0 0 0 0 38 0 36 0 0 0 35 DENIAL MESSAGES 271 266 265 0 253 240 239 235 233 4 3 8 198 197 194 180 179 170 169 165 3 162 158 153 150 3 2 142 128 111 101 89 0 74 0 70 69 68 1 68 68 66 0 2 55 55 52 51 51 1 49 1 44 44 43 43 0 37 1 37 37 36 0 OVERRIDDEN CLAIMS 618 91 1,384 43 93 0 2,222 118 11,461 178 224 35 158 145 835 1,642 163 398 764 1,535 83 603 955 1,597 1,578 3 51 415 1,059 1,490 0 173 0 263 7 56 3,295 91 43 24 13 31 13 57 219 0 183 364 376 6 112 18 171 89 71 306 268 0 50 200 194 34 13 TOTAL CLAIMS 43,565 11,041 232,002 6,886 17,150 268 336,282 11,436 123,138 7,841 35,622 1,614 32,601 14,247 20,998 231,563 17,754 38,897 76,702 150,295 3,274 84,919 78,047 150,301 138,365 334 4,892 45,059 145,545 138,003 0 23,571 328 19,933 1,188 6,654 306,981 9,443 7,660 2,976 3,436 4,299 1,111 14,586 15,394 0 14,923 39,965 43,614 636 36,478 2,399 25,079 19,871 11,159 12,947 5,736 256 3,363 37,420 8,425 2,627 1,532 11/14/06 PAGE 18

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 46 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: LOW DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME C3B R5A V1F C1W C6F Q5R Z2G C1F R1S C6M V1J W2E S2A Q6J B4W H2D W1G C1P W4E C3M H6I H2A P3L V1E W4A J5B C3C W4P A7C Q6S D7A M9K P2B W1K A1D A4Y C0D H2H Q3A Q5H R1E B4L D4F Q8W W1J B3A D4B Z2O C8A J2D P5S C5F W4L C1H D4N H3T J2A J5E P1B P1F Q4K W4K IRON REPLACEMENT URINARY TRACT ANEST MISC ANTINEOPLASTICS ELECTROLYTE REPLACEM PRENATAL VITAMIN PRE TOPICAL ANTIPARASITI IMMUNOMODULATORS CALCIUM REPLACEMENT URINARY PH MODIFIERS FOLIC ACID PREPARATI ANTIANDROGENIC AGENT ANTITUBERCULAR AGENT COLCHICINE MYDRIATICS DECON-EXP BARBITURATES ANTITUBERCULAR ANTIB PHOSPHATE REPLACEMEN TRICHOMONACIDES MISCELLANEOUS MINERA AMYOTROP LATERAL SCL CENTRAL NERVOUS SYST ANTITHYROID PREPARAT STEROID ANTINEOPLAST ANTIMALARIAL DRUGS ADRENERGIC AGENTS, A ZINC REPLACEMENT ANTILEPROTICS PERIPHERAL VASODILAT EYE SULFONAMIDES BILE SALTS HEPARIN PREPARATIONS ANTIDIURETIC AND VAS LINCOSAMIDES BRONCHODIALATORS HYPOTENSIVES MISCELL ANTIALCOHOLIC PREPAR MONOAMINEOXIDASE (MA RECTAL PREPARATIONS TOPICAL LOCAL ANESTH CARBONIC ANHYDRASE I NON-NARC ANTITUSS-DE ANTIULCER H.PYLORI A EAR PREPS ANTIBIOTIC VANCOMYCIN AND DERIV MUCOLYTICS ANTACIDS 2ND GEN ANTIHIST-DEC METALLIC POISON ANTI ANTICHOLINERGICS, AN MINERALOCORTICOIDS MISCELLANEOUS FOOD S ANTHELMINTICS MAGNESIUM REPLACEMEN ANTIFLATULENTS NARCOTIC ANTAGONISTS BELLADONNA ALKALOIDS SYMPATHOMIMETIC AGEN SOMATOSTATIC AGENTS PITUITARY SUPPRESSIV VAGINAL ESTROGEN MISC ANTIPROTOZOAL D TOTAL MESSAGES 33 33 33 31 31 30 30 29 28 27 27 27 24 23 22 22 22 21 21 19 19 18 18 18 17 13 12 12 11 11 10 10 10 10 8 8 8 8 8 8 8 7 7 7 7 6 6 6 5 5 5 4 4 3 3 3 3 3 3 3 3 3 PAID MESSAGES 0 33 0 0 0 0 0 0 0 0 27 0 0 0 22 0 0 21 0 0 19 18 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 7 0 0 0 0 6 5 0 0 4 0 0 0 0 0 0 0 0 0 0 DENIAL MESSAGES 33 0 33 31 31 30 30 29 28 27 0 27 24 23 0 22 22 0 21 19 0 0 18 18 17 13 12 12 11 11 10 10 10 10 8 8 8 8 8 8 8 0 0 7 7 6 6 0 0 5 5 0 4 3 3 3 3 3 3 3 3 3 OVERRIDDEN CLAIMS 716 47 44 30 205 849 46 887 69 293 59 2,101 88 13 65 214 222 10 297 2 3 36 49 16 239 9,500 8 19 2 13 140 327 118 1,161 437 19 131 3 21 155 39 1 7 37 66 84 310 48 0 58 52 0 13 536 164 75 72 71 5 16 37 0 TOTAL CLAIMS 89,754 12,317 7,636 5,298 76,588 18,843 1,945 92,745 3,953 42,385 835 6,090 9,852 2,745 11,816 17,447 2,595 1,399 21,769 340 210 649 4,058 2,069 48,556 96,892 2,625 2,428 146 5,312 3,446 14,944 8,302 23,214 52,394 5,997 3,470 31 13,394 23,694 2,591 737 1,270 16,484 3,840 2,706 45,569 5,611 328 15,346 3,254 2,305 1,825 12,521 12,487 1,279 12,205 19,557 315 1,357 7,189 327 11/14/06 PAGE 19

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 47 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: LOW DOSE ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME H2K J9B M4G W1S W7L B3S B3X B4R B5G B5S C7E Q4F Q8B ANTIDEPRESSANTS COMB ANTISPASMODIC AGENTS HYPERGLYCEMICS THIENAMYCINS GRAM POSITIVE COCCI NONARC ANTITUS-1G AH 1STGEN ANTIHIST-DECO NON-NARC ANTITUSS-DE DECON-NSAID,COX NON1ST GN ANTIHIST-ANAL APPETITE STIMULANTS VAGINAL ANTIFUNGALS EAR PREPS MISC ANTII TOTAL MESSAGES 2 2 2 2 2 1 1 1 1 1 1 1 1 170,662 PAID MESSAGES 0 2 0 0 0 1 1 1 1 1 1 0 0 106,857 DENIAL MESSAGES 2 0 2 2 2 0 0 0 0 0 0 1 1 63,805 OVERRIDDEN CLAIMS 0 11 19 48 8 0 3 0 0 9 15 279 5 311,741 TOTAL CLAIMS 0 337 3,886 753 1,285 2 109 268 30 1,211 1,299 18,245 1,483 15,560,715 11/14/06 PAGE 20

LOW DOSE ALERT SUM

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 48 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EXCESSIVE DURATION ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME D4E D6S H2E H2F W4A W2A H6H J9A W1C Q5F W1A W2F Z2A Q5R Q3S M9L H6A C3B D4B Q5W W1D H6J W1Q Q5P C1H W1B M9K H3F W4E Q6W S2B W5A Q4F H3D Q5V R5A Q6S J8A R1A H2J S2A C6K W1F M4G Q6I W1K Q8R Q3A W3B Q6P W2E W2G L3P J5B N1C H2D W1J C1W Q8B H6E Q6J ANTIULCER PREPARATIO LAXATIVES AND CATHAR NON-BARBITURATE, SED ANTI-ANXIETY DRUGS ANTIMALARIAL DRUGS ABSORBABLE SULFONAMI SKELETAL MUSCLE RELA INTESTINAL MOTILITY TETRACYCLINES TOPICAL ANTIFUNGALS PENICILLINS NITROFURAN DERIVATIV ANTIHISTAMINES TOPICAL ANTIPARASITI LAXATIVES, LOCAL/REC ORAL ANTICOAGULANTS, ANTIPARKINSONISM DRU IRON REPLACEMENT ANTACIDS TOPICAL ANTIBIOTICS MACROLIDES ANTI-EMETICS QUINOLONES TOPICAL ANTI FLAMMAT MAGNESIUM REPLACEMEN CEPHALOSPORINS HEPARIN PREPARATIONS ANTIMIGRAINE PREPARA TRICHOMONACIDES EYE ANTIBIOTICS ANTI-INFLAMMATORY AG ANTIVIRALS VAGINAL ANTIFUNGALS SALICYLATE ANALGESIC TOPICAL ANTIVIRALS URINARY TRACT ANEST EYE SULFONAMIDES ANOREXIC AGENTS URINARY TRACT ANTISP ANTIDEPRESSANTS COLCHICINE VITAMIN K PREPARATIO AMINOGLYCOSIDES HYPERGLYCEMICS EYE ANTIBIOTIC CORTI LINCOSAMIDES EAR PREPS EAR WAX RE RECTAL PREPARATIONS ANTIFUNGAL AGENTS EYE ANTIINFLAMMATORY ANTITUBERCULAR AGENT MISC ANTIBACTERIAL C ANTIPRURITICS, TOPIC ADRENERGIC AGENTS, A LEUKOCYTE STIMULANTS BARBITURATES VANCOMYCIN AND DERIV ELECTROLYTE REPLACEM EAR PREPS MISC ANTII EMETICS MYDRIATICS NOT ENTERED W4K MISC ANTIPROTOZOAL D TOTAL MESSAGES 137,253 100,996 50,207 47,749 22,390 15,296 13,843 11,105 10,825 10,807 8,986 6,589 6,580 6,562 5,502 4,984 4,629 4,404 4,378 4,193 4,171 4,125 4,104 3,754 3,622 3,489 2,837 2,637 2,346 2,080 1,992 1,903 1,749 1,385 1,294 1,009 984 956 938 904 838 830 692 617 604 583 572 546 457 380 375 331 322 275 263 243 228 211 178 173 155 140 126 PAID MESSAGES 118,669 98,548 43,654 37,351 21,751 14,850 13,076 9,986 10,600 10,305 8,763 6,439 6,212 6,550 5,448 4,827 4,483 4,219 4,215 4,067 4,071 4,095 3,973 3,585 3,511 3,353 2,658 2,388 2,322 2,020 1,627 1,825 1,716 1,308 1,280 964 967 946 911 1 820 790 659 602 599 558 572 530 421 285 360 292 305 168 254 225 211 210 178 173 118 134 116 DENIAL MESSAGES 18,584 2,448 6,553 10,398 639 446 767 1,119 225 502 223 150 368 12 54 157 146 185 163 126 100 30 131 169 111 136 179 249 24 60 365 78 33 77 14 45 17 10 27 903 18 40 33 15 5 25 0 16 36 95 15 39 17 107 9 18 17 1 0 0 37 6 10 OVERRIDDEN CLAIMS 223 3,295 8,477 28,998 239 390 2,017 376 376 958 5,968 158 0 849 306 2,010 817 716 310 368 976 955 764 954 536 0 327 344 297 112 16,591 407 279 1,384 67 47 13 0 770 0 88 35 34 19 46 1,161 28 21 516 93 2,101 13 11 9,500 13 214 66 30 5 0 13 91,277 0 TOTAL CLAIMS 12,470 306,981 200,107 378,799 48,556 70,132 231,387 52,845 43,614 116,702 198,494 32,601 268 18,843 12,947 107,540 54,408 89,754 45,569 54,077 106,483 78,047 76,702 142,291 12,521 0 14,944 54,098 21,769 36,478 525,789 37,861 18,245 232,002 4,753 12,317 5,312 1,030 76,201 13 9,852 1,614 2,627 3,886 7,593 23,214 3,305 13,394 50,279 17,150 6,090 3,436 1,516 96,892 1,550 17,447 3,840 5,298 1,483 30 2,745 3,140,038 327 11/14/06 PAGE 21

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 49 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: EXCESSIVE DURATION ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME W1P J3A W8F P2B V1A H0A C8A G3A Q7D W4P W3A Q6C H3A Q5B W1S Q6V Q6G Q6A S2H A9A P4L P0A Z3G C6A W4M W7K V1B W1G OXABETA LACTAMS GANGLIONIC STIMULANT IRRIGANTS ANTIDIURETIC AND VAS ALKYLATING AGENTS LOCAL ANESTHETICS METALLIC POISON ANTI OXYTOCICS NOSE PREPS VASOCONST ANTILEPROTICS ANTIFUNGAL ANTIBIOTI EYE VASOCONSTRICTRS( NARCOTIC ANALGESICS TOPICAL ANTIBACTERIA THIENAMYCINS EYE ANTIVIRALS MIOTICS AND OTHER IN EYE PREPS, MISC (RX ANTIARTHRITICS AGTS CALCIUM CHANNEL BLOC BONE RESORBTION SUPP FERTILITY PREPARATIO MISCELLANEOUS AGENTS VITAMIN A PREPARATIO ANTIPARASITICS ANTISERA ANTIMETABOLITES ANTITUBERCULAR ANTIB TOTAL MESSAGES 103 89 81 75 68 65 59 56 54 54 40 35 32 31 31 28 26 25 25 14 11 9 9 4 4 4 3 2 533,733 PAID MESSAGES 102 89 81 72 63 65 59 56 54 51 40 35 32 24 30 24 4 24 23 13 11 8 9 4 4 4 3 2 487,100 DENIAL MESSAGES 1 0 0 3 5 0 0 0 0 3 0 0 0 7 1 4 22 1 2 1 0 1 0 0 0 0 0 0 46,633 OVERRIDDEN CLAIMS 2 3 61 118 50 116 0 16 2 19 572 4 28,724 37 48 2 388 10 0 1,496 844 0 0 1 0 1 219 222 TOTAL CLAIMS 71 3,998 4,030 8,302 3,328 11,807 328 2,304 2,090 2,428 18,340 841 1,250,585 3,332 753 352 62,808 1,501 825 227,566 114,460 183 199 112 112 561 15,394 2,595 8,685,761 11/14/06 PAGE 22

EXCESSIVE DURATION ALERT SUM

219,913

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 50 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: DRUG AGE PRECAUTION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME H2J H2L H2A H2F D4E D2A Q5F H4B C1D M9L R1A D6S C1W A1D A7B J2B A4D A9A J7C W5B W3B W1Q W1D G8A J9A H2E Q8R W5C S2B W1C P4L Q5P N1C Q4F R1L Z2F Q4K N1B J5D D7L A7C G1A C4K A4F R1F Z2A R1H P2B H6H A4A P1F H3D J2D Z2E H3F J7A H6J M9S R1M Q3A C4L S2A ANTIDEPRESSANTS ANTIPSYCHOTICS, NONCENTRAL NERVOUS SYST ANTI-ANXIETY DRUGS ANTIULCER PREPARATIO FLUORIDE PREPARATION TOPICAL ANTIFUNGALS ANTICONVULSANTS POTASSIUM REPLACEMEN ORAL ANTICOAGULANTS, URINARY TRACT ANTISP LAXATIVES AND CATHAR ELECTROLYTE REPLACEM BRONCHODIALATORS CORONARY VASODILATOR ANTICHOLINERGICS, QU HYPOTENSIVES ANGIOTE CALCIUM CHANNEL BLOC BETA ADRENERGIC BLOC ANTIVIRALS, HIV-SPEC ANTIFUNGAL AGENTS QUINOLONES MACROLIDES CONTRACEPTIVES, ORAL INTESTINAL MOTILITY NON-BARBITURATE, SED EAR PREPS EAR WAX RE ANTIVIR,HIV,PROTEASE ANTI-INFLAMMATORY AG TETRACYCLINES BONE RESORBTION SUPP TOPICAL ANTI FLAMMAT LEUKOCYTE STIMULANTS VAGINAL ANTIFUNGALS DIURETICS, THIAZIDE CHROMOLYN AND DERIVA VAGINAL ESTROGEN HEMATINICS, OTHER BETA-ADRENERGIC AGEN BILE SALT INHIBITORS PERIPHERAL VASODILAT ESTROGENIC AGENTS ORAL HYPOGLYCEMIC AG HYPOTEN ANGIOTEN REC THIAZIDE DIURETICS A ANTIHISTAMINES POTASSIUM SPARING DI ANTIDIURETIC AND VAS SKELETAL MUSCLE RELA HYPOTENSIVES VASODIL PITUITARY SUPPRESSIV SALICYLATE ANALGESIC ANTICHOLINERGICS, AN IMMUNOSUPPRESSIVES ANTIMIGRAINE PREPARA ALPHA-BETA ADRENERGI ANTI-EMETICS HEMORRHEOLOGIC AGENT LOOP DIURETICS RECTAL PREPARATIONS ORAL HYPOGLYCEMIC AG COLCHICINE TOTAL MESSAGES 3,677 2,912 2,597 2,156 1,401 1,338 1,276 1,008 957 787 762 746 701 669 578 405 396 379 375 339 294 293 272 262 212 211 196 177 157 139 137 134 125 117 117 114 110 105 99 85 64 64 63 51 50 50 46 44 43 42 42 40 38 33 31 31 30 30 26 22 21 19 PAID MESSAGES 3,575 2,911 2,511 1,864 1,108 1,320 1,274 833 934 760 747 730 683 639 574 381 389 354 351 339 288 291 272 0 83 161 196 174 142 137 137 134 125 116 115 114 110 102 99 83 63 63 63 51 50 48 46 42 43 42 42 39 38 19 31 30 30 21 26 22 19 19 DENIAL MESSAGES 102 1 86 292 293 18 2 175 23 27 15 16 18 30 4 24 7 25 24 0 6 2 0 262 129 50 0 3 15 2 0 0 0 1 2 0 0 3 0 2 1 1 0 0 0 2 0 2 0 0 0 1 0 14 0 1 0 9 0 0 2 0 OVERRIDDEN CLAIMS 0 0 36 28,998 223 3,518 958 21,815 1,597 2,010 770 3,295 30 437 601 318 2,336 1,496 2,791 0 516 764 976 1,059 376 8,477 28 151 16,591 376 844 954 13 279 322 6 37 194 2,222 32 2 569 1,578 1,535 939 0 398 118 2,017 91 16 1,384 58 835 344 618 955 31 2,306 21 1,336 88 TOTAL CLAIMS 13 0 649 378,799 12,470 50,054 116,702 767,967 150,301 107,540 76,201 306,981 5,298 52,394 84,959 4,036 378,145 227,566 349,306 0 50,279 76,702 106,483 145,545 52,845 200,107 3,305 10,999 525,789 43,614 114,460 142,291 1,550 18,245 48,876 1,482 7,189 8,425 336,282 5,042 146 89,574 138,365 150,295 173,287 268 38,897 8,302 231,387 9,443 1,357 232,002 15,346 20,998 54,098 43,565 78,047 4,299 203,186 13,394 171,858 9,852 11/14/06 PAGE 23

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 51 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: DRUG AGE PRECAUTION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME W5A G2A J1B H6A Q3S Z2G M9K A4B G3A L9D P0B Q5N C3B M4E L3P W2G C0D C4N P0A Q6G V1F L9C Q5B ANTIVIRALS PROGESTATIONAL AGENT CHOLINESTERASE INHIB ANTIPARKINSONISM DRU LAXATIVES, LOCAL/REC IMMUNOMODULATORS HEPARIN PREPARATIONS HYPOTENSIVES SYMPATH OXYTOCICS TOPICAL HYPERPIGMENT FOLLICLE STIMULATING TOPICAL ANTINEOPLAST IRON REPLACEMENT LIPOTROPICS ANTIPRURITICS, TOPIC NOT ENTERED MISC ANTIBACTERIAL C ANTIALCOHOLIC PREPAR INSULIN ENHANCER FERTILITY PREPARATIO MIOTICS AND OTHER IN MISC ANTINEOPLASTICS ANTIMELANIN AGENTS TOPICAL ANTIBACTERIA TOTAL MESSAGES 18 16 14 12 11 10 9 8 8 8 8 7 6 6 4 3 3 2 2 2 2 2 1 1 27,858 PAID MESSAGES 18 16 14 10 11 10 9 8 8 8 8 7 6 6 4 3 2 1 2 2 0 2 1 1 26,160 DENIAL MESSAGES 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 2 0 0 0 1,698 OVERRIDDEN CLAIMS 407 145 364 817 306 46 327 3,583 16 0 0 0 716 2,976 11 91,277 13 131 489 0 388 44 0 37 222,778 TOTAL CLAIMS 37,861 14,247 39,965 54,408 12,947 1,945 14,944 77,870 2,304 24 22 409 89,754 497,998 1,516 3,140,038 3,436 3,470 88,458 183 62,808 7,636 361 3,332 10,812,793 11/14/06 PAGE 24

DRUG AGE PRECAUTION SUM

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 52 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: DRUG GENDER ALERT FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME PRENATAL VITAMIN PRE BPH CONTRACEPTIVES, ORAL VAGINAL ANTIFUNGALS DRUGS TO TREAT IMPOT ESTROGENIC AGENTS CONTRACEPTIVES, INTR MISC ANTINEOPLASTICS VAGINAL ESTROGEN ANDROGENIC AGENTS BONE RESORBTION SUPP PROGESTATIONAL AGENT VAGINAL ANTIBIOTICS CONTRACEPTIVES, INJE ANTIANDROGENIC AGENT STEROID ANTINEOPLAST ESTROGEN/ANDROGEN CO FERTILITY PREPARATIO VAGINAL LUBRICANTS P OXYTOCICS CONTRACEPTIVES, IMPL NOT ENTERED L1C HYPERTRICHOTIC AGNTS Q4S VAGINAL SULFONAMIDES X1B DIAPHRAGMS/CERVICAL DRUG GENDER ALERT SUM C6F Q9B G8A Q4F F2A G1A G9A V1F Q4K F1A P4L G2A Q4W G8C V1J V1E G1B P0A Q4L G3A G8B TOTAL MESSAGES 3,694 1,417 947 655 193 179 103 88 73 69 60 35 35 32 26 24 16 14 13 9 8 3 3 2 1 7,699 PAID MESSAGES 0 1,400 0 634 172 158 103 86 70 69 60 32 35 0 25 24 16 13 13 9 0 3 3 2 1 2,928 DENIAL MESSAGES 3,694 17 947 21 21 21 0 2 3 0 0 3 0 32 1 0 0 1 0 0 8 0 0 0 0 4,771 OVERRIDDEN CLAIMS 205 224 1,059 279 29 569 40 44 37 59 844 145 104 56 59 16 0 0 0 16 0 91,277 0 0 3 95,065 TOTAL CLAIMS 76,588 35,622 145,545 18,245 3,498 89,574 1,890 7,636 7,189 5,287 114,460 14,247 6,740 6,654 835 2,069 627 183 35 2,304 0 3,140,038 41 4 480 3,679,791 11/14/06 PAGE 25

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 53 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: THERAPEUTIC DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME H3A H2J M4E H2F D6S D4K H4B H2L S2B D4E A4D M9L H2V P3A H6H R1M A7B J7C A9A Z2A J5B H2E C4K Z2P C4L W5B H6A C1D J5D H3D Z2E C4G Q5F G1A A4B G8A H2G R1F A4F Z2Q H2M W5C H6J H6B P4L M4A A1A H3E P5A R1A C3B X2B A1D W1A C4N Q9B H2D D4B C6F M9P J9A NARCOTIC ANALGESICS ANTIDEPRESSANTS LIPOTROPICS ANTI-ANXIETY DRUGS LAXATIVES AND CATHAR GASTRIC ACID SECRETI ANTICONVULSANTS ANTIPSYCHOTICS, NONANTI-INFLAMMATORY AG ANTIULCER PREPARATIO HYPOTENSIVES ANGIOTE ORAL ANTICOAGULANTS, ANTI-NARCOLEPSY/ANTI THYROID HORMONES SKELETAL MUSCLE RELA LOOP DIURETICS CORONARY VASODILATOR BETA ADRENERGIC BLOC CALCIUM CHANNEL BLOC ANTIHISTAMINES ADRENERGIC AGENTS, A NON-BARBITURATE, SED ORAL HYPOGLYCEMIC AG 1ST GEN ANTIHISTAMIN ORAL HYPOGLYCEMIC AG ANTIVIRALS, HIV-SPEC ANTIPARKINSONISM DRU POTASSIUM REPLACEMEN BETA-ADRENERGIC AGEN SALICYLATE ANALGESIC IMMUNOSUPPRESSIVES INSULINS TOPICAL ANTIFUNGALS ESTROGENIC AGENTS HYPOTENSIVES SYMPATH CONTRACEPTIVES, ORAL ANTI-PSYCHOTICS,PHEN THIAZIDE DIURETICS A HYPOTEN ANGIOTEN REC 2ND GEN ANTIHISTAMIN ANTI-MANIA DRUGS ANTIVIR,HIV,PROTEASE ANTI-EMETICS ANTIPARKINSONISM DRU BONE RESORBTION SUPP BLOOD SUGAR DIAGNOST DIGITALIS GLYCOSIDES ANALGESIC/ANTIPYRETI GLUCOCORTICOIDS URINARY TRACT ANTISP IRON REPLACEMENT MED SUPPLIES SYRINGE BRONCHODIALATORS PENICILLINS INSULIN ENHANCER BPH BARBITURATES ANTACIDS PRENATAL VITAMIN PRE PLATELET AGGREGATION INTESTINAL MOTILITY TOTAL MESSAGES 500,308 214,219 87,876 83,745 82,716 72,838 65,034 63,882 62,808 48,988 39,661 37,475 35,446 35,391 35,275 33,614 33,201 32,804 31,484 29,056 26,732 23,968 20,264 19,344 17,864 17,411 17,166 16,590 16,065 15,347 15,254 14,501 14,223 13,067 11,430 10,857 10,672 10,117 9,672 9,198 9,147 8,764 8,070 7,726 7,324 7,265 7,242 7,008 6,902 6,852 6,562 6,416 6,371 6,348 5,453 5,392 4,671 4,420 4,215 4,148 4,137 PAID MESSAGES 492,598 211,116 87,393 0 82,385 72,353 48 62,898 0 0 39,619 35,895 35,023 35,165 31,260 33,600 32,833 32,402 31,363 28,702 26,633 10 20,134 19,283 17,171 17,348 16,199 16,388 14 15,141 15,066 17 14,209 12,670 9,950 10,684 10,323 9,770 9,556 8,970 8,541 8,751 7,824 7,607 7,084 7,265 7,018 6,900 6 6,826 6,537 6,416 6,346 6,212 5,440 5,386 4,657 4,415 4,201 4,019 3,300 DENIAL MESSAGES 7,710 3,103 483 83,745 331 485 64,986 984 62,808 48,988 42 1,580 423 226 4,015 14 368 402 121 354 99 23,958 130 61 693 63 967 202 16,051 206 188 14,484 14 397 1,480 173 349 347 116 228 606 13 246 119 240 0 224 108 6,896 26 25 0 25 136 13 6 14 5 14 129 837 OVERRIDDEN CLAIMS 28,724 0 2,976 28,998 3,295 8,310 21,815 0 16,591 223 2,336 2,010 11,461 1,642 2,017 2,306 601 2,791 1,496 0 9,500 8,477 1,578 3,201 1,336 0 817 1,597 2,222 1,384 835 2,222 958 569 3,583 1,059 262 939 1,535 2,254 1,980 151 955 415 844 1,378 354 1,490 1,542 770 716 458 437 5,968 489 224 214 310 205 603 376 TOTAL CLAIMS 1,250,585 13 497,998 378,799 306,981 695,874 767,967 0 525,789 12,470 378,145 107,540 123,138 231,563 231,387 203,186 84,959 349,306 227,566 268 96,892 200,107 138,365 220,971 171,858 0 54,408 150,301 336,282 232,002 20,998 199,513 116,702 89,574 77,870 145,545 17,972 173,287 150,295 223,394 49,974 10,999 78,047 45,059 114,460 118,382 47,533 138,003 182,512 76,201 89,754 77,282 52,394 198,494 88,458 35,622 17,447 45,569 76,588 84,919 52,845 11/14/06 PAGE 26

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 54 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: THERAPEUTIC DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME B3J R1L J7B C1F C1A A4A J7A R1H W1Q Q6T Q7P W4A B3K Q5P H3F W2A W1B J1B V1B Q5W D6D Z4B C6M A1B Q6G W1D J5G W1C Y3A C1B W2E Q6W W3B W5A G2A W2F C6B A2A C6C M9K Q6P L2A Q5R D2A C7A U6W C6D J2A X2A X1A Q5H C6E P2B J2D L6A D8A B4S V1A C1H F1A D9A A4Y EXPECTORANTS DIURETICS, THIAZIDE ALPHA ADRENERGIC BLO CALCIUM REPLACEMENT ELECTROLYTE DEPLETER HYPOTENSIVES VASODIL ALPHA-BETA ADRENERGI POTASSIUM SPARING DI QUINOLONES ARTIFICIAL TEARS NOSE PREPS ANTIINFLA ANTIMALARIAL DRUGS COUGH COLD PREPARATI TOPICAL ANTI FLAMMAT ANTIMIGRAINE PREPARA ABSORBABLE SULFONAMI CEPHALOSPORINS CHOLINESTERASE INHIB ANTIMETABOLITES TOPICAL ANTIBIOTICS ANTIDIARRHEALS LEUKOTRIENE RECEPTOR FOLIC ACID PREPARATI XANTHINES MIOTICS AND OTHER IN MACROLIDES BETA-ADRENERGICS GLU TETRACYCLINES MED SUPPLIES MISCELL SODIUM REPLACEMENT ANTITUBERCULAR AGENT EYE ANTIBIOTICS ANTIFUNGAL AGENTS ANTIVIRALS PROGESTATIONAL AGENT NITROFURAN DERIVATIV VITAMIN B PREPARATIO ANTIARRHYTHMICS VITAMIN C PREPARATIO HEPARIN PREPARATIONS EYE ANTIINFLAMMATORY EMOLLIENTS TOPICAL ANTIPARASITI FLUORIDE PREPARATION PURINE INHIBITORS BULK CHEMICALS VITAMIN D PREPARATIO BELLADONNA ALKALOIDS MED SUPPLIES NEEDLES CONDOMS TOPICAL LOCAL ANESTH VITAMIN E PREPARATIO ANTIDIURETIC AND VAS ANTICHOLINERGICS, AN IRRITANTS PANCREATIC ENZYMES NARC ANTITUSS-EXP ALKYLATING AGENTS MAGNESIUM REPLACEMEN ANDROGENIC AGENTS AMMONIA INHIBITORS HYPOTENSIVES MISCELL TOTAL MESSAGES 3,847 3,783 3,776 3,760 3,677 3,524 3,516 3,399 3,294 3,081 3,011 2,995 2,922 2,784 2,733 2,691 2,658 2,574 2,453 2,403 2,400 2,357 2,061 1,972 1,907 1,812 1,808 1,792 1,639 1,503 1,447 1,424 1,414 1,400 1,380 1,319 1,197 1,194 1,140 1,126 1,108 1,064 960 955 911 867 866 827 817 794 751 729 717 696 694 647 641 621 597 593 592 587 PAID MESSAGES 3,804 3,780 3,774 3,743 3,637 3,481 3,351 3,298 3,180 3,076 2,695 2,985 2,898 2,202 2,263 2,485 2,580 2,535 2,413 2,403 2,374 2,348 2,040 1,812 0 1,662 1,457 1,772 1,639 1,503 1,427 1,390 1,267 1,277 1,311 1,227 1,194 1,084 1,140 1,065 912 1,064 934 955 0 867 805 824 817 794 741 729 708 693 694 601 637 621 573 592 566 582 DENIAL MESSAGES 43 3 2 17 40 43 165 101 114 5 316 10 24 582 470 206 78 39 40 0 26 9 21 160 1,907 150 351 20 0 0 20 34 147 123 69 92 3 110 0 61 196 0 26 0 911 0 61 3 0 0 10 0 9 3 0 46 4 0 24 1 26 5 OVERRIDDEN CLAIMS 173 322 368 887 263 91 618 398 764 264 409 239 0 954 344 390 0 364 219 368 200 289 293 91 388 976 492 376 584 21 2,101 112 516 407 145 158 253 118 166 327 93 131 849 3,518 171 47 163 72 131 399 155 196 118 58 112 71 341 50 536 59 183 19 TOTAL CLAIMS 23,571 48,876 42,759 92,745 19,933 9,443 43,565 38,897 76,702 39,793 111,558 48,556 256 142,291 54,098 70,132 0 39,965 15,394 54,077 37,420 66,387 42,385 11,041 62,808 106,483 75,439 43,614 46,371 5,080 6,090 36,478 50,279 37,861 14,247 32,601 25,827 11,436 21,301 14,944 17,150 26,926 18,843 50,054 25,079 2,668 17,754 12,205 16,376 14,498 23,694 15,932 8,302 15,346 17,983 11,159 40,630 3,328 12,521 5,287 14,923 5,997 11/14/06 PAGE 27

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: THERAPEUTIC DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME V1F N1B Q3S W5D Z2F J5E M9S W5G S2A Q4F S2J L5F H2A W1K W3A Q6I H0A L0B L5A H6C G8C C6L W8E Q5S W8F H0E B4D C6H V1E D1D C0D G9A P3L L9B C6Q U6N D4N D7L C6Z U6H W1J Q8W Q6R Q4K J2B W1G P5S Y7A Z2N C6N L3A W4E M4G Q6A W4P R1E S2I W5F P1F B0A D7A W2G B3T MISC ANTINEOPLASTICS HEMATINICS, OTHER LAXATIVES, LOCAL/REC ANTIVIRAL MONOCLONAL CHROMOLYN AND DERIVA SYMPATHOMIMETIC AGEN HEMORRHEOLOGIC AGENT HEPATITIS C TREATMEN COLCHICINE VAGINAL ANTIFUNGALS TUMOR NECROSIS INHIB ANTIPSORIATICS AGENT CENTRAL NERVOUS SYST LINCOSAMIDES ANTIFUNGAL ANTIBIOTI EYE ANTIBIOTIC CORTI LOCAL ANESTHETICS TOPICAL/MUCOUS MEMBR KERATOLYTICS ANTITUSSIVE, NON-NAR CONTRACEPTIVES, INJE VITAMIN B12 PREPARAT ANTISEPTICS, GENERAL TOPICAL SULFONAMIDES IRRIGANTS AGENTS TO TREAT MULT NARC ANTITUSS-1ST GE PEDIATRIC VITAMIN PR STEROID ANTINEOPLAST DENTAL AIDS AND PREP ANTIALCOHOLIC PREPAR CONTRACEPTIVES, INTR ANTITHYROID PREPARAT VITAMIN A DERIVATIVE VITAMIN B6 PREPARATI VEHICLES ANTIFLATULENTS BILE SALT INHIBITORS MISCELLANEOUS MULTIV SOLVENTS VANCOMYCIN AND DERIV EAR PREPS ANTIBIOTIC EYE ANTIHISTAMINES VAGINAL ESTROGEN ANTICHOLINERGICS, QU ANTITUBERCULAR ANTIB MINERALOCORTICOIDS MED SUPPLIES INHALAT 1ST GEN ANTIHIST-DEC NIACIN PREPARATIONS PROTECTIVES TRICHOMONACIDES HYPERGLYCEMICS EYE PREPS, MISC (RX ANTILEPROTICS CARBONIC ANHYDRASE I PYRIMIDINE SYNTH INH HEPATITIS B TREATMEN PITUITARY SUPPRESSIV GENERAL INHALATION A BILE SALTS MISC ANTIBACTERIAL C NON-NARC ANTITUSS-EX TOTAL MESSAGES 577 562 547 505 477 468 463 453 444 438 431 429 413 408 397 394 393 369 369 367 361 360 358 346 335 324 318 316 315 313 311 306 303 288 284 282 276 270 265 263 262 256 246 244 239 239 234 229 227 224 224 221 217 217 215 201 198 196 188 187 187 187 170 PAID MESSAGES 556 541 517 505 475 467 428 433 430 431 425 429 409 398 247 385 393 369 369 365 334 128 358 346 335 315 307 314 303 287 307 306 294 288 284 282 270 269 265 263 256 254 228 238 221 225 229 229 226 224 224 204 217 215 208 198 165 196 180 187 169 149 169 DENIAL MESSAGES 21 21 30 0 2 1 35 20 14 7 6 0 4 10 150 9 0 0 0 2 27 232 0 0 0 9 11 2 12 26 4 0 9 0 0 0 6 1 0 0 6 2 18 6 18 14 5 0 1 0 0 17 0 2 7 3 33 0 8 0 18 38 1 OVERRIDDEN CLAIMS 44 194 306 4 6 71 31 209 88 279 95 40 36 1,161 572 46 116 32 68 98 56 536 119 95 61 178 311 169 16 361 131 40 49 24 258 18 164 32 57 9 66 37 89 37 318 222 52 137 313 51 1 297 19 10 19 39 83 13 16 26 140 13 87 TOTAL CLAIMS 7,636 8,425 12,947 2,993 1,482 19,557 4,299 10,972 9,852 18,245 10,477 4,703 649 23,214 18,340 7,593 11,807 5,851 9,911 17,329 6,654 15,923 16,692 8,117 4,030 7,841 28,015 15,507 2,069 16,280 3,470 1,890 4,058 7,391 7,458 2,399 12,487 5,042 14,586 3,116 3,840 16,484 19,871 7,189 4,036 2,595 3,254 14,551 17,195 3,697 1,677 21,769 3,886 1,501 2,428 2,591 3,274 1,532 1,357 2,656 3,446 3,436 21,855 11/14/06 PAGE 28

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: THERAPEUTIC DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME C4M J1A L1B P1A W1F R5A Q3A C3C R1S W7B Y9A Q5B G1B B4W N1C Q6Y C0K Q6S J5H Z2G C5J H3T Q3D L5E C6K L5H V1J R1R Z2O Q8B C5K Q5V L1A B4C C1W R4A C7D Q8F H2H Q6J Q7E M0E B3A Q7D Q7A Q7H H2K Q4W R5B L3P C1P N1D C8A C7E B3R C0B P1B W4L B3Q C3M W7K C5B HYPOGLYC;ALPHA-GLUCO PARASYMPATHETIC AGEN ACNE AGENTS, SYSTEMI GROWTH HORMONES AMINOGLYCOSIDES URINARY TRACT ANEST RECTAL PREPARATIONS ZINC REPLACEMENT URINARY PH MODIFIERS VIRAL VACCINES MED SUPPLIES DIABETI TOPICAL ANTIBACTERIA ESTROGEN/ANDROGEN CO DECON-EXP LEUKOCYTE STIMULANTS EYE PREPARATIONS, MI BICARBONATE PRODUCIN EYE SULFONAMIDES ADRENERGIC VASOPRESS IMMUNOMODULATORS IV SOLUTIONS; DEXTRO NARCOTIC ANTAGONISTS HEMORRHOIDAL PREPARA ANTISEBORRHEIC AGENT VITAMIN K PREPARATIO ACNE AGENTS, TOPICAL ANTIANDROGENIC AGENT URICOSURIC AGENTS 2ND GEN ANTIHIST-DEC EAR PREPS MISC ANTII IV SOLUTIONS; DEXTRO TOPICAL ANTIVIRALS ANTIPSORIATIC AGENTS NARC ANTITUSS-ANTICH ELECTROLYTE REPLACEM KIDNEY STONE AGENTS METABOLIC DEFICIENCY EAR PREPS ANTIBIOTIC MONOAMINEOXIDASE (MA MYDRIATICS NOSE PREPS ANTIHISTA ANTIHEMOPHILIC FACTO MUCOLYTICS NOSE PREPS VASOCONST NOSE PREPS MISC RX O NASAL MAST CELL STAB ANTIDEPRESSANTS COMB VAGINAL ANTIBIOTICS URINARY TRACT ANALGE ANTIPRURITICS, TOPIC PHOSPHATE REPLACEMEN PLATELET REDUCING AG METALLIC POISON ANTI APPETITE STIMULANTS NONARC ANTITUSS-1G A WATER SOMATOSTATIC AGENTS ANTHELMINTICS NARC ANTITUSS-1ST GE MISCELLANEOUS MINERA ANTISERA PROTEIN REPLACEMENT TOTAL MESSAGES 169 169 163 154 152 141 140 136 134 133 124 122 119 115 112 111 110 103 102 100 98 85 83 81 74 72 71 70 70 67 66 66 64 62 62 61 60 60 58 58 58 57 52 51 46 46 45 43 42 41 39 39 37 36 35 33 33 32 31 31 31 30 PAID MESSAGES 169 147 163 154 132 134 128 134 128 133 124 122 119 114 112 111 110 96 102 85 98 76 82 81 73 72 69 70 70 67 66 66 64 61 50 61 60 52 54 35 58 57 51 51 46 46 43 43 41 41 39 39 37 36 35 33 31 30 31 17 31 30 DENIAL MESSAGES 0 22 0 0 20 7 12 2 6 0 0 0 0 1 0 0 0 7 0 15 0 9 1 0 1 0 2 0 0 0 0 0 0 1 12 0 0 8 4 23 0 0 1 0 0 0 2 0 1 0 0 0 0 0 0 0 2 2 0 14 0 0 OVERRIDDEN CLAIMS 22 24 12 39 34 47 21 8 69 0 25 37 0 65 13 28 15 13 10 46 1 75 2 19 35 17 59 1 48 5 4 67 6 50 30 0 15 268 3 13 26 18 84 2 12 2 0 104 13 11 10 3 0 15 43 4 5 13 51 2 1 6 TOTAL CLAIMS 2,459 2,976 1,235 3,279 2,627 12,317 13,394 2,625 3,953 884 9,214 3,332 627 11,816 1,550 3,635 775 5,312 1,203 1,945 705 1,279 1,906 4,931 1,614 4,242 835 1,158 5,611 1,483 859 4,753 636 3,363 5,298 105 2,104 5,736 31 2,745 3,519 522 2,706 2,090 2,344 504 0 6,740 1,111 1,516 1,399 334 328 1,299 6,886 763 315 1,825 4,892 340 561 557 11/14/06 PAGE 29

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: THERAPEUTIC DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME C5F B4E Q8R F2A J3A Q8H W4K U6E A7E J5F S2H R3W B5S D4F W1S D4G Q5A Q6V C6A V1I P1C U6F U7A W1P C6T X1C A7C Q5N W8J C5O J9B L8B Q6D L9A P1E Q6C X5B Q7Y R3U X1B C7B L0C B4L D5P J8A M9D R3Z U6A Z2H C3H H6I M4B U7K G8B Q3B Q7W U5B W7C W7L W8D A1C B4Q C5M MISCELLANEOUS FOOD S NON-NARC ANTITUS-1G EAR PREPS EAR WAX RE DRUGS TO TREAT IMPOT GANGLIONIC STIMULANT EAR PREPS LOCAL ANES MISC ANTIPROTOZOAL D OINTMENT/CREAM BASES VASODILATORS MISCELL ANAPHYLAX THERAPY AG ANTIARTHRITICS AGTS URINE ACETONE TEST A 1ST GN ANTIHIST-ANAL ANTIULCER H.PYLORI A THIENAMYCINS GASTRIC ENZYMES TOPICAL PREPARATIONS EYE ANTIVIRALS VITAMIN A PREPARATIO CHEMOTHERAPY ANTIDOT LUTEINIZING HORMONES CREAM/OINTMENT BASES SUSPENDING AGENTS OXABETA LACTAMS VITAMIN B1 PREPARATI IUD PERIPHERAL VASODILAT TOPICAL ANTINEOPLAST MISC ANTIBACTERIAL A MISCELLANEOUS SOLUTI ANTISPASMODIC AGENTS ANTIPERSPIRANTS EYE VASOCONSTRITRS ( MISCELLANEOUS TOPICA ADRENOCORTICOTROPHIC EYE VASOCONSTRICTRS( MED SUPPLIES MISC BA NOSE PREPS MISC OTC URINE GLUCOSE TEST A DIAPHRAGMS/CERVICAL DECARBOXYLASE INHIBI DIABETIC ULCER PREPA NON-NARC ANTITUSS-DE INTESTINAL ADSORBENT ANOREXIC AGENTS ANTIFIBRINOLYTIC AGE URINE GLUC/ACET TEST PHARMACEUTICAL ADJUV SYSTEMIC ENZYME INHI IODINE REPLACEMENT AMYOTROP LATERAL SCL IV FAT EMULSIONS FLAVORING AGENTS CONTRACEPTIVES, IMPL RECTAL/LOWER BOWEL P NOSE PREPS ANTIBIOTI HERBAL DRUGS INFLUENZA VIRUS VACC GRAM POSITIVE COCCI OXIDIZING AGENTS INOTROPIC DRUGS NARC ANTITUS-DECON-E IV SOLUTIONS; DEXTRO TOTAL MESSAGES 29 25 25 24 24 24 23 22 20 20 19 18 17 17 17 16 16 16 15 15 14 14 14 14 13 13 12 12 11 10 10 10 9 8 8 7 7 6 6 6 5 5 4 4 4 4 4 4 4 3 3 3 3 2 2 2 2 2 2 2 1 1 1 PAID MESSAGES 29 25 25 19 24 23 22 22 20 20 19 18 17 17 15 16 16 16 15 15 14 14 14 14 13 13 8 12 11 10 10 10 9 8 8 5 7 6 6 6 5 5 4 4 4 4 4 4 4 3 3 3 3 2 2 2 2 2 0 2 1 1 1 DENIAL MESSAGES 0 0 0 5 0 1 1 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 4 0 0 0 0 0 0 0 0 2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 0 OVERRIDDEN CLAIMS 0 43 28 29 3 71 0 0 0 30 0 21 9 7 48 0 3 2 1 0 0 4 0 2 2 4 2 0 0 0 11 4 2 3 3 4 0 0 0 3 7 1 1 0 0 7 4 0 0 2 3 0 0 0 2 0 0 9 8 0 0 7 0 TOTAL CLAIMS 2,305 7,660 3,305 3,498 3,998 6,390 327 352 4 6,800 825 1,291 1,211 1,270 753 309 1,104 352 112 431 0 210 262 71 1,258 488 146 409 0 68 337 1,117 1,210 624 78 841 999 3,028 28 480 235 499 737 72 1,030 153 195 1 141 292 210 55 41 0 197 406 174 7,114 1,285 183 16 1,188 62 11/14/06 PAGE 30

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Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 2.3 -- Continued – Response To P.O.S. Alerts By Therapeutic Category
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM ATTACHMENT 2. PRO-DUR ACTIVITY BY THERAPEUTIC CATEGORY RXRQ4098-R001 CONSULTEC PRESCRIPTION DRUG CARD SERVICES DRUG CONFLICT CODE: THERAPEUTIC DUPLICATION FISCAL YEAR 10/1/05 - 9/30/06 THERAPEUTIC CLASS CODE/NAME C6G G3A H2T H3H L4A M9M P1U Q5X R3Y Z3G GERIATRIC VITAMIN PR OXYTOCICS ALCOHOL ANALGESICS ANESTHETI ASTRINGENTS ORAL ANTICOAGULANTS, METABOLIC FUNCTION D TOPICAL ANTIBIO/INFL URINE MULTIPLE TEST MISCELLANEOUS AGENTS TOTAL MESSAGES 1 1 1 1 1 1 1 1 1 1 2,207,877 PAID MESSAGES 1 1 1 1 1 1 1 0 1 1 1,848,834 DENIAL MESSAGES 0 0 0 0 0 0 0 1 0 0 359,043 OVERRIDDEN CLAIMS 0 16 0 0 4 0 0 0 1 0 235,066 TOTAL CLAIMS 801 2,304 0 45 273 0 0 218 71 199 13,768,448 11/14/06 PAGE 31

THERAPEUTIC DUPLICATION SUM ******** END OF REPORT

******

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

ATTACHMENT 3. RETRODUR ACTIVITY
Instructions for Contents ATTACHMENT 3 is a year-end summary report on retrospective DUR screening and interventions. Separate reports on the results of retrospective DUR screening and on interventions are acceptable at the option of the State. The report(s) should: 1) Report the level of criteria exceptions by drug class (or drugs within the class) and problem type. (An exception is an instance where a prescription submitted for adjudication does not meet the DUR Board-approved criteria for one or more problem types within a drug class.) NOTE: a) Reporting levels of criteria exceptions by only drug class (drug) or problem type is not acceptable. b) Year end summary reports may cover all criteria exceptions or (at the option of the State) be limited to drug classes (drugs)/problem types with the largest number of exceptions.

2) Include a denominator for each drug class/problem type for which criteria exceptions are reported. A denominator is the number of prescription claims adjudicated for a drug class (or individual drugs in the class) during a given time period compared to the number of criteria exceptions for the drug class (or individual drugs in the class) during that time period. 3) Also report, for each drug class/drug and problem type included in this summary report, the number of interventions (letters, face-to-face visits, etc.) undertaken during the reporting period. 4) States which engage in physician, pharmacy profile analysis (i.e., review prescribing or dispensing of multiple prescriptions for multiple patients involving a particular problem type or diagnosis) or engage in patient profiling should report the number of each type of profile (physician, pharmacy, patient) reviewed and identify the subject(s) (diagnosis, problem type, etc.) involved.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 3.1

Top 40 Therapeutic Classes – # Claims & Amount Paid
# Rx Claims Amount Paid 11,105,435 $498,640,457
Amount Paid (Total) $71,041,823 $43,637,156 $24,625,137 $20,855,987 $19,726,075 $18,712,587 $14,153,302 $13,102,662 $9,743,949 $8,504,680 $7,628,727 $6,820,502 $6,663,445 $6,313,752 $5,949,767 $5,550,235 $5,343,405 $5,285,302 $5,151,432 $5,123,014 $5,042,083 $4,984,359 $4,581,283 $4,462,909 $4,395,126 $4,114,746 $4,047,429 $4,038,457 $3,852,903 $3,794,294 $3,688,463 $3,630,948 $3,375,387 $3,276,399 $3,217,182 $2,799,520 $2,780,013 $2,767,482 $2,648,849 $2,628,874

From: 10/1/05 To 09/30/06 (FFY 2006)

Thera Class Code Spec Thera Class Description H7T H4B D4K M4E H3A M0E H2S H7X C4G H7C J5G C4N J5D M4A H0E A9A S2J H2V W5G P5A S2B H6J H7D G8A Q7P P4L H7Y J5B M9P W5C A4F Z4B H3F P1A Z2E N1B A1D H2F W1D M9K ANTIPSYCHOTICS,ATYPICAL,DOPAMINE,& SEROTONIN ANTAG ANTICONVULSANTS GASTRIC ACID SECRETION REDUCERS LIPOTROPICS ANALGESICS, NARCOTICS ANTIHEMOPHILIC FACTORS SELECTIVE SEROTONIN REUPTAKE INHIBITOR (SSRIS) ANTIPSYCHOTICS, ATYP, D2 PARTIAL AGONIST/5HT MIXED INSULINS SEROTONIN-NOREPINEPHRINE REUPTAKE-INHIB (SNRIS) BETA-ADRENERGICS AND GLUCOCORTICOIDS COMBINATION HYPOGLYCEMICS, INSULIN-RESPONSE ENHANCER (N-S) BETA-ADRENERGIC AGENTS BLOOD SUGAR DIAGNOSTICS AGENTS TO TREAT MULTIPLE SCLEROSIS CALCIUM CHANNEL BLOCKING AGENTS ANTI-INFLAMMATORY TUMOR NECROSIS FACTOR INHIBITOR TX FOR ATTENTION DEFICIT-HYPERACT(ADHD)/NARCOLEPSY HEPATITIS C TREATMENT AGENTS GLUCOCORTICOIDS NSAIDS, CYCLOOXYGENASE INHIBITOR - TYPE ANTIEMETIC/ANTIVERTIGO AGENTS NOREPINEPHRINE AND DOPAMINE REUPTAKE INHIB (NDRIS) CONTRACEPTIVES,ORAL NASAL ANTI-INFLAMMATORY STEROIDS BONE RESORPTION INHIBITORS TX FOR ATTENTION DEFICIT-HYPERACT.(ADHD), NRI-TYPE ADRENERGICS, AROMATIC, NON-CATECHOLAMINE PLATELET AGGREGATION INHIBITORS ANTIVIRALS, HIV-SPECIFIC, PROTEASE INHIBITORS HYPOTENSIVES,ANGIOTENSIN RECEPTOR ANTAGONIST LEUKOTRIENE RECEPTOR ANTAGONISTS ANTIMIGRAINE PREPARATIONS GROWTH HORMONES IMMUNOSUPPRESSIVES HEMATINICS,OTHER GENERAL BRONCHODILATOR AGENTS ANTI-ANXIETY DRUGS MACROLIDES HEPARIN AND RELATED PREPARATIONS

Rx Count 352,361 490,916 501,537 396,215 859,791 504 416,837 43,198 139,761 81,162 58,863 68,858 233,250 85,629 4,736 180,396 4,399 67,684 4,830 129,168 268,146 43,736 79,469 111,660 84,111 91,064 31,859 48,224 52,947 8,464 94,353 50,938 26,284 1,701 12,256 4,019 37,183 266,321 74,220 6,359

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 3.2

ACS Heritage’s RetroDUR Criteria Definitions & Development Description

ACS’ CRITERIA DEVELOPMENT & REFERENCES
 Copyright 1999 – 2007 Affiliated Computer Services, Inc. All rights reserved.

Ensuring the soundness of clinical criteria is of paramount importance when delivering care recommendations to providers and patients. ACS Heritage is constantly reviewing best-practice guidelines for the prescribing and use of drugs to ensure the integrity of the thousands of clinical criteria that we deploy for our clients. The systematic process that our clinicians follow ensures that we can readily identify care management issues and implement meaningful targeted intervention strategies to help our clients accomplish their goals.

Clinical Resources
ACS Heritage clinical pharmacists have access to an extensive library of medical resources. These resources are used on a daily basis to identify new criteria for development and update existing current criteria to ensure program improvement is maximized. Clinical resource examples include:                 American Hospital Formulary Service Drug Information, United States Pharmacopoeia-Drug Information American Medical Association Drug Evaluations Clinical Pharmacology DRUGDEX E-Facts Physician’s Desk Reference Pharmacotherapy Drug monographs Iowa Drug Information Service Redbook with monthly updates Encoder Pro (this is an online ICD-9, CPT, HCPC reference) Medical Letter Pharmacist’s Letter First data Bank – NDDF Plus Virginia Commonwealth University (VCU) Medical Library - ACS Clinical Staff have a preceptor role with the Virginia Commonwealth University. This relationship provides the Richmond Staff with full access to all holdings and all subscription services such as PubMed, Medline, e-Journals, and Micromedex.

Using the following methods, ACS Heritage tracks new developments in pharmacotherapy:           Subscriptions to journals and newsletters (pharmacy and medical) Email list with Center for Drug Evaluation and Research at the FDA (daily) Email list with Medwatch at the FDA Medscape email notifications (weekly) and journal scan on Medscape site Weekly FDB updates New drugs PPI updates Drug disease contraindication module Drug-drug interaction module Traditional literature searches

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Peer-review Criteria Development Process
All new criteria and criteria updates go through a rigorous internal ACS Heritage peer-review process before placed into production. The peer-review process for developing new clinical interventions is systematic and scientifically sound. A literature search is conducted, and applicable articles are compiled and reviewed by ACS Heritage pharmacists. Reviewed materials include printed, on-line, and CD-ROM drug information sources, such as MedLine, DrugDex, American Hospital Formulary Service, The Formulary Service, etc. Clinical practice guidelines, such as AHCPR, are also used to guide criteria development. There are seven basic components to the clinical criteria development process that ACS Heritage uses to develop and maintain proposed clinical criteria prior to placing them in production: literature search, internal peer review, rules writing, data modeling, clinical rules validation, and external peer review. 1. Literature search – ACS Heritage clinical pharmacists, on a daily basis, review clinical resources to generate ideas for new clinical criteria or to identify how literature impacts current criteria. The clinical pharmacists identify the specific medical criteria necessary to comprehensively address the drug therapy problem/issue in question. Depending on the clinical topic, clinical pharmacists or physicians that have expertise or specialization in a particular area are assigned the protocol development. A standardized initiative proposal form is used to organize the information and documentation concerning the initiative. Ideas may also be generated by clients. For all criteria, the clinical pharmacist also develops a clinical algorithm (i.e., flowchart) based on best-practice guidelines and literature. The algorithm contains all information (e.g., drug lists, ICD-9 codes, CPT/HCPCS codes, etc.) required to write the clinical rule. 2. Internal peer-review – Clinical algorithms are presented by the respective clinical pharmacist at the weekly Clinical Management Services (CMS) meetings. CMS meets weekly to review existing and new clinical interventions. The weekly CMS meetings are chaired by ACS Heritage’s Clinical Services Director, Robert Berringer, PharmD, and has representation from account management, rules administration, and clinical management services. All CMS clinicians review the algorithm and provide feedback/comments. Based on this review, the criteria may require additional research and an update of the algorithm. 3. Rules writing – After the clinical algorithm has been finalized, it is then used to write the clinical rule. 4. Data modeling – The written rule is modeled against client data to identify specific clinical/business opportunities. 5. Clinical rule validation – Based on the data modeling step, patient profiles are generated that include profiles of patients who flag on the respective criteria. These profiles are then reviewed by the clinical pharmacist who developed the algorithm to validate the clinical rule. Based on this review, the clinical pharmacist may identify clinical rule changes that are required. If necessary, the clinical pharmacist may request additional profiles for review until the clinician is ensured the rule is correctly identifying issues and is validated. 6. External peer-review – For all criteria sets, clinical proposals are provided to clients that defines the criteria and includes components such as specific clinical criteria, drug lists, ICD-9 codes, and CPT/HCPCS codes. These proposals are typically presented to client boards/committees (e.g., Drug Utilization Review Boards, Pharmacy and Therapeutics Committees, pharmacy staff, etc.) for review and approval. After this review the client may request changes to the criteria that are then communicated back the respective clinical pharmacist to create client-specific criteria. These changes would then be tested and validated before placed into production. 7. Production – After each algorithm has been reviewed and validated, it is placed into the client-specific set of clinical rules.
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 Copyright 1999 – 2007 Affiliated Computer Services, Inc. All rights reserved.

Peer-Review Criteria Development Process
Peer-review Criteria Development Process

Literature Search New clinical criteria or update to existing criteria initiated by clinical pharmacist or client Production Validated rule(s) place added to client-specific rule set automatically or after client review and approval Internal Peer-Review Flowchart created and presented at weekly CMS meeting

External Peer-Review Specific criteria presented to client for review and changes/approval

Rule Writing Clinical/Business rule written

Rule Validation Clinical pharmacist manually reviews patient profiles to validate rule

Data Modeling Client data modeled against clinical rule to identify clinical/business opportunities

This graphic illustrates the internal process that ACS Heritage’s clinicians use to develop and test criteria before they are put into production.
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EXECUTIVE SUMMARY: RetroDUR Criteria Development
Purpose: Setting & Population: Promote prescribing of all drugs and drug classes through e-prescribing. All patients Brand w/generic Drug-disease interaction Drug-drug interaction Discontinuation of therapy Doctor Shopper Dose consolidation Duplicate therapy Duration of therapy Only administrative databases High Dose Medication adherence Multiple prescribers Overutilization Pregnancy caution Underutilization Use without an indication

Type of Criteria:

Data Sources:

Databases + Prescriber-supplied

RetroDUR ALERT CRITERIA DEFINITIONS Drug Therapy Issue
Brand w/generic

Criteria*
History of a brand name medications that have A-rated generics based on First Data Bank (FDB) classifications (excludes drugs with narrow therapeutic index such as warfarin, carbamazepine, etc). Severity 1 drug-disease interactions as classified by FDB. Severity 1 drug-drug interactions as classified by FDB. Targeted medications must have > 7 days of overlap for chronic meds and > 3 days of overlap for acute medications. History of the targeted therapy in the last 365 days without history in the most recent 90 days of pharmacy claims history. Patients with targeted pharmacy claims attributed to > 3 prescribers and > 3 pharmacies within a 60-day period. Patients currently receiving greater than once dosage unit per day of targeted medications. > 35 days of overlapping therapy between to two targeted medications in the most recent 60 days of pharmacy claims history. Duration of therapy exceeds that supported by package labeling or clinical literature. Daily dose for the most recent 30 days of pharmacy claims history exceeds package labeling clinical literature maximum dosing recommendations. < 60 days of therapy in the last 90 days for targeted chronic medications. Targeted pharmacy claims attributed to > 3 prescribers within a 60-day period Pharmacy utilization above a defined threshold for targeted medications within a 60day period that indicates excessive dosages or inappropriate utilization of the respective drugs/drug class. Patients currently pregnant according to medical claims data and prescribed a medication that has a pregnancy category X classification. Absence of standard of care therapy in the presence of specific diseases/conditions. Patients with history of contraindications to the standard of care therapy are excluded. History of targeted drug therapy but in the absence of an indication in the medical claims data that is supported in package labeling or clinical literature.

Drug-disease interaction Drug-drug interaction

Discontinuation of therapy Doctor Shopper Dose consolidation Duplicate therapy Duration of therapy High Dose Medication adherence Multiple prescribers Overutilization

Pregnancy caution Underutilization

Use without an indication

*May differ according to targeted drug/drug class.
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Attachment 3.3

Washington IBM Profiles Screened & Interventions Summary
TAS= Therapeutic Academic Services

* IBM=Intensive Benefits Management

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Attachment 3.4

Physician, Pharmacy, & Patient Profiling Report

CMS Instructions States which engage in physician, pharmacy profile analysis (i.e., review prescribing or dispensing of multiple prescriptions for multiple patients involving a particular problem type or diagnosis) or engage in patient profiling should report the number of each type of profile (physician, pharmacy, patient) reviewed and identify the subject(s) (diagnosis, problem type, etc.) involved.

Overall Description of RetroDUR Analyses & Profile Review Program The DUR criteria is developed and approved by the DUR Board with the assistance of the Health & Recovery Services Administration (HRSA), Department of Social and Health Services. The DUR Board either creates criteria, adopts criteria from other states/universities, adopts criteria developed from a mental health committee or agency, or revises other criteria developed outside the state, such as established guidelines or standards of care. The DUR Board does not adopt all the criteria presented to it. The DUR Board has traditionally focused its screening and educational efforts toward prescribers and recipients, but not toward pharmacies. Over the past 2 years, the DUR Board has taken a strong focus toward PDL education and mental health drug appropriate use. Affiliated Computer Services (ACS) Heritage does not suggest or present RetroDUR criteria to HRSA or the DUR Board. ACS conducts the Retrospective DUR activities, once the criteria have been approved, under the direction of the HRSA with the assistance of the DUR Board. ACS uses its RetroDUR services in two ways: 1) A type of RetroDUR called Intensive Benefits Management (IBM) services. IBM interventions involved ACS pharmacists faxing practitioners about targeted drug therapy problems. The IBM pharmacists encouraged practitioners to consider changing targeted recipients’ therapy to a more appropriate drug therapy and discussed various alternatives with practitioners (depending upon the criteria given by HRSA to ACS to perform) through letter and educational brochures or charts. A type of RetroDUR called Therapeutic Academic Services (TAS) or Academic Detailing services. These interventions involved two ACS pharmacists having face-to-face visits with practitioners about targeted drug therapy problems. The TAS pharmacists encouraged practitioners to consider changing targeted recipients’ therapy to a more appropriate drug therapy and discussed various alternatives with practitioners (depending upon the criteria given by HRSA to ACS to perform) through face-toface visits with patient profiles and educational brochures or charts as additional written collateral.

2)

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Attachment 3.4.A.
* IBM=Intensive Benefits Management

Washington IBM Interventions Summary
TAS= Therapeutic Academic Services

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Attachment 3.4.B.

Washington TAS Interventions Summary

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ATTACHMENT 4. Summary of DUR Board Activities
CMS Instructions ATTACHMENT 4 is a brief descriptive report on DUR Board activities during FFY 2006. This report should: a) b) Indicate the number of DUR Board meetings held.
Four meetings were held in FFY 2006. See Attachment 4.1 for meeting minutes.

List additions/deletions to DUR Board approved criteria. 1. For prospective DUR, list problem type/drug combinations added or deleted.
For prospective DUR, the DUR Board did not approve, delete, or change any NCPDP ProDUR criteria. However, the DUR Board did approve 2 edits that some call ProDUR and others call concurrent DUR – two criteria requiring PA prior to filling. The DUR Board approved: 1) ADHD - maximum dose and age limits with PA for override. Edits were included as part of the PDL program; and 2) Atypical antipsychotics - maximum dose and age limits with EPA for emergency overrides and an expert 2 nd opinion if max dose is exceeded in children < 13 years.

2. For retrospective DUR, list therapeutic categories added or deleted.
See Attachment 4.2 for additions and deletions of DUR Board-approved RetroDUR criteria.

c)

Describe Board policies that establish whether and how results of prospective DUR screening are used to adjust retrospective DUR screens. Also, describe policies that establish whether and how results of retrospective DUR screening are used to adjust prospective DUR screens.
There are no written Board policies per se. However, it has been standard practice of HRSA and the DUR Board to analyze new ProDUR and RetroDUR edits, and criteria have always been used by the HRSA and DUR Board to help establish new cost-containment initiatives and to monitor rational drug use and prescribing. It has been standard practice by the HRSA and DUR Board to expect that they would be the source of criteria for DUR Board review, sometimes with the help of an outside expert or committee, such as the Mental Health Drug Workgroup. The contractor is not involved in developing and presenting innovative ideas on cost containment & therapeutic appropriateness through the RetroDUR program efforts. The DUR Board decides, under recommendation by experts and the HRSA, whether criteria are significant enough to be handled via PA process, PDL preferred or non-preferred status, or through RetroDUR education alone. The DUR Board advises on RetroDUR program letters and accompanying educational materials that address educational issues that relate to the prescribing and utilization of prescription drugs in the most cost-effective manner.

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Attachment 4 – continued --

d)

Describe any policies used to encourage the use of therapeutically equivalent generic drugs. Include relevant documentation, if available, as ATTACHMENT 5
See Attachment 5 5 for specific descriptions & relevant documentation

e)

Describe DUR Board involvement in the DUR education program. (e.g., newsletters, continuing education, etc.) Also, describe policies adopted to determine mix of patient or provider specific intervention types (e.g., letters, face to face visits, increased monitoring). See Attachments 4.2 and 4.3
 The DUR Board sets the types and quantities of all DUR interventions. HRSA performs monitoring of claims to review drug therapy problems or cost containment issues during the year.

 There are no written policies to determine mix of patient or provider specific intervention types. HRSA and the DUR Board determine the mix of patient and provider specific interventions types and quantity of interventions per year.  HRSA has contracted ACS to conduct RetroDUR prescriber contacts/interventions spread over the course of the year using two methods of RetroDUR: Intensive Benefits Management or IBM (faxed letters and educational material) and Therapeutic Academic Services or TAS (face-to-face prescriber education visits where patient profiles and educational packets are discussed).

 RetroDUR interventions performed by IBM (calls and fax letters to prescribers) resulted in 2,700 recipients and 5,400 prescribers targeted in FFY 2006. There were also 1,300 faceto-face visits in FFY 2006. Prescriber education via face-to-face visits occurred primarily in the Seattle and Spokane areas where the highest concentration of Medicaid recipients live.  IBM (faxed letters) and TAS (face-to-face) educational interventions were reviewed and approved by the DUR Board. Attachment 4.1 contains meeting minutes highlighting DUR Board involvement in DUR education. Attachment 4.3 contains specific RetroDUR criteria descriptions approved by the DUR Board.

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Attachment 4.1

SUMMARY OF MEETING MINUTES
WASHINGTON STATE MEDICAID

DUR BOARD ACTIVITY REPORT
In the state of Washington, there is no distinction between members of or meeting times between the Washington State Pharmacy and Therapeutics Committee and the DUR Board. Therefore, the P&T Committee and the DUR Board are one and the same. DUR BOARD MEMBERSHIP - 10/01/2005 to 09/30/2006
Robert Bray, MD; Daniel Lessler, MD; Vyn Reese, MD; Carol Cordy, MD; Alvin Goo, Pharm D; Jason Iltz, Pharm D.; T. Angelo Ballasiotes, Pharm D.; Janet Kelly, Pharm D; Kenneth Wiscomb, PAC; and Patti Varley, ARNP. Health and Recovery Services Administration (HRSA), Division of Medical Management Coordinating Staff: Siri Childs, Pharm D, Pharmacy Policy Office Chief; Nicole Nguyen, Pharm D, Clinical Staff Pharmacist; and Jeffery Thompson, MD, DMM Chief Medical Officer.

SUMMARY OF MEETING MINUTES December 21, 2005 DUR Board Meeting Minutes
I. ADMINISTRATIVE ITEMS The meeting was brought to order by chairperson, Daniel Lessler, MD. II. Poly-pharmacy for Dual Eligibles Dr. Jeffrey Thompson, Chief Medical Officer for HRSA, provided a presentation of a Medicaid pharmacy intervention to reduce poly pharmacy in the dual eligibles. Starting January 1, 2005 these clients will be transferred to the Medicare Part D Prescription Program and will have $1.00 to $3.00 copays for each prescription. There are about 95,000 dual eligible clients and these clients account for 48% of the fee for service pharmacy dollars spent. The average number of prescriptions these clients receive a month are 7, with some clients receiving more than 20 prescriptions a month. This intervention targeted 299 clients with ten or more prescriptions a month and two or more prescribers. A prescription history print out was sent to the prescribers of these clients. Prescribers were asked to coordinate with the other prescribers to consolidate drug therapy when appropriate, stop duplicate therapy, and compare the client’s drug regimen to the Medicare Part D PDP formulary to determine if the drugs are covered. 46% of prescribers found the information useful but did not make changes, 6% discontinued drugs, and 11% found the information not useful. III. Therapeutic Duplication of Atypical Antipsychotics Dr. Jeffrey Thompson presented the status of the Mental Health Drugs Workgroup’s work on duplication of the atypical antipsychotics. The number of clients with duplication of each drug combination for 3 out of 3 months is known and being reviewed. There are over 2000 clients receiving drug therapy with multiple atypicals totally over $5 Million in 4th quarter 2004. The dosages of the drugs will also be reviewed. IV. MANUFACTURERS’ PRESENTATION - None V. STAKEHOLDERS’ PRESENTATIONS - None VI. RECOMMENDATIONS OF COUNCIL - The presentation was informational only.

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Attachment 4.1 – continued --

February 15, 2006 DUR Board Meeting Minutes
I. ADMINISTRATIVE ITEMS The meeting was brought to order by chairperson, Daniel Lessler, MD. A review of the minutes from the December 2005 Drug Utilization Review (DUR) Board meeting was tabled until the April 19, 2006 meeting. II. ADHD Drugs Criteria for Appropriate Use The recommendations for the use of drugs in the treatment of Attention Deficit Hyperactivity Disorder (ADHD) came from the mental health workgroup. This workgroup consists of mental health providers from the community and from the state as well as other stakeholders. June Bredin, MD presented the recommendation to the DUR board. The presentation had three parts: what criteria and thoughts went into making recommendations; the gathering of information from child psychiatry groups including the people at Children’s; and then the general recommendations that resulted. The majority of the adults and children with an ADHD diagnosis are treated by primary care physicians. The recommendations were designed with this in mind to ensure that they were appropriate, but not too restrictive for both primary care and psychiatry providers. The guidelines were designed to promote clients to receive effective treatment quickly and safely. The group started by reviewing the Oregon Health Sciences Evidence Based Review on the ADHD drugs as well as data provided by Dr. Siri Childs showing the prescribing trends in Medicaid. The recommendations were developed using the American Academy of Pediatrics guidelines, the pharmacology of the drugs, and the Children’s and community child psychiatry’s review of the available research. Nondrug treatments were also considered since behavioral modification, educational support and parental education also play a very big role in treating this disease. The group also looked at whether there were more vulnerable populations such as the very young or those with comorbidities that required a higher level of evidence. There was not good evidence in all populations, and the group considered the possiblity that when there are no good studies the drugs could cause some harm. The drugs have side effects, especially at higher doses. There was a minority of clients receiving very high doses of the ADHD drugs and a minority receiving a combination of an ADHD drug with a sedative. The group looked at the FDA recommended dosing, the pharmacology of the drugs and the data showing the number of clients on doses above 150% of these limits. They found some very young children on high doses of these drugs. The group also looked at the number of clients on a combination of these drugs and also found that there really was not good evidence showing that these drugs should be combined. There was evidence to support having available both short and long acting drugs in both of the stimulant groups. If a patient fails a methylphenidate due to lack of response, it is best to try a drug from a different group such as dextroamphetamine or Straterra. The group also looked for children using sedatives on a chronic basis as well as a stimulant to treat ADHD. One of the recommendations was to require that two preferred drugs be tried before a non-preferred drug is tried since there are three drug groups available. There is a preferred option available specifically for adolescents and adults when there is a cardiovascular risk with stimulants or if there is any concern regarding diversion or abuse. The group agreed on the maximum dose guidelines. In clients greater than age 5 the maximum dose for methylphenidate is 120mg, and for children 3 to 5 years the maximum dose is 30mg a day. Children less than 3 years of age would not be approved without a review by an expert. The maximum dose for age 5 and up for amphetamines is 60 mg, and the maximum dose for children 3 to 5 years is 15mg a day.
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Attachment 4.1 – continued -The group is also currently trying to address both the issues in their recommendations that there are a fair number of children and adolescents that are on both classes of stimulants as well as a minority that are also on chronically prescribed sedatives. Dr Bredin informed the DUR board that the plan is to implement with their approval the dose and age limits when the ADHD drug class is implemented as part of the preferred drug list. There will be hard edits for children under 5 years of age and for any order over the recommended maximum dose. Eventually the plan is to implement the hard edit for combinations of ADHD drugs. This edit would allow a short and long acting methylphenidate for example, but not a mix of a methylphenidate long acting with an amphetamine short acting for example. The latter will require medical justification. At some point the combination of a stimulant with a sleeper will be implemented and this combination will require medical justification. For anyone under the age of 18 years an approval of a sleeper would only be for one time and a maximum of 5 doses. Patty Varley asked whether access would be denied or allowed to continue in the infrequent cases of clients who are fast metabolizers of these drugs. Dr Bredin conveyed that for children on doses greater than 150% of the FDA recommendation, the charts should be reviewed by an expert at Children’s, or Mary Bridge for example. This will help ensure that the right diagnosis has been determined and if the child is really a fast metabolizer and is doing well it should be approved. Patty Varley asked if it has been considered in the recommendations that some children may develop tolerance to the two types of stimulants and require switching back and forth from one to the other. Dr Bredin answered that they have discussed this and they will most likely be looking for a 30 day or more overlap of the medications. Dr Graham pointed out an error in slide eight. For non endorsing providers in the second bullet it says some documentation of intolerance to starting with a non preferred drug. Dr Bredin confirmed that this is incorrect and it should say intolerance to starting with a preferred drug. It was asked if there will be information made available from this group for providers to use to educate themselves. Dr Bredin answered that prescriber education will be done at least for the month before any implementation is done. Those prescribers who write for children less than 5 years of age and for doses greater than recommended will be targeted to receive a packet including the patient drug history and a request to either provide medical justification or to reconsider the treatment before the hard edit hits those patients. The material that has been developed by the group is available on the HRSA pharmacy website for any prescriber. Angelo Ballasiotes asked whether there would be recommendations for adults. Dr Bredin informed that the group did also talk about adults and using the same dosing guidelines that are to be used for adolescents and they realize that there may be more reasons not to use the amphetamines in adults either for cardiac reasons or for diversion or abuse potential. Dr. Childs informed the Board that the numbers of Medicaid clients that are under the age of 5 on these drugs are about 634, and the number of clients on doses higher than recommended is about 484 clients and the prior authorization lines are able to handle this call/fax volume. II. MANUFACTURERS’ PRESENTATION - None III. STAKEHOLDERS’ PRESENTATIONS – None IV. RECOMMENDATIONS OF COUNCIL Patty Varley recommended approval of the Washington State Mental Health Stakeholders work group ADHD drug therapy safety edit. Ken Wiscomb seconded the motion and it was approved by the DUR Board.
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Attachment 4.1 – continued --

June 21, 2006 DUR Board Meeting Minutes
Health and Recovery Services Administration (HRSA), Division of Medical Management coordinating staff: Siri Childs, Pharm D, Pharmacy Policy Office Chief; Jonell Blatt, Program Manager; and June Bredin, MD., Mental Health Drug Workgroup presenter. Labor and Industry (L&I) coordinating staff: Gary Franklin, MD, Medical Director; Jaymie Mai, Pharm.D., Pharmacy Consultant; and Doug Toumin, RPh, Pharmacy Consultant. I. ADMINISTRATIVE ITEMS The meeting was brought to order by chairperson, Daniel Lessler, MD. The minutes from the December 2005 and the February 2006 Drug Utilization Review (DUR) Board meetings were approved. II. Efficacy and Comparative Effectiveness of Off Label Use of Atypical Antipsychotics Gary Franklin, MD, Medical Director for L&I, introduced (via telephone conference call) the author, Paul Shekelle, MD, from Rand Health, Southern California Evidence Based Practice Center. Dr. Shekelle reviewed the five key questions researched for this report: 1) What are the leading off-label uses of antipsychotic drugs in the literature? 2) What does the evidence show regarding the effectiveness of antipsychotics for off label indications, such as depression? How do antipsychotic medications compare to other drugs for treating off label indications? 3) What subset of the population would potentially benefit from off label use? 4) What are the potential adverse effects and/or complications involved with off label antipsychotic prescribing. 5) What is the appropriate dose and time limit for off label indications? Dr. Shekelle discussed the Rand peer review process and the “fine-tuning” of the key questions: 1) The scope of the review project was narrowed by changing the term, “antipsychotics” “atypical antipsychotics, except clozapine”. 2) Key question #1 was dropped; instead the specific off label indications of interest were listed for the review:  Behavioral problems in dementia  Depression  Obsessive Compulsive Disorder  PTSD  Personality Disorder  Tourette’s Syndrome  Autism Dr. Shekelle reported on the results of the systematic review of comparative efficacy for each of the offlabel indications above. See attachment ( slide presentation by Dr. Shekelle). Next, Dr. Shekelle reported on the comparative evidence of safety for the atypical antipsychotics. Again, please see the attachment of his slide presentation. Looking at the results of the research for key question #3 and #5, there wasn’t evidence to show benefit in subpopulations, nor was there evidence about appropriate dose and time limit.

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Attachment 4.1 – continued -Dr. Shekelle summarized the overall findings in the report:  Some evidence of benefits in behavioral disturbances in dementia, obsessive compulsive disorder, and autism.  Perhaps onset of recovery is faster in patients with treatment resistant depression if augmented with atypical antipsychotics?  Too few trials to say anything about all other conditions.  No data on long term effectiveness.  Increased risk of death in patients with dementia  Increased weight gain with olanzapine  Data are most numerous for risperidone and olanzapine, least for aripiprazole and ziprasidone. The DUR Board discussed the findings of the report and asked clarifying questions of Dr. Shekelle. Chairman Lessler asked the Mental Health Drug Workgroup to continue their work, using evidence-based reports to develop the criteria for coverage for off-label indications. Dr. Thompson, Medical Director, HRSA, will continue to lead the group as they review the reports and determine the level of evidence and coverage by HRSA. Atypical Antipsychotic Review: Mental Health Drug Work Group Safety Recommendations Dr. June Bredin, Physician, Rainer School for Developmentally Disabled, and physician member of the Mental Health Drug Work Group delivered HRSA’s slide presentation for Dr. Thompson. See attached. Dr. Bredin started the presentation by describing the process that HRSA and the Mental Health Drug Work Group went through to develop the age and dose limits for atypical antipsychotics. Using pharmacy claims data the age groups were identified as the following:  <3  3-5  6-12  13-17  18-59  60 and over The number of clients taking atypicals was identified in each age group. The number of children prescribed doses above the recommendations set by the work group was tallied. The average daily dose for adults was reported. The DUR Board was asked to accept the age and dose recommendations of the Mental Health Drug Work Group to guide the safe use of atypical antipsychotics. The recommendations included requiring a second opinion from an HRSA-designated mental health expert for prescriptions written over the age and dose limits for children less than thirteen. The work group will work with HRSA to be sure that first orders for acute crisis treatment will be processed immediately. Dr. Thompson’s message to the DUR Board delivered by Dr. Childs was that atypical second opinion requests would be implemented only after an adequate network was developed to ensure access. V. MANUFACTURERS’ PRESENTATION – None VI. STAKEHOLDERS’ PRESENTATIONS Mr. Jim Adams, NAMI, spoke in favor of the work that the Mental Health Drug Work Group had done in conjunction with Dr. Thompson and HRSA. VII. RECOMMENDATIONS OF BOARD The Board unanimously approved the Mental Health Drug Work Group recommendations for age and dose limits for the atypical antipsychotics as presented by Dr. Bredin. See Attachment A below.
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Attachment 4.1 – continued --

Attachment A Mental Health Drug Work Group Recommendations

Drug

FDA Max Dosage 16 mg 20 mg 800 mg 160 mg 30 mg 900 mg

Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Clozapine

State Hospital Max Dosage 16 mg 20 mg 800 mg 160 mg 30 mg 900 mg

Work Group Max Dosage Recommendations for Children <3* 3-5* 6-12* 13-17 Yrs Yrs Yrs Yrs -02 mg 4 mg 6 mg -02.5 mg 10 mg 20 mg -0-0- 200 mg 600 mg -0-080 mg 160 mg -0-015 mg 30 mg -0-0-0- 900 mg

Work Group Max Dosage Recommendations for Adults 9 mg 40 mg 1200 mg 320 mg 60 mg 900 mg

*Under 13 requires HRSA designated expert opinion * EPA criteria will be developed to facilitate access for emergent use

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Attachment 4.1 – continued --

October 18, 2006 DUR Board Meeting Minutes
Health and Recovery Services Administration (HRSA), Division of Medical Management Coordinating Staff: Jeffery Thompson, MD, Chief Medical Officer. Guest presenters from Affiliated Computer Services (ACS) were Ileana Soto, RPh, (by telephone conference call) and Krista Issackson, RPh.

Medicaid DUR Activity – IBM/TAS Outcomes for 2005-2006
ACS presented the targeted DUR in Insensitive Benefit Management (IBM). Process and Purpose  Targeted review determined and approved by State of Washington, DSHS HRSA based on safety and outlier consideration in prescribing  Data analysis conducted to flag all clients meeting targeted review criteria  Clinical medication review performed for selected client profiles with the associated providers contacted and asked to consider: o Appropriate pharmaceutical care, or o Cost-effective drug therapies, or o Notification of changes to the Preferred Drug List (PDL), or o State clinical initiatives on safety limits and “off label” use Targeted review areas of concentration:  Provider Education  Preferred Drug List  Therapeutic Interchange Program (TIP)  Mental Health Initiatives  Duplication of Therapy  Cost-effective therapies  Safety and DUR consideration The areas of interest included:  Narcotic Review when clients exceed 10 narcotic Rxs per month  Poly Prescribing of second generation antidepressants (i.e. 2 or more docs)  Duplication of second generation (i.e. 2 or more SSRIs)  Age and dose safety limits for ADHD stimulants IBM Outcomes were:  2700 Clients Rx patterns targeted from 10/2005 through 8/2006  5400 Providers sent the client information  Response rates varied between 16-67%  Current therapy thought appropriate varied between 17-68%  Planned to change or discontinue therapies 1-14% DUR Discussion:  The DUR panel were unclear as to the value of the IBM program. Questions were asked regarding an ROI or how the IBM program fit into the DUR strategies.  Health and Recovery Services pointed out that the IBM program is a stand alone program and that an ROI has not been calculated. The IBM is part and parcel of an education and communication program for PDL rollouts and MHDWG safety limits.
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Attachment 4.1 – continued - The panel noted a marked difference in the number of prescribers of narcotic RX (1 client to 9 presribers) vs. non narcotic (1 client to 2 Prescribers).  Health and Recovery Services stated that there are several programs designed to address abuse/misuse including the Narcotic review, the AMDG narcotic guidelines, PRR, and DASA referral services  The Panel asked the agency if they would bring a strategic plan for DUR activities for their review and comment.  HRSA stated that their input would be critical to an effective strategic plan.

ACS presented the targeted TAS Therapeutic Consultative Services.
The rationale/processes for TAS include: Objectives:  Provide an overview of the Therapeutic Academic Service (TAS) Program utilized by the Department of Social and Health Services (DSHS) for Washington Medicaid  Review targeted review statistics from October 2005 through September 2006  Discuss provider feedback from each targeted review Therapeutic Academic Service (TAS)  Academic detailing program  Two clinical pharmacists  Seattle area  Spokane area  Face-to-Face targeted review with prescribers  120 prescribers visited each month  Targeted visit focus  PDL and Evidence Based Drug therapies  Client programs related to safety issues (DUR edits including age, dose, polyprescribing, and combinations)  Promote cost-effective therapies The areas of interest included:  Part D providers with high use clients  Narcotic Review when clients exceed 10 narcotic Rxs per month  Poly Prescribing of second generation antidepressants (i.e. 2 or more docs)  Duplication of second generation (i.e. 2 or more SSRIs)  Age and dose safety limits for ADHD stimulants The outcomes of the programs were:  Providers found the outreach efforts informative  1300 Prescribers were detailed from 10/2005 through 8/2006  Prescribers appreciated the client lists and would add them to charts  Narcotic RX lists and program information add clinical value  Prescribers did not wish to change their current ADHD therapies and Through PA and second opinion processes burdensome but liked the new clinical guidelines  Providers appreciated the PDL and TIP information brought by the academic detailers

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Attachment 4.1 – continued -Mental Health Drugs (Workgroup Intended Goals) HRSA presented the current work @ Mental Health Drug Work Group. A sheet was given to the DUR outlining the future communication education efforts with mental health drugs (see attachments). The current activity of the group includes:    Advance “evidence-based” mental health therapy. Promote effective collaboration with mental health community Measure and review mental health therapy utilization data.  Number of RX’s  12 month RX History  Polypharmacy  Poly-prescriber’s  Adherence  Coordination of care o Eastern o Western o DASA

The DUR Board members were in agreement of age, dose and poly-pharmacy limits to be included in the TAS/IBM activities. The DUR again wanted more information about the success of these programs. HRSA indicated that they would bring the ADHD second opinion activity. In addition HRSA indicated that they would be working with ADSA and Mental Health to coordinate care management and look for new opportunities to reduce inappropriate dosing and narcotic use.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 4.2

RETRO-DUR CRITERIA CHANGES (& ADDITIONS)

INAPPROPRIATE DOSE
1. 2. 3. * Attention Deficit Hyperactive Disorder (ADHD) High Dose Therapy 1. 2. 3.

THERAPEUTIC DUPLICATION
Second Generation Antidepressants Attention Deficit Hyperactive Disorder (ADHD) Agents

DRUG ALLERGY INTERACTION
1. 2. 3.

INAPPROPRIATE DURATION
1. 2. 3. 1. 2. 3.

DRUG/ DRUG INTERACTIONS
Combination of Triptans & (SSRI or SNRI) causing Serotonin Syndrome 1. 2. 3.

DRUG DISEASE CONTRAINDICATION

OTHER PDL Implementations
1. 2. 3. Immune Modulators

(specify) 1. 2. 3.

OTHER Monitoring Polypharmacy
Narcotics Review Program

(specify) 1. 2. 3.

OTHER Drug-Age Contraindication (specify)
*Attention Deficit Hyperactive Disorder (ADHD) Therapy for patients <5 yrs old *Identified Sedative/Hypnotics use in patients < 18 years of age

Antiemetics, Atypical Antipsychotic Thiazolidiones, Nasal Corticosteroids, Second Generation Antidepressant

Dual Eligibles clients receiving 20 unique medications in 60 days by > 2 physicians

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Attachment 4.3. RetroDUR Criteria Descriptions
WASHINGTON IBM CRITERIA DESCRIPTIONS - FFY2006 Intervention Description Patients included in this review were taking Schedule II and III narcotics. The HRSA has developed the Narcotics Review Project. This project informs providers of potential client NARCOTIC narcotic (schedule IIs and IIIs) misuse, highlights multiple narcotic prescribing, and offers Oct-05 REVIEW programs to risk manage strategies for complex clinical problems. The IBM pharmacist PROGRAM contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. Patients included in this review were dual eligible Medicaid clients dispensed more than POLYPHARMACY 20 unique medications in the last 60 days and prescribed by more than two prescribers. Nov-05 FOR DUAL The IBM pharmacist contacted the prescriber of record by fax/mail to request a reELIGIBLES evaluation of their patient's therapy. Month Intervention Patients included in this review were dual eligible Medicaid clients dispensed more than POLYPHARMACY 10 unique medications in the last 60 days and prescribed by more than two prescribers. Dec-05 FOR DUAL The IBM pharmacist contacted the prescriber of record by fax/mail to request a reELIGIBLES evaluation of their patient's therapy. Patients included in this review were taking Schedule II and III narcotics. The HRSA has developed the Narcotics Review Project. This project informs providers of potential client NARCOTIC narcotic (schedule IIs and IIIs) misuse, highlights multiple narcotic prescribing, and offers Jan-06 REVIEW programs to risk manage strategies for complex clinical problems. The IBM pharmacist PROGRAM contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. Patients included in this review received two or more 2nd Generation Antidepressants. Beginning March 1, 2006, the State implemented Prior Authorization on therapeutic Therapeutic duplication of 2nd Generation Antidepressants based on mechanism of action after 68 Duplication of 2nd days of concurrent therapy. Mental health experts participating in HRSA's Mental Health Feb-06 Generation Drug Initiatives Stakeholder Workgroup determined which drugs in this class are to be Antidepressants considered duplicative, based on the mechanism of action. The IBM pharmacist Intervention contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. Patients included in this review received high dose ADHD drug therapy including amphetamine, methylphenidate and dexmethylphenidate therapy, and/or patients < 5 years old receiving ADHD therapy. Beginning April 1, 2006, the State implemented Prior High dose ADHD Authorizations on high dose ADHD therapy and on use of ADHD therapy in patients < 5 drug therapy and years old. Maximum daily dosing was based on recommendations from the Washington ADHD therapy for State Drug Utilization Review (DUR) Board and the Washington Mental Health < 5yo Stakeholders’Workgroup. For the pediatric population, current available guidelines do not include recommendations on ADHD medications in children younger than 6 years old. The IBM pharmacist contacted the prescriber of record by fax/mail to request a reMar-06 evaluation of their patient's therapy. Patients included in this review received two or more 2nd Generation Antidepressants. Beginning March 1, 2006, the State implemented Prior Authorization on therapeutic Therapeutic duplication of 2nd Generation Antidepressants based on mechanism of action after 68 Duplication of 2nd days of concurrent therapy. Mental health experts participating in HRSA's Mental Health Generation Drug Initiatives Stakeholder Workgroup determined which drugs in this class are to be Antidepressants considered duplicative, based on the mechanism of action. The IBM pharmacist Intervention contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 4.3. – continued -Therapeutic Duplication of ADHD drug therapy Apr-06 Intervention/ Sedative use in patients < 18 yo Intervention Therapeutic Duplication of ADHD drug therapy Intervention/ Sedative use in patients < 18 yo May-06 Intervention

Patients included in this review either received combinations of two or more ADHD drugs and/or were patients < 18 years old receiving sedative/hypnotic therapy. Beginning June 1, 2006, the State implemented Prior Authorizations on combinations of two or more ADHD drugs. Mental health experts participating in HRSA’s Mental Health Drug Initiative Stakeholders’ Workgroup determined which drugs in this class are to be considered duplicative. The State also implemented Prior Authorizations on sedative/hypnotic medications in children younger than 18 years old. The IBM pharmacist contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy.

Patients included in this review either received combinations of two or more ADHD drugs and/or were patients < 18 years old receiving sedative/hypnotic therapy. Beginning June 1, 2006, the State implemented Prior Authorizations on combinations of two or more ADHD drugs. Mental health experts participating in HRSA’s Mental Health Drug Initiative Stakeholders’ Workgroup determined which drugs in this class are to be considered duplicative. The State also implemented Prior Authorizations on sedative/hypnotic medications in children younger than 18 years old. The IBM pharmacist contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. Patients included in this review received two or more 2nd Generation Antidepressants. Beginning March 1, 2006, the State implemented Prior Authorization on therapeutic Therapeutic Duplication of 2nd duplication of 2nd Generation Antidepressants based on mechanism of action after 68 days of concurrent therapy. Mental health experts participating in HRSA's Mental Health Generation Drug Initiatives Stakeholder Workgroup determined which drugs in this class are to be Antidepressants considered duplicative, based on the mechanism of action. The IBM pharmacist Intervention contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. HRSA updated their PDL list by adding 2 new classes. Patients included in this review were taking non-preferred medications in the Immune modulators and the Antiemetic PDL INITIATIVE classes. The IBM Pharmacist contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy and a switch to the PDL medications and a switch to the PDL medications. Seven previous behavioral health issues were repeated , providers were contacted Jun-06 regarding additional clients. These issues included Safety Edits on the use of Amphetamines, Methylphenidate and Dexmethylphenidate, and ADHD use in children Behavioral Health less than 5 yrs old and Sedative use in children less than 18 yrs old. In addition Initiative Therapeutic Duplication of ADHD medications and Therapeutic Duplication of Antidepressents were also readdressed. The IBM pharmacist contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy.

Patients included in this review were taking Schedule II and III narcotics. The HRSA has developed the Narcotics Review Project. This project informs providers of potential client NARCOTIC narcotic (schedule IIs and IIIs) misuse, highlights multiple narcotic prescribing, and offers Jul-06 REVIEW programs to risk manage strategies for complex clinical problems. The IBM pharmacist PROGRAM contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. Patients included in this review were taking both a Triptan and an SSRI or SNRI medication.On July 19th, the FDA had issued a Public Health Advisory regarding COMBINED USE serotonin syndrome in patients concurrently prescribed a triptan and either an SSRI or Aug-06 OF TRIPTANS SNRI antidepressant. The combination can increase serotonin levels and therefore AND SSRIs/SNRIs increase the risk of developing this syndrome. The IBM pharmacist contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy. HRSA updated their PDL list by adding 3 new classes and updating a fourth. Patients included in this review were taking non-preferred medications in the Atypical Antipsychotic, the Nasal Corticosteroid, the Thiazolidinediones, and/ or the Second Sep-06 PDL INITIATIVE Generation Antidepressant classes. The IBM Pharmacist contacted the prescriber of record by fax/mail to request a re-evaluation of their patient's therapy and a switch to the PDL medications.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 5.
POLICIES ON USE OF THERAPEUTICALLY EQUIVALENT GENERIC DRUGS Analysis of paid claims during the FFY 2006 date of service period covered by this Annual Report, revealed that the Washington State Medicaid program had the following: Generic dispensing rate (“GDR”, defined as the percentage of generic prescriptions dispensed as compared to the total number of prescriptions dispensed) was 60.9% for FFY 2006 (versus 58.1% in FFY 2005 and 55.5% in FFY 2004). The generic dispensing rate after Medicare D implementation for calendar year 2006 was 61.7%. The GDR has been steadily increasing over the past several years. The Washington State Department of Social and Health Services, Medical Assistance Administration policy on use of generics comes from [WAC 388-530] and is found in the Prescription Drug Program Manual for providers under C.9 Generic drugs. Other laws and regulations affect the policy on generics as well. For your reference, copies of the Washington state generic substitution laws and Washington Administrative Code are provided below and on subsequent pages.

C.9 Generic drugs policy
Prescribers and pharmacies should prescribe and dispense the generic form of a drug, whenever possible. Prior authorization may be required for reimbursement of brand name drugs at brand name pricing when a generic equivalent is available. If the brand name drug is prescribed instead of a generic equivalent, the prescriber must provide medical justification for the use of the brand name drug to the pharmacist. Prior authorization is based on medical need such as adverse reactions (clinically demonstrated, observed and documented) which have occurred when the generic drug has been used. Generic drugs should be substituted for listed brand name drugs when: They are approved by the FDA as therapeutically equivalent drugs; and They are permitted by the prescribing physician under current state law.

Washington Administrative Code 182-50 Chapter 182-50 WAC (Prescription drug programs).

Last Update: 2/23/04

WAC Section 182-50-200. Endorsing practitioner therapeutic interchange program; effect of practitioner's endorsing status; dispense as written instructions. (1) When filling prescriptions for participating state purchased health care programs, pharmacists shall dispense a preferred drug in place of a drug not included in the preferred drug list in a given therapeutic class whenever pharmacists receive a prescription from an endorsing practitioner except: (a) If the endorsing practitioner determines the nonpreferred drug is medically necessary by indicating "dispense as written" on the prescription; or

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Attachment 5. – continued --POLICIES ON USE OF THERAPEUTICALLY EQUIVALENT GENERICS

(b)

If the prescription is a refill of an antipsychotic, antidepressant, chemotherapy, antiretroviral, or immunosuppressive drug.

(2)

When a therapeutic interchange is made, the pharmacist shall notify the endorsing practitioner of the specific drug and dose dispensed.

The Revised Code of Washington (RCW) is the compilation of all permanent laws now in force.
RCW 69.41.100. Legislative recognition and declaration. The legislature recognizes the responsibility of the state to insure that the citizens of the state are offered a choice between generic drugs and brand name drugs and the benefit of quality pharmaceutical products at competitive prices. Advances in the drug industry resulting from research and the elimination of counterfeiting of prescription drugs should benefit the users of the drugs. Pharmacy must continue to operate with accountability and effectiveness. The legislature hereby declares it to be the policy of the state that its citizens receive safe and therapeutically effective drug products at the most reasonable cost consistent with high drug quality standards. [1986 c 52 § 1; 1977 ex.s. c 352 § 1.] Notes: Severability -- 1977 ex.s. c 352: "If any provision of this act, or its application to any person or circumstance is held invalid, the remainder of the act, or the application of the provision to other persons or circumstances is not affected." [1977 ex.s. c 352 § 10.] RCW 69.41.110. Definitions. As used in RCW 69.41.100 through 69.41.180, the following words shall have the following meanings: (1) "Brand name" means the proprietary or trade name selected by the manufacturer and placed upon a drug, its container, label, or wrapping at the time of packaging; (2) "Generic name" means the official title of a drug or drug ingredients published in the latest edition of a nationally recognized pharmacopoeia or formulary; (3) "Substitute" means to dispense, with the practitioner's authorization, a "therapeutically equivalent" drug product of the identical base or salt as the specific drug product prescribed: PROVIDED, That with the practitioner's prior consent, therapeutically equivalent drugs other than the identical base or salt may be dispensed; (4) "Therapeutically equivalent" means essentially the same efficacy and toxicity when administered to an individual in the same dosage regimen; and (5) "Practitioner" means a physician, osteopathic physician and surgeon, dentist, veterinarian, or any other person authorized to prescribe drugs under the laws of this state. [1979 c 110 § 1; 1977 ex.s. c 352 § 2.]

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 5. – continued --POLICIES ON USE OF GENERIC DRUGS

RCW 69.41.120. Prescriptions to contain instruction as to whether or not a therapeutically equivalent generic drug may be substituted — Out-of-state prescriptions — Form — Contents — Procedure. Every drug prescription shall contain an instruction on whether or not a therapeutically equivalent generic drug may be substituted in its place, unless substitution is permitted under a prior-consent authorization. If a written prescription is involved, the prescription must be legible and the form shall have two signature lines at opposite ends on the bottom of the form. Under the line at the right side shall be clearly printed the words "DISPENSE AS WRITTEN". Under the line at the left side shall be clearly printed the words "SUBSTITUTION PERMITTED". The practitioner shall communicate the instructions to the pharmacist by signing the appropriate line. No prescription shall be valid without the signature of the practitioner on one of these lines. In the case of a prescription issued by a practitioner in another state that uses a one-line prescription form or variation thereof, the pharmacist may substitute a therapeutically equivalent generic drug unless otherwise instructed by the practitioner through the use of the words "dispense as written", words of similar meaning, or some other indication. If an oral prescription is involved, the practitioner or the practitioner's agent shall instruct the pharmacist as to whether or not a therapeutically equivalent generic drug may be substituted in its place. The pharmacist shall note the instructions on the file copy of the prescription. The pharmacist shall note the manufacturer of the drug dispensed on the file copy of a written or oral prescription. [2000 c 8 § 3; 1990 c 218 § 1; 1979 c 110 § 2; 1977 ex.s. c 352 § 3.] Notes: Findings -- Intent -- 2000 c 8: See note following RCW 69.41.010.

RCW 69.41.130. Savings in price to be passed on to purchaser. Unless the brand name drug is requested by the patient or the patient's representative, the pharmacist shall substitute an equivalent drug product which he has in stock if its wholesale price to the pharmacist is less than the wholesale price of the prescribed drug product, and at least sixty percent of the savings shall be passed on to the purchaser. [1986 c 52 § 2; 1979 c 110 § 3; 1977 ex.s. c 352 § 4.]

RCW 69.41.140. Minimum manufacturing standards and practices. A pharmacist may not substitute a product under the provisions of this section unless the manufacturer has shown that the drug has been manufactured with the following minimum good manufacturing standards and practices: (1) Maintain quality control standards equal to those of the Food and Drug Administration; (2) Comply with regulations promulgated by the Food and Drug Administration. [1979 c 110 § 4; 1977 ex.s. c 352 § 5.]

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Attachment 5. – continued --POLICIES ON USE OF GENERIC DRUGS RCW 69.41.150. Liability of practitioner, pharmacist. (1) A practitioner who authorizes a prescribed drug shall not be liable for any side effects or adverse reactions caused by the manner or method by which a substituted drug product is selected or dispensed. (2) A pharmacist who substitutes an equivalent drug product pursuant to RCW 69.41.100 through 69.41.180 as now or hereafter amended assumes no greater liability for selecting the dispensed drug product than would be incurred in filling a prescription for a drug product prescribed by its established name. (3) A pharmacist who substitutes a preferred drug for a nonpreferred drug pursuant to RCW 69.41.190 assumes no greater liability for substituting the preferred drug than would be incurred in filling a prescription for the preferred drug when prescribed by name. [2003 1st sp.s. c 29 § 6; 1979 c 110 § 5; 1977 ex.s. c 352 § 6.] Notes: Finding -- Intent -- Severability -- Conflict with federal requirements -- Effective date -- 2003 1st sp.s. c 29: See notes following RCW 74.09.650. RCW 69.41.160. Pharmacy signs as to substitution for prescribed drugs. Every pharmacy shall post a sign in a location at the prescription counter that is readily visible to patrons stating, "Under Washington law, an equivalent but less expensive drug may in some cases be substituted for the drug prescribed by your doctor. Such substitution, however, may only be made with the consent of your doctor. Please consult your pharmacist or physician for more information." [1979 c 110 § 6; 1977 ex.s. c 352 § 7.] RCW 69.41.170. Coercion of pharmacist prohibited — Penalty. It shall be unlawful for any employer to coerce, within the meaning of RCW 9A.36.070, any pharmacist to dispense a generic drug or to substitute a generic drug for another drug. A violation of this section shall be punishable as a misdemeanor. [1977 ex.s. c 352 § 8.] RCW 69.41.180. Rules. The state board of pharmacy may adopt any necessary rules under chapter 34.05 RCW for the implementation, continuation, or enforcement of RCW 69.41.100 through 69.41.180, including, but not limited to, a list of therapeutically or nontherapeutically equivalent drugs which, when adopted, shall be provided to all registered pharmacists in the state and shall be updated as necessary. [1979 c 110 § 7; 1977 ex.s. c 352 § 9.]

Prescription Drug Therapeutic Interchange Program - Senate Bill 6088
In June 2003, Senate Bill 6088 was signed into law. The new law requires pharmacists to practice therapeutic interchange when filling prescriptions for state health care programs. The Therapeutic Interchange Program (TIP) is a process developed by HRSA, the Health Care Authority (HCA), and Labor and Industries (L&I), to allow physicians and other prescribers to endorse the Washington Preferred Drug List (PDL). TIP is intended to streamline administrative procedures and make prescription drugs more affordable to Washington residents and state health care programs. TIP applies only to drugs on the Washington PDL prescribed by an endorsing practitioner, and not to other drugs requiring prior authorization. An endorsing provider reviewed the Washington PDL and has notified the HCA that he or she has agreed to allow therapeutic interchange of a preferred drug for any non-preferred drug in a given therapeutic class.
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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 6.1
RXMU1000-R002 AS OF 09/30/06

ProDUR Program Savings Summary – FFY 2006
WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM CONSULTEC PRESCRIPTION DRUG CARD SERVICES

P R O S P E C T I V E

D U R

S A V I N G S

CLAIMS PAID FROM 10/01/05 - 09/30/06
DUR ALERTS SUMMARY GROUP: CONFLICT CODE DD HD ID LD SX TD 7850 WASHINGTON MEDICAID PRESCRIPTION DRUG PROGRAM NUMBER OF RX PAID 327,435 386,651 461,564 714,882 1,871 337,536 3,229,939 PERCENTAGE OF ALL DUR CLAIMS 10 12 14 22 0 41 AMOUNT PAID 6,350,198.46 3,073,247.79 7,036,254.82 6,784,522.83 162,109.37 604,669.36 24,011,002.63 PERCENTAGE OF ALL DUR CLAIMS 3 2 4 3 0 0 NUMBER OF RX REVERSED 31,152 47,126 49,261 77,008 263 161,049 365,859 AMOUNT REVERSED 1,890,131.93 4,906,072.14 2,048,029.04 3,447,741.75 20,045.13 3,480,426.73 $ 15,792,446.72

TYPE OF CONFLICT DRUG-DRUG INTERACTIONS HIGH DOSE ALERT INGREDIENT DUPLICATION LOW DOSE ALERT DRUG GENDER ALERT THERAPEUTIC DUPLICATION

PRO-DUR TOTALS

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 6.2

RetroDUR Program Savings Summary Estimates Washington Medicaid October 2005 – September 2006

RETRODUR (IBM AND TCS) OUTCOMES REPORTS ACS Heritage, Inc. has completed outcomes analyses for the Intensive Benefits Management IBM) and Therapeutic Consultation Services (TCS) programs conducted by ACS on behalf of Washington Medicaid from October 2005 through September 2006. Table 1 provides summary statistics for the IBM and TCS programs process. During FFY 2006, the 1,282 profiles that were reviewed generated 1,042 letters to 1,042 physicians and targeted 825 patients. While RetroDUR letters were mailed for 825 recipients, 498 were identified as continuously eligible and included in the outcomes assessments. Table 1: FFY06 Intervention Program IBM TCS Totals

Targeted Patients Targeted Physicians 954 1,513 1,422 835 2,251 2,158

Letters Faxed 1,901 NA 1,901

Table 2 summarizes the overall changes in the incidence of clinical indicators from baseline to the 6-month evaluation period for those recipients targeted at baseline and continuously enrolled throughout. Overall, the targeted group saw a decrease in the rate of drug therapy problems of 33%. The largest percent decrease and largest decrease in the number of drug therapy problems was seen in the “Duplicate therapy” flag (i.e., 50% and 121, respectively).

Table 2: Percent Change in Clinical Indicators for IBM Clinical Indicator Targeted Group Dosage -64% Duplicate therapy -66% Increased risk of adverse event -86% Narcotic overutlization* -52% Overall -56%
*Based on changes in the number of narcotic analgesic claims per and post.

Control Group -73% -65% -85% NA -71%

Table 3: Percent Change in Clinical Indicators for TCS Clinical Indicator Targeted Group Dosage -72% Duplicate therapy -56% Increased risk of adverse effect -81% Narcotic overutilization* -51% No indication -44% PDL -55% Overall -50%
*Based on changes in the number of narcotic analgesic claims per and post.

Control Group -41% -56% -90% -48% -39% -45% -47%

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-- continued -- Attachment 6.2 RetroDUR Program Savings Summary Estimates Table 4 exhibits the 6-month cost savings for both IBM and TCS interventions. Specific savings for each respective intervention may be found in the Outcomes Assessments. Per patient per month (PPPM) drug amount paid for total drugs were separately calculated for both the targeted (i.e., IBM or TCS) and control groups for the six-month baseline and six-month post-intervention periods. The percent difference between the baseline and post-period PPPM paid amount was then calculated for the control group. This percentage was then multiplied by the baseline PPPM amount paid for the detailed group in order to estimate the PPPM amount paid in the post-intervention period for the detailed group had there been no intervention. The actual PPPM amount paid for the detailed group was then subtracted to obtain the estimated PPPM savings. Finally, the PPPM savings was multiplied by the number of intervention months and number of targeted patients. Overall, a 6-month savings of $320,731 was reported.

Table 4: Total IBM and TCS 6-month Savings Intervention 6-month Savings IBM $307,757 TCS $12,974 Total for 6-months $320,731 RETRODUR CONCLUSION The IBM and TCS programs were effective in improving quality of care for Washington Medicaid recipients while also providing cost avoidance over the FFY 2006. The FFY 2006 net cost avoidance for the RetroDUR program administered by ACS, Inc. is estimated to be $641,462.

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State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 6.3

ProDUR & RetroDUR Program Savings Conclusions

DUR serves a vital monitoring purpose. Prospective DUR (ProDUR) and Retrospective DUR (RetroDUR) each serve a unique purpose in alerting practitioners and pharmacists with specific, focused and comprehensive drug information available from no other source. If practitioners and pharmacists use DUR as intended, then notification of a potential drug therapy problem will lead to appropriate action taken in response to a ProDUR alert or RetroDUR intervention. Appropriate actions include discontinuing unnecessary prescriptions, reducing quantities of medications prescribed, switching to safer drug therapies, or even adding a therapy recommended in published (evidence-based) guidelines from an expert panel. Estimated prescription drug savings resulting from ProDUR and RetroDUR programs for the Federal Fiscal Year (FFY) 2006 are shown in Attachments 6.1 and 6.2. Drug savings estimates from DUR programs are measured by the actual claims before and after interventions. The state of Washington Medicaid total estimated drug savings (or costs avoided) over the FFY 2006 for ProDUR program was at least $15,792,447. This figure does not include savings or costs avoided resulting from other policies and programs such as “hard alerts” (that is, ProDUR alerts that require a prior authorization) or the establishment of quantity or duration limits. These programs’ savings would be costs avoided in addition to the ProDUR edits. The state of Washington Medicaid total estimated drug savings (or costs avoided) over the FFY 2006 for the RetroDUR program was $ 641,462. RetroDUR programs, such as the IBM program, ensures program savings and ensures that alerted claims are medically necessary, reasonable, and appropriate. In sum, the state of Washington Medicaid total estimated drug savings (or costs avoided) over the FFY 2006 for both the ProDUR and RetroDUR programs was $ $16,433,909.

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 91 The preparation of this document was financed under an agreement with Washington State Medicaid.

Government Healthcare Solutions, PBM Group

State of Washington Medicaid Drug Utilization Review (DUR) Programs - Annual CMS Report FFY 2006

Attachment 6.4

RetroDUR Program Detailed Savings Estimates

Prepared by ACS Government Healthcare Solutions, PBM © 2006 / mlb Page 92 The preparation of this document was financed under an agreement with Washington State Medicaid.


				
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