dod pharmacy enterprise operations update april 1, 2015 pharmacy workgroup “medically ready...
TRANSCRIPT
DoD Pharmacy EnterpriseOperations Update
April 1, 2015
Pharmacy Workgroup
“Medically Ready Force…Ready Medical Force”
For Office Use Only
Opening Remarks
∎ Pharmacy Shared Service – Full Operating Capability3 March 2015 – 7 months ahead of projection!Chartered Work Group – Service Consultants, DHA Pharm
∎ Guiding DoD Pharmacy Enterprise to Sustained ExcellenceUniform Priorities; Standardized Process & Metrics
∎ Full Agenda
2“Medically Ready Force…Ready Medical Force”
“Medically Ready Force…Ready Medical Force” 3
Agenda Item Presenter
Opening Remarks Dr. Jones
Update on DHA Pharmacy Initiatives / Pharmacy Savings Index Update Dr. Jones / Maj Folmar
TPharm 4 Changes Lt Col McManis
Playbook of Communicating Business Rules to Providers Dr. Jones/Maj Jarnot
Carepoint / Performance Management System Overview Bill Davies
P&T Committee Update Dr. Allerman
Specialty Medications LTC Ridderhoff
Brand to Generic and National Contract Compliance Update LTC Conrad
Prime Vendor Credits Update Lt Col Castiglia/MAJ Sweeney
Narcotic Order Review and Approval Lt Col Castiglia/MAJ Sweeney
Prime Vendor Global Status Lt Col Castiglia/MAJ Sweeney
Compounding Update Dr. Jones
Drug Takeback Update LCDR Nguyen
e-Prescribing Update Henry Gibbs
NDAA Update Dr. Jones
Questions All
Agenda
Update on DHA Pharmacy Initiatives – Dr. George Jones, Chief Pharmacy Operations Division
4“Medically Ready Force…Ready Medical Force”
∎ 2014 – Stood up operations – 3 Primary InitiativesRetail to MTF/Mail; Formulary Management; Compliance
∎ 2015 – Continue those 3 – Implement 2 more Pending status for newly FDA approved drugs ($4M)Consolidation of Automation Contracting action ($6.7M)
∎ Key Implementation – Transition of TFL PilotNDAA 2015 terminated PilotImplement Same MTF/Mail approach for all beneficiaries
∎ Pharmacy Savings Index Update
$31.0
$60.8
$88.6
$120.4
$146.6
$ 208M
$
$50
$100
$150
$200
$250
Oct
-14
Nov
-14
Dec
-14
Jan-
15
Feb-
15
Mar
-15
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May
-15
Jun-
15
Jul-1
5
Aug-
15
Sep-
15
Mill
ions
#1 - Retail Rx to Mail/MTF #2 - Formulary Management#3 - Brand to Gen & Nat'l Contracts (lagged one month) FY15 Total Estimated Cost SavingsFY15 Target
$ 29.8 $ 27.8 $ 31.8 $ 26.2
5
Pharmacy Savings Index (PSI) FY15 Overall Target – $208M
5Target $ 17.3 $ 34.7 $ 52.0 $ 69.4 $ 86.7 $ 104.0 $ 121.4 $ 138.7 $ 156.1 $ 173.4 $ 190.7 $ 208.1
Cost Savings $ 31.0 $ 60.8 $ 88.6 $ 120.4 $ 146.6
Goo
d
$208M = $85M DHP + $123M MERHCF
$13.2
$26.5
$39.1
$52.3
$64.7
$ 121M
$
$20
$40
$60
$80
$100
$120
$140
Oct
-14
Nov
-14
Dec
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Jan-
15
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Mar
-15
Apr-
15
May
-15
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Jul-1
5
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15
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Mill
ions
Over 65 Under 65 FY 15 Cumulative Total FY15 Target
$13.3 $12.7 $13.2 $12.4
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Initiative #1 - Retail Rxs to Mail/MTF Estimated Cost Savings
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Source: PDTS Data; Pharmacy POS Cost Analysis Data
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$12.0 $11.5$14.3 $13.8$12.0
$24.0
$35.5
$49.8
$63.6$61M
$
$20
$40
$60
$80
Oct
-14
Nov
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Dec
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15
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-15
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5
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Sep-
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Mill
ions
Monthly Cost Savings FY 15 Cumulative Savings FY15 Target
7
Initiative #2 - Formulary Management Estimated Cost Savings
Source: DoD P&T Committee First-Year Cost Savings Estimates
Goo
d
Monthly cost savings reported for therapeutic classes evaluated by DoD P&T with decisions
implemented in the last year; does NOT include potential cost increases in other therapeutic areas
associated with market approval of new drugs
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$5.8
$10.3
$13.9
$18.3
$ 15.6M
$
$10
$20
$30
Oct
-14
Nov
-14
Dec
-14
Jan-
15
Feb-
15
Mar
-15
Apr-
15
May
-15
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Jul-1
5
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Sep-
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Mill
ions
Brand To Generic Contract Compliance FY15 Total FY15 Target
$4.4
$3.7$4.3
Contract Compliance: Intermittent shortages of various drugs may decrease contract compliance.
B2G: The overall generic purchase rate for drugs that had purchases of both brand and generics is ~ 88%.
Initiative #3 - Generic & Contracting Compliance, Estimated Cost Savings
Goo
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Source: National Contract Compliance Report; Cost Savings CPOC B2G Sales DataNote: Initiative #3 lags others by one month due to availability of DLA Prime Vendor data.
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TPharm4 Changes: 1 MAY 2015SPECIALTY DRUGS
9“Medically Ready Force…Ready Medical Force”
∎ Express Scripts, Inc. (ESI) will implement a select retail pharmacy network for some specialty drugs List approved by P&T at the November 2014 meeting (79 items) and
subject to change based on P&T decision
∎ Beneficiaries impacted by this change have been contacted by ESI Beneficiaries will have until May 1st to move their specialty prescription
to a retail pharmacy in ESI’s select network: CVS, Walmart, Rite Aid, or Target
The letter states these drugs will continue to be available at the MTF pharmacy if on formulary
TRICARE Mail Order Pharmacy (TMOP) will continue to be an option
TPharm4 Changes: 1 MAY 2015SPECIALTY DRUGS
10“Medically Ready Force…Ready Medical Force”
∎ Beneficiaries who utilize the TMOP will have access to enhanced clinical services: Disease Management Nurses and Clinician Assessments Prescription and Disease Management Education Clinical Social Workers Physician Outreach and Refill reminders and Adherence Monitoring
∎ At the select retail specialty network, beneficiaries will receive the following: Prescription Education Refill Reminders and Adherence Monitoring Prior Authorization Services Clinical Assessments Prior to Refill
TPharm4 Changes: 1 MAY 2015FORMULARY SEARCH TOOL
11
∎ The TRICARE Formulary Search Tool will transition from the current DHA Pharmacy Website to ESI Website
∎ Explanation of Benefits (EOB) will now include MTF dispensed prescriptions as well as TMOP drug costs
TPharm4 Changes: 1 MAY 2015EXPLANATION OF BENEFITS (EOB)
12“Medically Ready Force…Ready Medical Force”
TPharm4 Changes: 1 MAY 2015DEPLOYMENT PRESCRIPTION PROGRAM (DPP)
13“Medically Ready Force…Ready Medical Force”
∎ ESI currently provides dispensing of prescriptions through the Deployment Prescription Program (DPP); under TPharm4 will also include administrative functions currently done by the DHA Pharmacy Analytics Support Section (PASS)
∎ The following items are currently under development: DPP training slides and programs specific for Providers,
Members, and for Deployed Sites Wallet cards A dedicated Sharepoint website Instructions for accessing the secure server Dedicated telephone number and email address
TPharm4 Changes: 1 MAY 2015MTF CLAIMS PROCESSING
14“Medically Ready Force…Ready Medical Force”
∎ MTF Claims Processing and Prospective Drug Utilization Reviews (ProDUR) will transition from Emdeon (PDTS) to ESI under the new contract
∎ Mountain Home Air Force Base, the MTF test site, will transition to ESI on May 1
∎ Remaining MTFs and CHCS host sites will transition on or before May 7 (estimated) NOTE: Detailed transition plans will be provided through your Pharmacy
Service Consultants/Specialty Leaders
∎ Some ProDUR messaging under ESI’s platform may be slightly different than current Emdeon messaging and will be apparent to MTF prescribers using AHLTA in addition to pharmacy personnel using CHCS
TPharm4 Changes: 1 MAY 2015MTF REPORTS (PROVIDED TODAY BY THE PASS)
15“Medically Ready Force…Ready Medical Force”
∎ MTF Claims Reports:
∎ MTF Data Report: ESI will provide data reports to support current MTF Prescription
Restriction Programs. MTFs will still coordinate with the DHA PASS for enrollment and disenrollment of members into lock or restriction programs.
Report Description Action
Daily Validity Rejects ReportList of rejected claims (broken out by MTF) sent to the pharmacy contact.
MTF pharmacy has 3 business days to correct these claims (reverse entirely or reverse and resubmit)
Weekly High Cost Claims ReportList of all completed MTF claims exceeding the $2,000 pricing threshold.
MTF has 7 business days to correct any incorrect claims (reverse or resubmit)
Weekly Data Integrity ReportList of completed MTF claims that generated the following ProDUR warnings: High Dose Alerts and Invalid Provider.
TPharm4 Changes: 1 MAY 2015MTF HELP DESK
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∎ ESI will staff a dedicated MTF Help Desk 24/7 to assist the MTF∎ Each MTF will also have a dedicated Account Manager
MTF Help Desk Account Team
Routine Support
• Once & Done Questions• Support MTF Pharmacies
with claims, Rx dispensing and status, clinical, and other questions
• 24 x 7 Service
855-201-3041 (May 1)
Specialized Support
• Aligned by branch of service• Service level to MTF
engagement• Single point of contact• Daily operational support• Resolve more complex requests• Educate MTF on Help Desk /
Account Team utilization
TPharm4 Changes: 1 MAY 2015
17“Medically Ready Force…Ready Medical Force”
∎ Transition specifics, updates, and additional information will be provided from the DHA Pharmacy Workgroup through the Pharmacy Service Consultants and Specialty Leaders.
∎ MHS Communications is developing a communication plan that will include information sharing with the military services.
∎ ESI Account Managers will be contacting MTF pharmacy POCs to support MTF claims corrections and reporting requirements.
Increased Adherence to Pharmacy Business Rules
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Pharmacy Benefit Channel Management– During 2nd quarter FY14, the average cost of a brand name non-specialty medication was 32-34% lower at the MTF and
Home Delivery than at retail
Formulary Management – As national and local P&T committees implement their decisions, provider switching and adherence to the new business
rules ensure that the balance of maximum savings and top clinical outcomes is met
Compliance with Purchasing Rules – At MTFs, prescribing the contract, preferred drugs enable maximum savings; it is imperative to regularly keep providers
informed of the business rules as drugs can come on and off contract intermittently
MTF Provider adherence to business rules is an enabler of savings for three major pharmacy initiatives:
“Medically Ready Force…Ready Medical Force”
Increased Adherence to Pharmacy Business Rules
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There are five guiding principles for achieving high levels of provider adherence:
Clearly defined pharmacy business rules
Consistent direction and support from leadership
Diverse menu of evidence-based options
Flexibility to customize and tailor solutions
Strong relationships and collaboration amongst stakeholder groups
How will DHA help?
DHA Pharmacy will distribute an Enhanced Communication of Pharmacy Business Rules Playbook to the field with best practices and examples of tools that have shown success in increasing MTF provider adherence
DHA Pharmacy will provide actionable reports, allowing MTFs to monitor the prescribing behavior of providers, compare providers against their peers, and take the necessary action
“Medically Ready Force…Ready Medical Force”
Increased Adherence to Pharmacy Business Rules - Example from the field
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• Leveraging Local Educational Institutions‒ Local pharmacy students intern at Hill AFB and are often charged with contacting MTF and purchased care
providers to ensure that they are informed about pharmacy business rules
• Standardized Provider Onboarding‒ Every Hill AFB provider inprocesses through the MTF pharmacy; they are provided with an onboarding
packet and the pharmacy provides them with guidance for navigating the system
• CHCS / AHLTA Keys and Comments‒ Hill AFB places keys on nonpreferred drugs so that providers cannot order them and uses the comment field
to recommend alternative approaches
Hill AFB
With a over 72,000 beneficiaries in its catchment area, accounting for more than 1 million prescriptions annually, Hill Air Force Base has made communicating pharmacy business rules to its MTF provider community a priority.
Since enacting several specific practices, they have realized 98% overall adherence by MTF providers to the business rules of their location.
What are they doing?
“Medically Ready Force…Ready Medical Force”
Playbook of Enhancing Communications of Business Rules to Providers
21“Medically Ready Force…Ready Medical Force”
$ RECAPTURE SAVINGS $
AC
CE
SS
AC
CU
RA
CY
SERVICE
Recapture Savings
“Medically Ready Force…Ready Medical Force” 22
• MTF/Mail Order have significantly lower costs to the enterprise• Two Data Sets Every MTF Pharmacy Should Be Aware Of
• Market Share within their catchment area (MTF/Mail/Retail/VA)• MTF Provider leakage report
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$0.00
$15.00
$30.00
$45.00
$60.00
$75.00
$90.00
$105.00
$120.00
$135.00
Average Amount Due Adjusted to a 30 Day Supply
MTFs Retail MAIL
Do
llar
s
Reports
“Medically Ready Force…Ready Medical Force” 23
Leakage Report Pulled centrally Provides detail down to provider name
to help identify specific issues Set goals for improvement
Market Share Report Request data from PAAS Provides total picture of RX processing
within catchment area Set goals for improvement
Service
∎ PatientsHave a choice of what Point of Service to fill atIncentive to fill at the MTF built in with copay structureMust make utilizing MTF appealing
Wait-times Personalized care Additional services (refill synchronization)
∎ ProvidersMust be advocates for utilizing MTF pharmaciesAccess is key
“Medically Ready Force…Ready Medical Force” 24
Access
∎ MTF providers must feel like they have the ability to order what they feel they need to treat their patientNon-formulary medication process
AF uses AHLTA consult function to process Keys used to require consult function for non-formulary PEC business rules guidebook provided to providers with
authorization requirements▻Expedites justification for providers (copy/paste)
Pharmacists serve as approval authority Process non-formulary requests in real time
▻Stock common non-formulary items
“Medically Ready Force…Ready Medical Force” 25
∎ Leverage robust non-formulary process with BCF optimizationDrug comments identifying BCF agents
Example: When provider selects Crestor will see a comment encouraging use of BCF agent first. If the provider attempts to select Crestor they will be alerted they do not have the appropriate key which triggers them to use non-form consult.
Most providers will take the path of least resistance and use a BCF agent. However if they truly require a non-form item they have the ability to order.
“Medically Ready Force…Ready Medical Force” 26
Access
Access
∎ Provide regular communication to providers regarding pharmacy business rulesProvide cost data on formularydecisions Recognize providers with highBCF utilization Call providers to recommendchanges to BCF items (leverage pharmacist/tech students) Every provider in-processes through pharmacy and
receives on-boarding packet with formulary guidance
“Medically Ready Force…Ready Medical Force” 27
Future Steps∎ Expand non-formulary approval process to non MTF providers
In place at many MTFs Tremendous ROI when recapturing from Retail Recapture model easily extended to non-empanneled beneficiary
population
∎ Hurdles Often requires manpower/facilities Culture change for some leadership
Increased MTF spending = enterprise savings = GOOD!
∎ Integrate process steps into new EHR
“Medically Ready Force…Ready Medical Force” 28
Overview of CarePoint Application Portal - Performance Management System (PMS)
∎ CarePoint hosts the Performance Management System (PMS) and other applications New 4G Web site: https://carepoint.health.mil/SitePages/Default.aspx
Use email certificate for access Permission based access currently via 3G link and follow prompts:
https://carepoint.afms.mil/CAREPOINT/
∎ PMS includes the Percent Retail Pharmacy Spend with drill down by Service – Major Commands – MTF – Clinics
∎ Current Views Include: Pharmacy % Retail Spend – All Beneficiaries (in catchment area) Pharmacy % Retail Spend YTD Comparison Pharmacy % Retail Spend by POS Service (based on fully burden costs) Pharmacy % Retail Spend by ACV Category (under development)
29“Medically Ready Force…Ready Medical Force”
“Medically Ready Force…Ready Medical Force” 38
November 2014 P&T Committee Update
39
Uniform Formulary Class Review
∎ Self Monitoring Blood Glucose System Test Strips (SMBGS) Test Strips
∎ Multiple Sclerosis Drugs
“Medically Ready Force…Ready Medical Force”
SMBGS Test Strips: Formulary Status
“Medically Ready Force…Ready Medical Force”
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Basic Core Formulary Uniform Formulary Non-formulary
Step-preferred:• Precision Xtra (Abbott)
-Precision Xtra meter• FreeStyle Lite (Abbott)
-FreeStyle Freedom Lite meter
N/A – see BCF items
Non step-preferred:*• Accu-Chek Aviva Plus (Roche)• Glucocard 01-Sensor (Arkray)• Glucocard Vital (Arkray)• Contour NEXT (Bayer)• FreeStyle Insulinx (Abbott)• Nova Max (Nova)• One Touch Ultra Blue (Lifescan)• One Touch Verio (Lifescan)• TRUEtest (Nipro)• Plus any test strip other than
BCF selections, including earlier versions of FreeStyle Lite and Precision test strips
40* Step therapy applies to all new users and current users of a test strip – must try
Precision Xtra or FreeStyle Lite first
(SMBGS) Test StripsFormulary Status
“Medically Ready Force…Ready Medical Force”
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∎ Precision Xtra test strips remain on the Basic Core Formulary (BCF). FreeStyle Lite test strips were added to the BCFThese two are the most cost-effective test strips at $0.11/strip
∎ Patients currently using Precision Xtra test strips should continue to receive them. Reserve FreeStyle Lite for those facilities not currently using Abbott test strips; for new patients; or those with dexterity issues
∎ All test strips except Precision Xtra and FreeStyle Lite are non-formulary and non-preferred
∎ Prior Authorization (step therapy) now applies to all current and new users of a non-formulary test strip – “no grandfathering” Current users of non-preferred strips must try FreeStyle Lite or
Precision Xtra first, or meet PA criteria for the Non-formulary strips∎ New Quantity Limits apply; #100 strips/30 days and #300 strips/90 days
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(SMBGS) Test StripsPrior Authorization Criteria
“Medically Ready Force…Ready Medical Force”
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∎ Patient is blind/severely visually impaired and requires a test strip used in a talking meter - Prodigy Voice, Prodigy AutoCode, or Advocate Redicode
∎ Patient uses an insulin pump and requires a specific test strip that communicates wirelessly with a specific meterContour NEXT strip with CONTOUR NEXT Link meter for Medtronic
pumpNova Max strip with Nova Max Link meter for Medtronic pumpAccu-Chek Aviva Plus test strips for patients using the Accu-Chek
Aviva Combo meter or Accu-Chek Aviva Spirit Combo meter∎ The patient has a documented physical or mental health disability
requiring a special strip or meter
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(SMBGS) Test StripsMTF Conversion
“Medically Ready Force…Ready Medical Force”
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∎ MTFs not currently using Abbott test strips have the highest priority to convert patients to Freestyle Lite
∎ Abbott Diabetes Care Team for conversion assistance:Carole Hamm, Senior National Account Manager, Government
Channels; 858-776-5245; [email protected] Tveit, Senior Government Account Manager; (949) 244-7348;
∎ The BCF decision is for the test strips, not the glucometers, however, Abbott will continue to provide glucometers at no charge to the MTFsPrecision Xtra meter is for the Precision Xtra test stripsFreeStyle Freedom Lite meter is the “workhorse” meter for the
FreeStyle Lite test strips
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(SMBGS) Test StripsMTF Conversion
“Medically Ready Force…Ready Medical Force”
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∎ For Meter replenishment:Please contact the Abbott Inside Sales Team at
800-401-1183 (ext below); fax 866-222-3715 Patty NcNett [email protected] ext 3006 Dawn Rayens [email protected] ext 8536
∎ Reserve new meters for the following patients:Patients not currently using Precision Xtra or FreeStyle Freedom Lite
(patients currently using a non-formulary test strip)Patients newly diagnosed with DM
∎ Abbott will supply 1 no-charge meter per patient to MTFs during the 3-year meter warranty period
44
Multiple Sclerosis Formulary Status
“Medically Ready Force…Ready Medical Force”
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Basic Core Formulary (BCF) Uniform Formulary (UF) Non-formulary (NF)
• Interferon beta- I b SC (Betaseron)
• Interferon beta- Ia SQ (Rebif and Rebif Rebidose)
• Interferon beta-la IM (Avonex IM)
• Interferon beta- I b SC (Extavia)
• Dalfampridine (Ampyra)• Dimethyl fumarate
(Tecfidera)• Fingolimod (Gilenya)• Glatiramer (Copaxone)• Teriflunomide (Aubagio)
• None
45
Prior Authorization criteria apply to Tecfidera and Gilenya (updated for cardiovascular toxicity)
Multiple Sclerosis Oral Drugs Key Points
“Medically Ready Force…Ready Medical Force”
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∎ Gilenya More efficacious than Avonex Associated with serious AEs including AV block and bradycardia
∎ Aubagio Similar efficacy to interferon beta-1a (Rebif) Associated with hepatotoxicity and teratogenicity
∎ Tecfidera Similar efficacy to Copaxone Associated with flushing and GI side effects Long term risk of PML unknown
∎ No head-to-head trials of oral medications
46
Multiple Sclerosis Injectables Key Points
“Medically Ready Force…Ready Medical Force”
47
∎ No one interferon is preferred over the other in terms of efficacy and safety Avonex possibly less effective
∎ No clinically relevant differences in efficacy comparing Copaxone to the Interferons (Cochrane 2014)
∎ Avonex Presented as less effective than Rebif and Betaseron (Oregon Drug Effectiveness
Review Program) Cochrane 2014 shows no difference in efficacy among Interferon and Copaxone
∎ Copaxone or Interferon beta 1b recommended as initial choice of treatment (CADTH 2013)
∎ Interferons have more flu like symptoms than Copaxone∎ Copaxone
QD formulation has more injection site reactions than interferons 40 mg 3x/week has convenience of less frequent administration pregnancy category B
47
48
New Drugs in Previous Reviewed Class
“Medically Ready Force…Ready Medical Force”
New Drugs in a Previously Reviewed ClassSummary
“Medically Ready Force…Ready Medical Force”
49
∎ Drugs designated as non-formulary: failed to show an advantage in terms of clinical or cost effectiveness over formulary agents Valeritas V-Go – disposable insulin delivery device for diabetes
mellitus. Prior Authorization criteria apply. Bromfenac 0.07% Ophthalmic Solution (Prolensa) – NSAID for
cataract surgery∎ Drugs designated as Uniform Formulary
COPD: Umeclidinium/vilanterol (Anoro Ellipta) Glaucoma: Brinzolamide 1%/Brimonidine 0.2% ophthalmic
suspension (Simbrinza)
49
50
Umeclidinium/Vilanterol (Anoro Ellipta)Background
∎ First in class combination∎ Combination long-acting muscarinic antagonist (LAMA) with
long-acting beta-agonist (LABA)∎ QD Dosing∎ Indicated for maintenance treatment of COPD
Active Ingredient
Brand (Manufacturer) Strengths Dosage
Form
FDA Approval
Date
Patent Expiration
Date
Umeclidinium/Vilanterol
Anoro Ellipta (GSK)
62.5 mcg/ 25 mcg
Dry powder inhaler
12/18/2013 2022
51
Umeclidinium/Vilanterol (Anoro Ellipta) Formulary Placement
∎ DecisionUF: Umeclidinium/Vilanterol (Anoro Ellipta)Encourage pts to fill Rxs at Mail or MTFs
∎ JustificationOffers the patient convenience of two bronchodilators in one
inhaler, dosed once dailyAnoro Ellipta is the only LAMA/LABA commercially available
combination product. Combined therapy may improve adherence
Safety profile in COPD patients appears similar to the other LABAs and LAMAs
Brinzolamide 1%/Brimonidine 0.2% (Simbrinza)Background
52
∎ 1st fixed dose combination product for glaucoma that has components other than a beta blocker
∎ Intraocular pressure (IOP) lowering with Simbrinza is similar to that attained with Prostaglandin Analogs
∎ The safety profile reflects adverse effects of the individual components
GenericBrand
(Manufacturer) Concentration Dosing Mechanism of Action
Brinzolamide/brimonidine
Simbrinza(Alcon) 1%/0.2% TID
alpha-adrenergicreceptor agonist/
carbonic anhydrase inhibitor
53
Brinzolamide/Brimonidine 1%/0.2% (Simbrinza)Formulary Placement
∎ Decision UF: Brinzolamide/Brimonidine 1%/0.2% (Simbrinza) Encourage pts to fill Rxs at Mail or MTFs
∎ Justification IOP lowering is greater with the combination than with
the individual components alone Patient convenience of 2 drugs in one; but still TID dosing Simbrinza was similar in cost to UF carbonic anhydrase
inhibitors and alpha-agonists when used in combination
DoD P&T Committee Past Meeting – Feb 2015
∎ UF Class reviews Pulmonary Arterial Hypertension Prostate Cancer
Survival-Prolonging Drugs Anti-Androgens
Transmucosal Immediate Release Fentanyl Products
∎ New drugs Sedatives: tasimelteon (Hetlioz) SGLT-2 Inhibitors: empagliflozin (Jardiance) Antiplatelet Agents: vorapaxar (Zontivity) PDE-5 Inhibitor: avanafil (Stendra) PPI: esomeprazole strontium
54
DoD P&T Committee Upcoming Evaluations
May 2015 ∎ UF Class reviews
Oral Anticoagulants Warfarin and newer agents
HCV Direct-Acting Antiviral Agents
∎ New drugs Sedatives: suvorexant (Belsomra) MS: Interferon beta 1a SQ
(Plegridy) Nausea/Vomiting:
doxylamine/vitamin B6 (Diclegis)
August 2015∎ UF Class review
CML SGLT-2 Inhibitors GLP-1 Receptor Agonists Narcotic Analgesics
∎ New Drugs COPD drugs: umeclidinium
(Incruse Ellipta)
55
Specialty Rx Filled by Point of Service; Jan-14 to Feb-15
56
∎ Interventions began in August 2014 (P&T; education; working with DLA; formulary expansion; reimbursement)
“Medically Ready Force…Ready Medical Force”
Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-150
2000
4000
6000
8000
10000
12000
14000
Mail OrderMTFRetail
Based on Clinical Services Drug List
Specialty Rx Filled by Point of Service; Jan-14 to Feb-15
57
∎ Decreasing the Retail market share
“Medically Ready Force…Ready Medical Force”
Based on Clinical Services Drug ListJan
-14
Feb-14
Mar-14
Apr-14
May-14
Jun-14Jul-1
4
Aug-14
Sep-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
0%
10%
20%
30%
40%
50%
60%
Mail OrderMTFRetail
Top 20 Rx written by MTF providers and filled at Retail Point of Service, Jan-14 to Feb-15
58Based on Clinical Services Drug List; adjusted for refunds & copays
Sum of # RXSum of Net Cost to Government Mean Cost/RX Target 30% Recapture
NOVOSEVEN RT 30 $792,002 $26,400 $237,601GLEEVEC 57 $457,084 $8,019 $137,125COPAXONE 102 $804,815 $7,890 $241,445SPRYCEL 33 $241,858 $7,329 $72,558REBIF 45 $321,844 $7,152 $96,553GILENYA 72 $509,058 $7,070 $152,717REBIF REBIDOSE 36 $240,985 $6,694 $72,296AVONEX 20 $122,734 $6,137 $36,820BETASERON 36 $205,413 $5,706 $61,624TECFIDERA 414 $2,306,524 $5,571 $691,957SIMPONI 24 $117,425 $4,893 $35,227AUBAGIO 18 $86,866 $4,826 $26,060HUMIRA 436 $1,688,256 $3,872 $506,477CIMZIA 38 $132,286 $3,481 $39,686ENBREL 198 $625,942 $3,161 $187,783BENEFIX 25 $69,638 $2,786 $20,892ORENCIA 24 $66,494 $2,771 $19,948XELJANZ 13 $27,442 $2,111 $8,233LEUPROLIDE ACETATE 124 $29,736 $240 $8,921RIBAVIRIN 15 $2,466 $164 $740Grand Total 1,760 $8,848,868 $2,654,660
New “Resources” Tab under DOD P&T Committee
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Based on Clinical Services Drug List
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Brand to Generic Update
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FY15 $10.8M
Cost Avoidance
National Contract Compliance Update
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Nexium NDC Transition Plan
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Prime Vendor Credits Update
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Narcotic Order Review and Approval (NORA)
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Due to security and information assurance issues accrediting a Commercial off-the-shelf (COTS) CSOS solution, the Government is building an off-the-shelf (GOTS) system to enable electronic C-II ordering. The Joint Medical Logistics Functional Development Center (JMLFDC) at Ft. Detrick, MD is the process owner, and is currently developing a program/process called "NORA" (instead of CSOS)
KEY FEATURES:- Allows customers to submit C-II controlled orders electronically to the PPV - Allows on-line signature of electronic DEA 222 request
BENEFITS:- Faster order placement/fulfillment- Increased data accuracy of items being ordered/certified - Complete audit of C-II orders and confirmations
Expected Go-Live Dec 2015
Region Go-Live
Designated Providers April 1, 2015@
Other Government Agencies April 1, 2015@
Upper Prairie (DMLSS) April 1, 2015
North (DMLSS/Web Ordering)North (TEWLS)
May 1, 2015May 4, 2015
South (DMLSS/Web Ordering)South (TEWLS)
May 8, 2015May 11, 2015
West (Hawaii and Alaska) (DMLSS/Web Ordering)West (TEWLS)
May 15, 2015May 18, 2015
North OCONUS (Europe) (All) June 1, 2015
West OCONUS (Pacific) (All) June 1, 2015
@Non-DMLSS/TEWLS*The Back-up Supplier will go live with the Primary for Each Region
Prime Vendor Global Status: Go Live Dates
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Prime Vendor Global Status: Catalogs
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∎ Usage has been sent to ABC for the West and OCONUS sites for the first 5 months of FY15 11,560 NDCs with Cardinal sales Oct14-Feb15 372 NDCs “discontinued” ABC will not supply 22 NDCs “not recognized” ABC will not supply
∎ DLA CPOC will review the 394 NDCs to ensure there are alternatives available to meet customers’ needs
Overview: Compounds
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∎ Lack of Scientific Evidence – lack of peer reviewed clinical research evaluating the safety and effectiveness of many compounded products
∎ Costs – DoD’s costs for compound drugs have risen tenfold between 2012 and 2015, doubled from $250M to over $500M between FY-13 and FY-14, and are on pace to reach $2B in FY15, with the majority of the costs stemming from retail.
∎ Management Strategy – Express Scripts, TRICARE’s pharmacy benefit manager has developed an enhanced claims screening process for compound claims that has been in place for commercial clients and will be implemented on May 1, 2015.
∎ Strategy includes:
DoD Pharmacy and Therapeutics Committee (P&T) Committee Recommendation – Prior Authorization
Express Scripts – Network Agreements
HA request for Service/eMSM support
Compound Pharmacy Expenses
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$0
$25,000,000
$50,000,000
$75,000,000
$100,000,000
$125,000,000
$150,000,000
$175,000,000
$200,000,000 Actual for January 2015: $194M
Management Strategy
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∎ In November 2014, DoD Pharmacy & Therapeutics (P&T) Committee recommended a Prior Authorization be implemented for compound prescriptions
∎ The Uniform Formulary Beneficiary Advisory Panel met in January, recommended non-concurrence offered input about P&T recommended implementation period and review of other cost containment options
∎ The Director, Defense Health Agency considered recommendations of both the DoD P&T committee and the Beneficiary Advisory Panel delaying decision for further review. To include input and suggestions from the compounding industry
∎ After careful consideration the Director approved modifications to P&T recommendations that will ensure beneficiaries have sustainable access to compound medications while addressing safety and efficacy concerns
Prior Authorization Screening Criteria and Process
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∎ When a TRICARE retail network pharmacy files a claim for a compound drug, each ingredient will be screened based on these criteria: Is it lawfully marketed in the US Is it considered safe and effective Is it appropriate for the patient based on clinical need and cost effectiveness
∎ Prior authorization is a standard process used by TRICARE and other health plans to evaluate individual patient needs and manually review additional evidence not considered in the initial screening
∎ If the prior authorization is denied, beneficiaries also have the option of using the standard TRICARE appeals process
∎ This is similar to the process currently now used by TRICARE to ensure that other prescriptions meet TRICARE’s coverage standards
Prior Authorization Criteria
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∎ What is the diagnosis?∎ Has the patient tried commercially-available products for the diagnosis?∎ Is there a national drug shortage of commercially available product?∎ What is the proposed duration of therapy?∎ Has the prescriber submitted evidence supporting the therapy for this
patient and that an FDA-approved, commercially-available product is not appropriate because the patient requires a unique dosage form or concentration (e.g., inability to take a solid dosage form, dose based on age or weight, ineffectiveness of such products for the patient) and/or an FDA-approved product cannot be taken due to allergies or contraindication?
∎ Is the prescription cost-effective, does it meets the pricing standard?∎ Other information the requestor believes supportive of the request.
Changes to Network Agreement
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∎ ESI will work with TRICARE retail network pharmacies to establish agreed upon pricing standard for approved compound drug agreements Compound claims for TRICARE beneficiaries received by ESI from pharmacies
that choose not to negotiate rates will rejected
∎ Network pharmacies will be required to sign and adhere to the pricing when submitting compound claims
∎ ESI will monitor claim processing for adherence
How You Can Support
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∎ Review MTF Provider Leakage Report Provided Monthly by DHA POD – currently being refined to reduce false +’s Allows drill down to either eMSM, Service, MTF level Can filter specific drugs (e.g. Compounds) Can examine what prescriptions (Compounds) your MTF providers write that
are filled in the Retail Network∎ Review MTF Prime Leakage Report – being refined to file size
Provided Monthly by DHA POD –Similar drill down and filtering Can examine what prescriptions your MTF Prime patient are filling in the
Retail Network from purchase sector care provider∎ Actionable information supports the following ways to control leakage
Prescriber education on costs and expectations of DHA You Write It You Fill It policy – see earlier slides on Hill AFB and communicating of business rules
∎ Mirror Retail and TMOP procedures for Prior Authorization criteria
Key Messages
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∎ DoD’s highest priority is to ensure we are providing safe and effective care to our beneficiaries.
∎ Most compound drugs will not be affected by this policy, and these most beneficiaries will experience no delay in getting their drugs.
∎ Some compound drugs contain ingredients whose use is not supported by a widely recognized body of peer-reviewed clinical evidence.
∎ TRICARE including our MTF Providers must be a responsible steward of taxpayer dollars, and provide value for the care we cover.
∎ Reviewing prescription drugs to ensure they are covered is standard operating procedure for TRICARE and other government and civilian health care plans.
Drug Take Back Update
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∎ DoD Instruction (DoDI) from HA is being formally coordinated∎ Finalizing DHA Interim Procedure Memorandum (IPM) for
coordination∎ Next Steps
Contracting efforts Funding
∎ Service Level Interim Solutions Army: Identified 41 sites to receive collection receptacles and organizing next
Drug Take Back Day in May 2015 Navy: Identified 20-25 high risk sites/pilot sites to receive collection
receptacles Air Force: Several sites with collection receptacles and high risk training sites
are utilizing mail-back envelopes
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e-Prescribing Update
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∎ There have been issues reported where a CHCS drug has mismatched to an electronic prescribing (eRx) drug
Examples▻Coumadin 5mg (eRx) Coumadin 3mg (CHCS)▻ Lisinopril 5mg (eRx) Lisinopril 2.5mg (CHCS)
∎ It has been determined that this issue was caused by the civilian provider's ePrescribing system sending the wrong NDC for the prescribed drug
∎ A Pharmacy Ops review of eRx transactions from Oct 2014 - Jan 2015 found that 0.17% of transactions were impacted by this issue
e-Prescribing Update
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∎ In Feb 2015, the ability for eRx transactions to bypass the holding queue and “auto-create” a CHCS prescription was disabled All eRx’s are placed in the holding queue for pharmacy staff verification
∎ As an on-going safety practice, it is recommended that pharmacy personnel closely review all eRx incoming transactions and compare to the CHCS possible "Match Found" drug
∎ There are two ways in CHCS to verify that the eRx and CHCS drugs match: eRx Holding Queue & Prescription Inquiry (PRI) option
∎ An additional recommendation is for pharmacy personnel to review/update the CHCS Legal Status setting for compounded medications
NDAA 2015 Pharmacy Actions – Four Main Actions Related to DoD Pharmacy
Increase Co-Pays by $3 – Retail and Mail Order- 1 Feb Except Mail Order generic and Remain $0 Retail (30 days- $8/$20); Mail – (90 Days - $0/$16); NF-$46
Non-Formulary Medications – Primarily through MOP Available through MTF and/or Retail by Medical Necessity Details Under Development
Transition TFL Pilot to All Beneficiaries – 1 Oct Brand Maintenance Meds; Details Under Development
Medication Therapy Management Demo Project MTF and other Locations; Details Under Development
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∎ Questions?
∎ For additional information, please reach out to one of the following: DHA Pharmacy Operations Division Chief: Dr. George Jones, [email protected]
Air Force Pharmacy Consultant: Col Scott Sprenger, [email protected]
Army Pharmacy Consultant: COL John Spain, [email protected]
Navy Pharmacy Consultant: CAPT Thinh Ha, [email protected]
Questions