18 july 2013 1. follow-up to previous reviews botulinumtoxin dur hydrocodone/apap dur...

Idaho Medicaid Drug Utilization Review Program

18 July 2013

1

Follow-up to Previous ReviewsBotulinumtoxin DURHydrocodone/APAP DURNystatin/triamcinolone Combo DUR

2

Botulinumtoxin DUROnly payable on the medical side (not self-

administered and not safe for patient to “brown bag” to physician’s office).

Prior authorization was instituted 7/1/2013.Before June 2013:

Prior authorization requests received were returned to prescriber with a note that prior authorization was not required at this time but would be required starting 7/1/13.

3

Botulinumtoxin DURStarting June 1, 2013:

Prior authorization requests were processed. Approvals were dated 7/1/13 with a note that

prior to July, prior authorization was not required.

Denials were sent back with an explanation of why request was denied. Claims still paid through 6/30/13.

4

Botulinumtoxin DURChronic daily headaches/migraines

New prior authorization form specifically for Botox for chronic daily headaches/migraines was written and posted on the website in June 2013.

Letter was sent in June with a copy of this prior authorization form to the Boise physician that was prescribing and administering the majority of Botox for this indication.

5

Botulinumtoxin DURBotox for indications other than chronic daily

headaches/migrainesAnother prior authorization form was created

for all other indications.

6

Botulinumtoxin DURTherapeutic criteria for chronic daily

headaches/migraines1. At least 15 days per month 2. At least four hours per day (on average)3. Prophylactic medication tried and failed4. Abortive medications (e.g. triptans) filled

monthly for at least 3 months

7

Botulinumtoxin DURDocumentation provided by prescribers has

dramatically improved after feedback from Idaho Medicaid on what information is needed.

Prescriber is now sending us a “Chronic Daily Headache” two page data collection sheet that the patient fills out.

Majority of requests received for this indication have been approved.

For new patients, two injections (12 weeks apart) are approved. This duration was chosen as in the licensing trial, reduction in headache frequency was seen by this length of time.

8

Botulinumtoxin DURFor patients who have already received one

dose prior to 7/1/13, a second dose will be approved if the patient meets the therapeutic criteria.

For patients with a positive response who have already received two or more doses, therapy will be approved for six months.

9

Hydrocodone/APAP DUR

What are the utilization numbers on the various hydrocodone/APAP products?

10

Hydrocodone/APAP DURGCN Seq Number (GSN)

Brand Name Strength Desc

Unique Recipient

s

Total Claims

Avg Qty per Days Supply

Max Qty per Day in System

Cost per tablet or ml (WAC)

60338 HYDROCODONE-ACETAMINOPHEN

5MG-300MG 39 43 4.26 Q06 $1.41


7.5-300MG 20 22 2.85 Q06 $1.55


5MG-325MG 6,149 9,425 3.98 Q06 GAAC=$0.14


7.5-325MG 2,267 4,273 3.75 Q06 GAAC=$0.17


10MG-325MG 4,500 12,591 4.24 Q06 GAAC=$0.15


2.5-500 MG 7 7 1.96 Q06 GAAC=$0.13


5 MG-500MG 2,230 3,291 3.78 Q06 GAAC=$0.05


7.5-500MG 879 1,591 3.65 Q06 GAAC=$0.09


10MG-500MG 198 506 3.74 Q06 GAAC=$0.14


10MG-650MG 12 29 2.99 Q03 GAAC=$0.10


10-660MG 7 19 2.36 Q03 GAAC=$0.16


7.5-750MG 72 110 2.64 Q03 GAAC=$0.58


7.5-325/15 5 5 16.96 Q90 $0.25


7.5-500/15 1,367 1,647 32.80 Q60 GAAC=$0.18

11Idaho Medicaid paid pharmacy claims between 1/1/2013 and 4/30/2013

Nystatin/Triamcinolone Combo DUR

What are the utilization numbers on the various nystatin/triamcinolone combo products?

12


Cream Ointment0

20406080

100120140160180200

161

39

175

44

Paid Pharmacy Claims 1/1/2013 through 4/30/2013

RecipientsClaims

13


14

0 to 3 4 to 6 7 to 18 19 to 55 56 to 670

20

40

60

80

10080

13

34

60

12

90

13

34

66

16


RecipientsClaims

Age of Recipients

Current Interventions/Outcomes StudiesHepatitis C DURDemographics of the Idaho Medicaid Utilizer of

Rx’s PopulationCHIC – Children’s Healthcare Improvement

CollaborationGeo‐Mapping Analysis

Utilization of Narcotic Analgesics (HIC3 = H3A)

15

Current Interventions/Outcomes StudiesP&T Committee Narcotic Analgesic Studies

Narcotic Analgesics in Chronic Non-Malignant Pain 2012 Update

Participants Receiving More Than 1 Long Acting at a Time

Suboxone and Participants Paying Cash for Other Opioids

16

Hepatitis C AgentsIncivek and Victrelis

Review past 6 months of data for usage Are patients that started on therapy continuing

therapy? Will be requesting chart notes to determine why

patients discontinued therapy (e.g. intolerable side effects vs. non-responders to therapy based on viral counts) vs. non-compliance.

Will look for trends in patients that discontinued therapy (e.g. does rate vary between practices or geographically)

Are patients on TRIPLE therapy with ribavirin and interferon? Check for adherence to all three medications.

Audit for checking viral counts at appropriate time intervals

17

Hepatitis C AgentsIncivek and Victrelis

Look at quarterly trends in usage since Incivek/Victrelis were approved by the FDA in May 2011 as patients were not started on double therapy (ribavirin/interferon) as the specialists were waiting for triple therapy to be available.

In the future an all oral regimen is going to be available for treatment of Hepatitis C so there may be patient “warehousing” again.

18

Hepatitis C DUR

2Q20

11

3Q20

11

4Q20

11

1Q20

12

2Q20

12

3Q20

12

4Q20

12

1Q20

13

2Q20

130

10

20

30

40

50

Incivek & Victrelis

Total Paid Claims Unique Prescribers Unique Recipients

19

Hepatitis C DUR

2Q20

11

3Q20

11

4Q20

11

1Q20

12

2Q20

12

3Q20

12

4Q20

12

1Q20

13

2Q20

130

102030405060

Incivek & Victrelis

Total Paid Claims Unique PrescribersUnique Recipients

20

Hepatitis C DUR

2Q20

11

3Q20

11

4Q20

11

1Q20

12

2Q20

12

3Q20

12

4Q20

12

1Q20

13

2Q20

1305

101520253035

Incivek & Victrelis

Total Paid Claims Incivek Total Paid Claims Victrelis

21

Hepatitis C DURReview from 5/1/2012 thru 5/26/2013Total of 53 patients prescribed Incivek or Victrelis36 Incivek17 VictrelisMean age: 47 years (range: 18 – 61)Female: 26Male: 27**All patients had a diagnosis for Hepatitis C (ICD-9 code 070.4 or 070.5)

22

Hepatitis C DUR36 Incivek PatientsMean age: 46 years (range 28 – 61)Female: 16Male: 2029 completed treatment (3 months)5 did not complete treatment1 patient was co-infected with HIV (2

months)2 patients exceeded 3 months 5 months (50 y/o male)4 months (28 y/o male)

23

Hepatitis C DUR

Incivek PaymentTotal payment $1,613,601.00Payment/month $18,000.00

6 months should not have been submitted ($108,000.00)

**All Incivek patients were started on Interferon and Ribavirin

24

Hepatitis C DUR

17 Victrelis patientsMean age: 47 years (range 18 – 60)Female: 10Male: 78 completed treatment Mean # of months: 7 2 did not complete treatment7 active treatment

25

Hepatitis C DUR

Victrelis PaymentTotal payment $355,187.00Payment/month $5074.00

**All Victrelis patients were on Interferon and Ribavirin for 4 weeks prior to Victrelis treatment

26

Hepatitis C DURLetters sent out requesting the following information:HCV GenotypeBaseline Laboratory values (CBC, LFT’s,

SVR)Follow-up Laboratory values while on Incivek

or Victrelis (SVR, LFT’s)Documentation/chart notes of follow-up

treatment and response to treatmentIf documented: Co-infection of HIVIf applicable: reason why therapy was

discontinued (side effects, inadequate response, etc) 27

Demographics of the Idaho Medicaid Utilizer of Rx’s Population

0 to 9 10 to 19 20 to 29 30 to 39 40 to 49 50 to 59 60 to 69 70 to 79 80 to 89 90 to 99 100 to 109

-

5,000

10,000

15,000

20,000

25,000 Paid Pharmacy Claims 1/1/2013 through 4/30/2013

Male Female

Age in Years

Un

iqu

e R

ecip

ien

ts

28



- 10,000 20,000 30,000 40,000 50,000 60,000 70,000 80,000 90,000


Male Female

Age in Years

To

tal

Cla

ims

29



$-

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000

$7,000,000

$8,000,000

$9,000,000


Male Female

Age in Years

To

tal

Paym

en

t A

mo

un

t

30


Unique Recipients Total Claims Total Payment Amount 10,000

100,000

1,000,000

10,000,000

100,000,000

46,096

260,503

23,059,720

61,189

445,347

26,968,052

107,285

705,850

50,027,771 Paid Pharmacy Claims 1/1/2013 through 4/30/2013

Male Female Combined31

CHIC – Children’s Healthcare Improvement Collaboration

Mental Health Learning Collaborative – Depression Screening in Adolescent

Patients

32

CHICTarget Prescribers: Pediatricians and

Family PracticeGoal: Increase screening for depression in

adolescent patients with appropriate follow-up for those patients with positive screeningsPsychosocial support including counselingMedications (e.g. SSRIs)

Target Dates: Learning session for enrolled providers in

August 2013. Sessions to be held in Boise, Twin Falls, and Pocatello

Start tracking screenings and follow-up in October 2013

Duration of project: 6 months

33

CHICBaseline Data for 2012

3265 unique patients age 12-17 years with at least one paid claim for an SSRI

18,063 total paid claims for SSRIs$265,842

4604 unique patients age 12-17 with at least one paid claim for any antidepressant

30,198 total paid claims for all antidepressants$467,419

34

Geo Mapping Analysis‐Utilization of Narcotic Analgesics (HIC3 = H3A)

Prepared by MMA 6/13/2013Please refer to handout in Packet

35

P&T Committee Narcotic Analgesic StudiesNarcotic Analgesics in Chronic Non-

Malignant Pain 2012 UpdateParticipants Receiving More Than 1 Long

Acting at a Time

36

Narcotic Patterns of Use in Chronic Non-Malignant Pain

Follow-Up from 2011 Study

37

Profile ReviewGenerated profiles for the top 150 recipients by

total narcotic claim count from the recipients who had at least one narcotic claim in each of the 24 months of the period ending March 2013

Time Period: October 1, 2012 through March 31, 2013

Original study: May 1, 2011 through December 31, 2011

Evaluated 142 Cancer Diagnosis found in 8All profiles were hand reviewed by Idaho

Medicaid Pharmacists

38

Review FocusYears of opioid use Number of different opioids usedDaily morphine equivalentsNumber of different prescribersOther concurrent central acting/ potentially

addictive drugsDiagnosis or indication for chronic opioid useAverage days between refillsHistory of abuse diagnosisCurrently in lock-in program?Additional opioid use paid outside of Medicaid

39

Length of Time for Continuous Opioid Use

40

Number of Different Opioids

41

Includes different drugs or dosage formsMay or may not be concurrent, but over course of therapy

Daily Morphine Equivalents

42

Lowest = 14 mgHighest = 1340 mg

Number of Prescribers per Participant

43

Diagnosis/IndicationsDiagnosis Number of Participants

(incidence)

lubago: unspecified disorder of back; back pain 92

chronic pain; chronic pain syndrome; other chronic pain 73

intevertebral disc disorder; lumbar disc degeneration; cervical disc degeneration; cervicalgia; sciatica; disc degeneration; spondylosis

30

knee injury; shoulder injury; pain in limb; lower leg pain; neck injury; hip and thigh injury; wrist injury

20

hand joint pain; osteoarthritis; rheumatoid arthritis; pain in joint of ankle and foot; ankylosing spondylitis; other disorders of synovium tendon and bursa

37

headache; migraine 9

disorders of muscle ligament and fascia; other disease of bone and cartilage; myalgia 2

abdominal pain, generalized pain 12

multiple sclerosis 1

peripheral neuropathy; diabetic peripheral neuropathy 1

chronic pancreatitis 4

Unknown 2

Most patients had multiples diagnoses

45

Average Days Prior to Refill

46

Other Information GatheredNumber on Medicaid Pharmacy Lock-In

5 currently on lock-inNon-Medicaid Opioid Fills

From Board of Pharmacy Reports Many gaps in Board of Pharmacy Reports

34 of the 142 patients ( 24%) had fills not paid for by Medicaid

Concurrent Drug Abuse Diagnosis 66 (46%)

47

Comparison of Original and Follow-up Data2011 Current

Number with Cancer DX 6 8

Average # of Years on Opioids

8.2 (Range 3-14) 9 (Range 2-13)

Average # of Different Opioids

2.9 ( Range 1-10) 3 (Range 1-7)

Average Daily Morphine Equivalents

256 (Range 10 mg -2421mg)

208 (Range 14 mg- ) Does not include non-Medicaid paid

Average # of Prescribers/Participant

4 ( Range 1-12) 1 (Range 1-8)

Average Days Prior to Refill

27 25

Lock-in Patients 3 5

Patients with Prescriptions Paid Outside of Medicaid

30% 24%

Concurrent Drug Abuse Diagnosis

39% 46%

48

Evaluation of Participants Receiving More than One

Long-Acting Narcotic Analgesic Concurrently

49

Long-Acting Narcotic EvaluationGoal: To evaluate impact of planned change

that would only allow one long-acting and one short-acting narcotic analgesic per participant without further prior authorization

Report was run and profiles generated for participants who had a claim for more than one unique long-acting narcotic analgesic between 12/1/2012 and 5/31/2013

N = 65

50

EvaluationProfiles were reviewed and all eliminated for

further review that did not meet the following criteria:Two or more consecutive months of receiving

two or more long-acting agents. Must include most recently evaluated month

(May 2013)Participants meeting criteria = 6Refer to attached table for characteristics of

use for these 6 participants

51

Buprenorphine DURSuboxone and Participants Paying Cash for

Other Opioids(includes Suboxone film, Suboxone tablets, buprenorphine/naloxone tablets, buprenorphine

tablets)

52

Buprenorphine DUR Identified all participants with at least one paid claim by

Idaho Medicaid between 2/1/13 and 4/30/13.

Ran Board of Pharmacy report for all of these participants to identify anyone who had received any other opioid with overlapping days of service and noted payment method (cash, Idaho Medicaid, other insurance). This DUR includes opioid claims from January 2013 that would overlap into February (e.g. paid cash for hydrocodone tablets 1/31/13 and had Idaho Medicaid pay for Suboxone 2/1/13). As the Board of Pharmacy only reports number of tablets and not days of service, we assumed a reasonable number of tablets used per day (e.g. six for hydrocodone/acetaminophen, two for OxyContin). Idaho Medicaid has a manual system for entering a block from paying for opioids for patients on Suboxone therapy but an occasional participant is overlooked allowing Idaho Medicaid to pay for opioids for patients also on Suboxone.

53

Buprenorphine DURData Collected

1. Sex (M/F)2. Age as of 4/30/13 (years)3. Overlapping paid claims for opioids (Y/N)4. What is opioid in addition to Suboxone ?5. Quantity of paid claims6. Duration of therapy of Suboxone7. Concomitant benzodiazepine usage8. Cost of therapy ($ and percentage) for patients paying cash

for opioids

54

Buprenorphine DURFor those patients identified who had paid

claims for other opioids that overlapped with days of service for Suboxone, a letter was sent to prescribers of both Suboxone and any other opioid. The Board of Pharmacy report was included as an attachment to these letters. (See packet for copy of letter)

One week after the letter was sent, payment for Suboxone was blocked by Idaho Medicaid and the lock on paying for other opioids was removed.

55

Buprenorphine DUR

Paid Cash26

13%

Did not pay cash17487%

Patients identified who paid cash for opioids while Idaho Medicaid was paying for Suboxone during time period 2/1/13 -

4/30/13

5666 letters sent out between June 3-10, 2013 to 56 unique prescribers. Gave prescribers one week to respond prior to initiating Suboxone payment block.

Buprenorphine DUR

Paid Cash Didn't pay cash0

20

40

60

80

100

120

140

7

42

19

132

Sex

Male Female

# o

f p

ati

en

ts

57

Buprenorphine DUR

Male Female0

20

40

60

80

100

120

140

160

49/200, 24.5%

151/200, 75.5%

Percentage in DUR study

58

Buprenorphine DUR

Male Female02468

101214161820

7/26, 27%

19/26, 73%

Paid Cash

59

Buprenorphine DUR

60

50

45

40

35

30

25

20

15

10

5

0Paid Cash Didn’t Pay Cash All Patients in DUR

Average Age: 38.3Standard Deviation: 10.8



Buprenorphine DUR

60/200, 30%

140/200, 70%

All patients in DUR

benzo use no benzo use

10/26, 38%

16/26, 62%

Patients who paid cash for opioids and who were also on benzo's

on benzo not on benzo

61

Buprenorphine DUR: Analysis of Prescribers

One prescriber for both Sub-

oxone and other opioid

Two pre-scribers (one for Suboxone and one for

other opioid)

Two pre-scribers (one for buprenor-

phine and Oxycontin, second pre-

scriber for hy-drocodone)

Three pre-scribers (one for Suboxone and two for

other opioids)

Three pre-scribers (two

prescribers for buprenorphine, third prescriber

for hy-drocodone)

Four pre-scribers (one for Suboxone and three for other opioids)

Ten prescribers (one for subox-one and nine for other opi-

oids)

0

2

4

6

8

10

12

14

16

3

14

1

4

12

1

# o

f p

ati

en

ts

62

Buprenorphine DUR

Suboxone paid for patients paying cash;

$25,889

Suboxone paid for pa-tients not paying cash;

$202,230

Three Month Time Period

63

11.3% of total expenditure - potential cost savings: $103,557 annually

Buprenorphine DUR

1 2 3 4 5 9 10 1202468

101214

12

5

2 21

21 1

# of opioid prescriptions paid cash for by patients during 3 month time period

# of opioid prescriptions

# o

f p

ati

en

ts

64

Buprenorphine DUR

73

2

Of 12 patients with one cash paid opioid prescription during the three month DUR

study had paid for addi-tional opioids be-fore/after study periodwere patients recently started on Suboxonehad been on Subox-one for a while with only the one paid opioid claim

65

Buprenorphine DUR

60

15

3 2 1

Opioids paid cash for

hydrocodoneoxycodonehydromorphonemethadonemorphine

66

Buprenorphine DUR

Feb -

Apr 2

013

Oct 2

012

-Jan

...

Jan

- Sep

201

220

1120

1020

0920

0820

0720

0620

0520

0420

0305

101520253035404550

paid cash

did not take other opioids

Suboxone Therapy Initiated

# o

f p

ati

en

ts

67

Buprenorphine DURBottom Line: Patients were found to be

paying cash for opioid therapy even after many years on Suboxone therapy.

Example – Patient who has been on Suboxone since 2006 paid cash 9 times for opioids during the 3 months of this DUR and 52 times total in the last two years (42 fills for oxycodone and 10 fills for hydrocodone).

68

Buprenorphine DURFeedback from week 1

One physician called and left message. Pharmacist called back and spoke to his nurse to explain what was happening. The physician never called back.

One participant called to complain, Pharmacist called and spoke to physician and re-authorized payment for Suboxone (second chance).

69

Buprenorphine DURFeedback from week 2

Participant called to state that Norco was not filled by her. Pharmacist called prescriber of both Suboxone and Norco. Giving her a second chance.

Physician called and stated that patient had knee surgery and was “off” Suboxone immediately post-op but plan is to stop other opioid and restart Suboxone.

Physician called and stated that patient had one fill of hydrocodone for dental surgery and would like patient to continue on Suboxone.

70

Buprenorphine DURContinued feedback

Patient’s Suboxone discontinued by prescriber due to other opioid use: 2 patients

Prescriber requested (and was granted) re-authorization for Suboxone after fill of other opioid s/p surgery: 2 patients

71

Buprenorphine DURFuture Plans

The department plans on running routine Board of Pharmacy reports every 3-6 months on all Suboxone patients.

Questions/Comments ?

72

Proposed Studies for Next Quarter:SynagisP&T Committee Narcotic Analgesic

Studies – Next StepsUse of Psychotropic Medications in Foster

Children – Next Steps2012 Data Analysis UpdateThree (3) or more concomitant mood stabilizer

medicationsIVIG

73

Proposed Studies for Next Quarter:LevofloxacinAntipsychotic Indication Evaluation- Hold

for Future

74

Synagis DUR

75http://healthandwelfare.idaho.gov/Portals/0/Health/Epi/RSV/RSV%20graph.pdf

Synagis DUR

76

What should the focus be for the DUR project for the concluded 2012-2013 RSV season?

P&T Committee Narcotic Analgesic Studies – Next Steps

77

Use of Psychotropic Medications in Foster Children The U.S. Government Accountability Office

released the results from a study that they performed examining the rates of psychotropic medications for foster and nonfoster children in 2008.

It was determined that HHS Guidance Could Help States Improve Oversight of Psychotropic Prescriptions.

78

Foster Children Psychotropic Drugs Red Flags

7/18/2013

79

Red FlagsFive (5) or more psychotropic medications prescribed

concomitantly (reviewed August 2012)Two (2) or more concomitant antidepressants

(reviewed October 2013)Two (2) or more concomitant antipsychotic

medications (current)Two(2) or more concomitant stimulant medications

long-acting plus short-acting okThree (3) or more concomitant mood stabilizer

medicationsPsychotropic polypharmacy (2 or more agents) for a

given mental disorder prescribed before utilizing psychotropic monotherapy 80

81

Implementation of Red Flags

Retroacti

ve Evaluatio

n

Identify outliers

Profile

Review

DUR Board Intervention• Targ

eted education

Re-evaluation• indi

viduals

• overall

Further

Action

Point of service edits• Inform

ational (soft) – pharmacist override

• Hard Stop

ADHD Drugs Anti-depressants Mood Stabilizers Atypical Antipsychotics0%

5%

10%

15%

20%

25%

30%

35%

40%

36%

23%

13%

21%

9%

6%

0%

4%

Percent of Foster and Non-Foster Children Psychotropics by Drug Class

Calendar Year 2011

% Foster Children% Non-foster Children

Total foster =2785Total Non-Foster = 106,024

82

Use of Psychotropic Medications in Foster Children: Next Steps2012 Data Analysis UpdateThree (3) or more concomitant mood

stabilizer medications

83

IVIGIVIG follow-up as implemented prior

authorization criteria 1-1-13. Will look at cost of therapy (pharmacy and medical) January – June 2012 vs. same dates 2013 as well as some comments on prior authorization requests received.

84

LevofloxacinLevofloxacin – changed minimum age from 16

down to zero 11-1-12 so look at usage Jan – June 2012 vs. same dates 2013 for children and compare utilization.

85

Antipsychotic Indication Evaluation- Hold for Future

86

Prospective DUR ReportHistory Errors:

• DD – drug-to-drug• PG – drug to pregnancy• TD – therapeutic

duplication• ER – early refill• MC – drug-to-disease

Non-History Errors:• PA – drug-to-age• HD – high dose• LD – low dose• SX – drug-to-gender

87

Prospective DUR ReportIdaho Medicaid ProgramProDUR Message Report

June-13

ProDUR ProDUR Message MessageMessage Severity Count Amount

Drug To Drug 1 1,381 $373,620.15 2 13,026 $2,521,971.05 3 67,204 $12,025,994.08Drug To Gender 1 146 $34,461.03 2 2,195 $265,410.63Drug To Known Disease 1 65,499 $9,849,442.93 2 229,816 $42,448,043.20 3 291,920 $54,632,417.89Drug To Pregnancy 1 23 $301.97 2 15 $483.73 A 4 $39.35 B 70 $10,458.15 C 126 $12,492.54 D 7 $130.78 X 10 $844.76Duplicate Therapy 0 108,162 $24,283,884.93Min Max 0 29,517 $4,838,004.04Too Soon Clinical 0 19,545 $3,632,514.43

ALL 828,666 $154,930,515.64 Total Number of Claims with Messages 200,209 Average ProDUR Message Per Claim 4.14

88

DUR Summer NewsletterCopy of Spring Newsletter in packetBrainstorm for new topics

89

Medicaid Update

90

18 july 2013 1. follow-up to previous reviews botulinumtoxin dur hydrocodone/apap dur...

Documents

botulinumtoxin dur botox

hydrocodone acetaminophen

botulinumtoxin dur starting

prior authorization

new patients

majority of botox

majority of requests

days supply max qty