PHSL Newsletters

It’s back…PHSL’s annual review of the big 3 PBM formulary exclusion list updates! Express Scripts (ESI), CVS Caremark, and OptumRx published their formulary exclusions for January 2023. Based on PHSL’s review, OptumRx leads the way with over 77 new formulary exclusions. ESI added 36 new exclusions, while CVS Caremark only excluded an additional 26 drugs. Although CVS Caremark excluded nearly 30 new drugs, they anticipate that 99.72% of their clients will not be impacted by any medication changes because of these formulary removals. The January 2023 exclusions, as researched by PHSL, are as follows:

During the review, PHSL made the following observations:

• ESI focused more attention on anticonvulsant agents. Examples of exclusions in this category include Banzel, Onfi, Klonopin, and Vimpat.
• CVS Caremark’s focus was on chemotherapy agents, such as Rubraca, Sutent, and Alimta.
• OptumRx focused on autonomic and central nervous system agents. Specific agents excluded by OptumRx are Daytrana, Ponvory, and Quillichew ER.
• All three PBMs excluded numerous respiratory products. CVS Caremark excluded Flovent Diskus, instead preferring Flovent HFA or Pulmicort Flexhaler. OptumRx excluded generic fluticasone-salmeterol products in favor of Advair Diskus, likely due to rebates.  OptumRx also excluded Dulera, Incruse Ellipta, Tudorza, Bevespi, and QVAR Redihaler.  Like OptumRx, ESI excluded Incruse Ellipta and Tudorza Pressair in favor of Spiriva.  Although many of these changes are likely rebate driven, from a clinical perspective, the Global Initiative for Asthma (GINA) guidelines were also updated in 2022 and now seem to generally prefer the combination of formoterol paired with an inhaled corticosteroid when an inhaled corticosteroid is prescribed.
• Both OptumRx and ESI excluded the Glucagen Hypokit for 2023, while the product was already excluded by CVS Caremark in 2022.The Glucagon Emergency Kit manufactured by Eli Lilly is the preferred alternative for each of these PBMs. ESI specifically notes that the Fresenius brand of the Glucagon Emergency Kit is also excluded, with only the Eli Lilly Glucagon Emergency Kit being a preferred alternative.
• As CVS Caremark did in 2022, ESI greatly restricted coverage of diabetic supplies and needles. Any insulin needle or syringe that is not BD Diabetes brand is excluded by ESI in 2023. PHSL suspects that this change is largely rebate driven.
• OptumRx still requires prior authorization for Hepatitis C, Multiple Sclerosis, and Immunomodulator treatments. In 2022, OptumRx changed many of their preferred agents by replacing Simponi Aria and Renflexis with Avsola as a preferred immunomodulator. Kesimpta and dimethyl fumarate DR replaced Tecfidera for multiple sclerosis preferred treatments. There was no change in preferred Hepatitis C medications. For 2023, no additional changes are expected.
• CVS Caremark excluded brand Narcan after previously covering the opioid reversal agent. Although no alternative agent was listed, PHSL suspects that the change is due to the introduction of numerous generic agents.
• As mentioned in our 2022 Exclusion List Review, ESI continues to use indication-based management for the “inflammatory conditions” drug class. There are no additional excluded medications this year.

Each of the major PBMs have taken a different approach to managing drug expenditure in 2023, with formulary exclusions continuing to play a significant role. PBMs exclude products because of clinical, financial, and humanistic reasons. Each PBM makes value judgements and determines what coverage is no longer warranted. This article represents PHSL’s analysis of publicly available information regarding the three PBM’s formulary exclusion for 2023. Readers are encouraged to assess the lists for themselves, using the formulary and exclusion list source information provided in the links below.

• CVS Caremark 2023 Formulary
• ESI National Preferred Formulary 2023 Exclusions
• OptumRx 2023 Premium Formulary Exclusions
• CVS Caremark Formulary Watch
• CVS Caremark 2023 Formulary Updates

Posted January 11, 2023

Winter 2023 Newsletter:

Dispenser Track and Trace: Applicability to Patients

The Drug Supply Chain Security Act, also known as the Track-and-Trace Law, has been a topic of discussion for almost a decade. The FDA announced their 10-year plan in November of 2013 with the goal that each drug product would be traceable from the moment it was manufactured to the moment it was dispensed to the patient. The end of this 10-year roll out is in sight. The FDA set a compliance deadline of November 27, 2023, with pharmacies being the last stop in this journey.

The FDA implemented multiple staged deadlines throughout the past 10 years, with the first step in 2017 being manufacturers’ development of a 2D barcode that records the product NDC, serial number, lot number, and expiration date. Since then, repackers, wholesalers, and pharmacies have adapted their systems and workflow to comply with the new 2D barcode and tracking regulations. The goal is to directly identify recalled or suspect products and those who directly handled and received them.

The focus is now on the dispenser, i.e., pharmacy or healthcare facility. Review of the regulations is generating discussion around patient level tracking and potential best practices. Currently, the FDA only requires pharmacists to:

1. Confirm that the entities you do business with are licensed and registered.
2. Receive, store, and provide transaction history, transaction information, and transactions statements (3Ts). The 3Ts must be stored for at least 6 years. When dispensing to another entity instead of to an individual patient, such as dispensing to an ambulance service, the 3Ts must be provided to first responders or the other pharmacy. If a pharmacy transfers a product to another pharmacy that is not for a specific patient, the pharmacy may need to register as a wholesaler in the future.
3. Investigate and handle any suspect or illegitimate products.
4. In the event of a recall, upon request by the FDA or other appropriate Federal or State official, the pharmacy must provide the 3Ts for that product within two business days.

Each of these requirements are not cut and dried. Pharmacies must upgrade their software and modify their workflow to meet these standards. In addition, new guidance has been published by the FDA exempting certain products from this Act, including naloxone and some COVID-19 treatment and prevention products.

Many large chain pharmacies and hospital networks already have barcode scanning and inventory systems implemented into their workflow, but some of these systems only work with linear barcodes. Third-party tech companies have jumped into action offering new technology to fill this need. For large companies, the financial commitment is understood, but for small independent pharmacies, the financial burden of meeting these requirements could be substantial.

The DSCSA 10-year plan ends with the dispenser, but industry leaders question the process being implemented by certain pharmacies. The purpose of this law is to improve the safety of the patient, so why not extend this practice to the patient level? Extending to the patient level comes with numerous benefits, but also many concerns. In terms of patient safety, those affected by a recall or illegitimate product could be directly identified and notified sooner, avoiding the need for a patient to make a trip into the pharmacy or an unnecessary phone call. This allows the pharmacist to focus on the patients truly at risk.  Patients not at risk could still be a part of the notification for peace of mind, removing any patient uncertainty. If the tracing system is automated, time pharmacy personnel previously spent checking the shelves for recalled products would be alleviated. That time can be focused on other areas of demand, like point-of-care testing.

So, how would pharmacies extend this to the patient level? Pharmacy leaders first need to ensure that their technology and software can scan 2D barcodes and link the product information to a patient profile. Ideally, the system would be able to generate a report listing each patient that received a certain NDC, lot #, and expiration date. In the pharmacy workflow, pharmacy personnel would queue a prescription to be dispensed and added to a patient profile, scan the 2D barcode, and fill the prescription just as they do now. All the changes would occur behind the computer screen. The software would generate an inventory of all products received and the 3Ts for each product. Hypothetically, if a recall is issued, the system would identify if the pharmacy even received the product and then determine who the pharmacy dispensed the product to and generate a report. The next question is how does the pharmacy notify the affected patients? Just as many systems now notify the patient via phone call, text message, or email that their prescription is ready for pick-up, the pharmacy systems would do the same with recall information.

This idea sounds great in theory, but the costs required to develop, test, and implement new software may be prohibitive.  Additional resources would also be needed to retrain employees. The accuracy of the information within a patient profile is a key component, since this would be how the patient is notified. It would be vital for pharmacy leaders to discuss and formulate a plan before extending to the patient level.

The Drug Supply Chain Security Act has reshaped the pharmacy industry to ensure patient safety. Pharmacy leaders have overcome many challenges throughout this journey, but a lot of work is still needed to meet the November 27, 2023 deadline and before pharmacies can implement tracking at the patient level. The FDA has yet to budge on the November 2023 deadline, so PHSL encourages organizations to talk with their software vendors or IT support to ensure necessary steps are being taken to meet the requirements before this deadline. PHSL also encourages pharmacy personnel to be prepared to demonstrate their ability to access the 3Ts data upon an FDA or Board of Pharmacy inspection.

PHSL has written about Track-and-Trace since President Obama signed this Act in 2013. Please see the below publications for more information:

https://phsirx.com/news-events/phsi-newsletters/track-and-trace-implementation-update

Posted January 11, 2023

Winter 2023 Newsletter:

2023 Formulary Exclusions Lists: A Review of Express Scripts, CVS Caremark, and OptumRx

Are you trying to keep up with the latest from pharma manufacturers and their participation in 340B? Just want to keep your pharmacy 340B compliant? The Health Resources & Services Administration (HRSA) website states, “In order to fulfill the ongoing obligation of compliance, all covered entities are required to provide oversight of the contract pharmacy, maintain auditable records and are expected to conduct, at a minimum, annual audits of their contract pharmacies, completed by an independent auditing firm. Any compliance activity or audit performed by a covered entity that indicates a violation of 340B Program requirements should be disclosed to HRSA … and include the entity’s plan to address the violation.”[1]

With the increasing pushback of manufacturers against the widespread use of contract pharmacies by covered entities (CE) participating in the 340B program, maintaining trust through internal compliance audits is even more critical to 340B program viability.

The following chart provides an overview of the 18 manufacturers who are looking to stop providing 340B discount to contract pharmacies or are looking to receive claims data to avoid paying duplicate discounts.  PHSL has captured key action dates and findings, although the chart may not be all inclusive due to the rapidly changing nature of these events.

340B Manufacturer Updates

PHSL’s 340B Third-Party Audit Service clients include both contract pharmacies and the covered entities themselves.

340B Third-Party Compliance Audit Services for Contract Pharmacy:

PHSL’s role is to ensure that the pharmacy practices comply with covered entity agreements. PHSL’s independent review provides contract pharmacy management teams with insight into the compliance with policies, procedures, and established protocols. Specifically, PHSL services include:

• Validate that contract pharmacies are complying with HRSA 340B regulations and covered entity agreements.
• Help develop the covered entity’s plan to address any 340B Program requirements violations.
• Quantify any discrepancies identified during the audit, provide a risk assessment, and recommend steps for a corrective action plan as needed.

An example of when PHSL has helped a client discover a potential violation during a “self-audit” and address it to remain compliant can be found here.

340B Third-Party Compliance Audit and Related Services for Covered Entities (CE):

In addition to the third-party audit services covered above, PHSL can assist covered entities in standing up in-house outpatient specialty pharmacies that can then access 340B drug pricing.

As more manufacturers are limiting their 340B participation based on contract pharmacy usage, many covered entities are bringing outpatient specialty and retail pharmacy services under covered entity ownership. Our consultants have experience working with several health systems to successfully stand up their own in-house specialty pharmacy.

340B Third-Party Compliance Audit Service for Manufacturers:

More drug manufacturers, eighteen as of July 2022 (see “Timeline of Events” table), are looking to stop providing 340B discounts to contract pharmacies or are looking to receive claims data to better avoid paying duplicate discounts (“double dipping”). Many manufacturer-covered entity agreements allow for auditing of claims data and 340B program compliance. PHSL can assist manufacturers with this claims data review process to audit not only standard program compliance but also ensure that specific manufacturer compliance guidelines are followed.

Who We Are

Pharmacy Healthcare Solutions LLC (PHSL) consultants have extensive healthcare industry knowledge to support clients with business strategy development, primary and secondary research, environmental scans, operational assistance, and leading-edge training programs across these market segments. With our focus squarely positioned in pharmacy and prescription products, we offer clients a 360-degree view of the markets we serve. Our diverse clientele allows us to provide market insights into the business and marketing challenges posed by a rapidly changing healthcare market and enables our consultants to develop strategies and solutions that best meet our clients’ needs.

[1] https://www.hrsa.gov/opa/implementation-contract

Posted September 12, 2022

Fall 2022 Newsletter:

Management of Drug Shortages in the U.S.

In April 2022, PHSL asked website visitors to weigh in on how drug supply shortages in 2022 had changed compared to shortages in 2021. Forty-four percent of respondents believe more products are being impacted in 2022, while another 44% believe the same number of products are being impacted. According to the University of Utah Drug Information Service and reported by the American Society of Health-Systems Pharmacists (ASHP), the total number of active drug shortages in 2022 (262 products) has not yet hit the peak seen in early 2021 (271 products). However, new (recently reported) drug shortages at the midpoint of 2022 are on pace to surpass the number of new drug shortages in 2021, as seen in the chart below.

Source : https ://www.ashp.org/drug-shortages/shortage-resources/drug-shortages-statistics

Publicly available information on drug shortages is available from two main sources:

1. The FDA’s Drug Shortage Staff (DSS), which resides in the Center for Drug Evaluation & Research (CDER).
2. Drug Shortage Bulletins developed by the University of Utah Drug Information Service and distributed by ASHP.

Both organizations report on drug shortages for different purposes and audiences.

While the FDA works to mitigate issues, drug shortages can still occur quickly and unexpectedly. During the early months of the COVID-19 pandemic, an increased demand for critical hospital medications and those treating symptoms of respiratory illnesses resulted in drug shortages. There were also issues acquiring raw materials and packaging, which was being prioritized for COVID-19 vaccines. In response to the pandemic, the FDA Drug Shortage Staff monitored the supply chain, asking manufacturers to evaluate their entire supply chain for potential impact.

However, drug shortages and supply chain issues have been an issue since long before the COVID-19 pandemic. Drug shortages occur for a variety of reasons:

• Manufacturing and Quality Issues
• Production Delays
• Discontinuations
• Increased Demand

The FDA CDER states that its mission is to “prevent, mitigate and alleviate drug shortages,” while the DSS seeks to oversee and facilitate the resolution of all drug shortage situations. The DSS facilitates temporary and long-term strategies, coordinating risk/benefit decisions and distributing shortage information by working with suppliers and facilities.   The FDA maintains a list of current drug shortages, resolved drug shortages, and discontinuations on the FDA website.

In a 2019 report, an FDA Task Force identified three root causes for drug shortages:

1. Lack of incentives for manufacturers to produce less profitable medications
2. The market does not reward manufacturers for mature quality management systems
3. Logistical and regulatory issues make it difficult for the market to recover from disruption

The report also offered three recommendations for enduring solutions to address shortages:

1. Understanding the impact of drug shortages on patients and the contracting practices that may contribute to shortages
2. Developing a rating system to incentivize manufacturers for quality management system maturity (when drug manufacturers have consistent, reliable, robust business process to achieve objectives and promote continual improvement)
3. Promoting sustainable private sector contracts to ensure reliable supply of medically important drugs

The FDA published the draft guidance document “Risk Management Plans to Mitigate the Potential for Drug Shortages” in May 2022 “to help stakeholders develop, maintain, and implement risk management plans (RMPs) to proactively assist in the prevention of human drug product and biological product shortages.” The FDA seeks to address problems by requiring that manufacturers notify the FDA about supply disruptions, delays, discontinuations, and certain manufacturing changes. Manufacturers are required to notify DSS no later than 5 days after a manufacturing interruption and before a supply disruption. If a product will be discontinued by a manufacturer, the FDA requires 6 months advanced notice.

The FDA seeks to prevent shortage by receiving early notification, allowing for the prioritization of products that are medically necessary and maintaining availability when possible. The FDA communicates possible shortage concerns in the market to other suppliers, which prompts them to look at their demand and supply.  The FDA may also consider expedited reviews of company proposals and in rare cases, drug importation from other countries. The FDA has implemented programs attempting to mitigate shortages through outsourcing facilities and has created the “essential medicines list” to reduce reliance on foreign suppliers.

While the FDA helps to prevent and manage drug shortages with a focus on medically necessary drugs, ASHP reports all submitted and substantiated supply issues to provide “practitioner-focused resources to help the healthcare community manage shortages.” ASHP provides frequent updates on shortages, noting available manufacturers, products on allocation, and discontinuations. ASHP states that their information includes “unapproved drugs and unlabeled uses (when well-researched and reported to be safe and effective); recommendations for therapeutic alternatives; drug to drug comparisons and comparisons within individual drug classes; and safety recommendations.”

Respondents to the PHSL poll were split between those that believe shortage will get worse in 2022 and those that believe they will not change. A small number also believe shortages improved in 2022. A closer look at the types of drugs impacted by these shortages may help explain these differing opinions. In 2021 and the first half of 2022, more than 60% of all shortages reported by ASHP were for injectable drugs, which are more likely to be used in a hospital or specialty setting compared to products dispensed in a community setting.

Source: https://www.ashp.org/drug-shortages/shortage-resources/drug-shortages-statistics

Drug shortages occur for a variety of reasons and will continue to present challenges in healthcare. The FDA cannot require a manufacturer to make a drug, but it does have a clear plan to monitor and assist when potential shortages are identified.

On the provider side, ASHP provides valuable information on drug shortages and product considerations to help minimize the effects of shortages on patient care. These organizations have helped to avert drug shortages and provide key details for providers impacted by these shortages, but can more be done? Will a focus on US-based production be the key to minimizing shortages?

Posted September 12, 2022

Fall 2022 Newsletter:

Manufacturer 340B Participation Updates

There is no doubt that pharmacists’ role in immunizations dramatically increased with the COVID-19 pandemic, as pharmacies administered vaccinations to much of the country’s population.  In addition to solving a public health crisis, at approximately $40 per dose, the Medicare Part B administration fees for COVID-19 initial and booster vaccines created additional revenues for pharmacies.  With declining drug ingredient cost reimbursement rates and negligible dispensing fees, vaccines were a welcomed revenue stream for many pharmacies.

As we approach the annual flu season, another vaccine opportunity will present itself to pharmacies.  Medicare Part B payments for vaccine administration have increased 77%  this year.  For influenza, pneumococcal, and hepatitis B vaccines, the administration reimbursement increased from $16.94 per dose in 2021 to $30 per dose in 2022.  This change is a nice reversal in immunization reimbursement rate trends, after we saw the rate decrease from $20.88 to $16.94 in 2019.

For 2022, the Medicare Part B pharmacy payment for COVID-19 vaccine administration remains at $40 per dose.  Because commercial reimbursement rates often follow the rates set by Medicare, it is expected that this administration rate increase will have wider reaching effects, beyond simply those of the Medicare population.

For the 2022-2023 flu vaccine, two of the four strains included in the quadrivalent vaccine will differ from the 2021-2022 version.  This coming fall, the influenza vaccine will include the following strains:

• H3N2 component: A/Darwin/9/2021 (H3N2)-like virus (for egg-based vaccines) or A/Darwin/6/2021 (H3N2)-like virus (for cell culture or recombinant vaccines)
• Influenza B: B/Austria/1359417/2021-like virus
• Influenza B: B/Phuket/3073/2013 (B/Yamagata lineage)-like virus
• Influenza A: A/Victoria/2570/2019 (H1N1) pdm09-like virus (for egg-based vaccines) and A/Wisconsin/588/2019 (H1N1) pdm09-like virus (for cell culture or recombinant vaccines)

Knowing that two new strains are included should enable pharmacists and healthcare practitioners to have more educated discussions with their patients concerning the importance of receiving the 2022-2023 influenza vaccine.  With the increased reimbursement rates available to pharmacies, we expect that vaccines will continue to play a key role in retail pharmacy profitability, as pharmacies continue to seek alternative revenue streams outside of traditional drug dispensing.

Posted June 28, 2022

Summer 2022 Newsletter:

U.S. Reliance on Foreign Sources of API

Active Pharmaceutical Ingredient (API) production is a complex and global process. APIs are the active biological or chemical components of any drug. The process of converting raw ingredients and turning them into APIs through various chemical, biochemical, or fermentation processes can be expensive and can lead to a considerable portion of the total drug cost. The production of APIs has been concentrated overseas to reduce costs, with 72% of those facilities found outside of the US. In the chart below, we can see the total production of APIs used in the US market.  Interestingly, although not unexpectedly, only 30% of the API facilities used for US drugs comes from North America.

U.S. Food & Drug Administration. (2019, October 29). Safeguarding pharmaceutical supply chains in a global economy. U.S. Food and Drug Administration. Retrieved May 30, 2022, from https://www.fda.gov/news-events/congressional-testimony/safeguarding-pharmaceutical-supply-chains-global-economy-10302019

The below graph shows the API sources of the top 100 brand name drugs in Medicare Part D in 2018.  Although this data is a few years old, we do not expect that significant changes in API origin have taken place since that time.

*Multiple countries may be represented for a single API

Adapted from Levitt, G., & Mueller, L. (2022, January). Not Made in the USA: The Global Pharmaceutical Supply Chain and Prospects for Safe Drug Importation. Pharmacy Checker. Retrieved May 30, 2022, from https://cdn.pharmacychecker.com/pdf/Not+Made+in+the+USA+-+2022.pdf

Comparing the two charts above, a large discrepancy is noted for India and China.  While India and China account for over 30% of the API facilities for all drugs, they account for only 2% of the top 100 brand drugs.  The following table indicates that China and India account for 44% of the kilogram mass of pharmaceutical imports, yet only 11.7% of the dollar value (i.e., generics).  Meanwhile, Germany and Ireland account for 60% of the dollar value and less than 10% of kilogram mass (i.e., brands).

Public Citizen. “China Is the Top Source of U.S. Pharmaceutical Imports, with India and Mexico Also Major Sources.” Public Citizen, 7 Apr. 2020.

The PharmacyChecker report focuses on top brands, and therefore China and India each only account for a single imported brand API.  These results make sense due to the high cost of single-source brand drugs.  Brand companies typically rely on high quality materials from trusted sources and labor to ensure continued supply to avoid disruptions and lost sales, oftentimes from the large number of registered API facilities in Europe.

These APIs, often imported from various countries, are critical to the development of drugs which enter the supply chain to be delivered to patients in healthcare facilities and pharmacies. Errors in containment, contamination, and other aspects of the supply chain can cause drug shortages in pharmacies and hospitals.  These shortages may delay treatment, potentially affecting hundreds of thousands of people. During the pandemic, supply chain issues were abundant. China, which doubled the number of registered facilities producing APIs between 2010 and 2019, has seen many disruptions in supply of its products. 57% of companies reporting worsened lead times in getting their products to the market to meet demand, according to the Institute for Supply Chain.

With supply chain issues being a continued and growing problem for American markets, the FDA suggests the use of new technologies in advanced manufacturing, such as continuous manufacturing or the Emerging Technology Program (ETP), to streamline processes and guarantee safety and efficacy or products. The FDA states that these innovations, “can be used to reduce the Nation’s dependence on foreign sources of APIs, increase the resilience of our domestic manufacturing base, and reduce quality issues that trigger drug shortages or recalls.” With the increasing production of APIs overseas, it is important to consider the supply chain and quality control issues that may arise.  Manufacturers may consider the use of homegrown production of APIs to combat those risks. Domestic supply and European supply of drugs and biologics can alleviate or lessen the risk for these products.

PHSL expects that more manufacturers, even commodity generic manufacturers, will have an increased emphasis on using US or EU-sourced API for their drugs in the future, if the cost is comparable.  The COVID-19 pandemic is a reminder that worldwide events can have a significant impact on Americans receiving their daily medications.

Posted June 28, 2022

Summer 2022 Newsletter:

Vaccine Profitability Increases for Pharmacies

It has now been more than eight years since the Track-and-Trace law, known as the Drug Supply Chain Security Act (DSCSA), was signed.  The Act outlines the steps that participants in the pharmaceutical supply chain and pharmacy industry must take to build a system that identifies and traces pharmaceuticals and facilitates the exchange of information at the individual package level by showing where a drug has been in the supply chain.  The deadline to implement all of this is the tenth anniversary of the Act being signed, November 27, 2023.

Recently, the HDA (Healthcare Distribution Alliance) Research Foundation published a survey[1] that assessed the industry’s progress.  The Foundation’s survey concluded that industry business partners are just now beginning to establish interoperable connections and work with data exchange in a production environment.

Even though over 80% of manufacturers have prepared to send data downstream, few are exchanging data in production today. Currently, almost 60% of manufacturers say they are not sharing data with distributors.  A little over 60% of manufacturers plan to connect directly with distributors, but nearly 40% of manufacturers will rely on third-party logistics providers, adding a layer of complexity to the process.  Only 16% of manufacturers are connected to dispensers.  Manufacturers stated they have run into obstacles like a lack of resources, slow movement in the industry as a whole, and delays caused by “either past or potential future enforcement discretion.”[2]

Around 50% of distributors are setting up connections currently, while approximately 40% are connected to manufacturers in a production environment; none have any connections with dispensers.  Even when implemented, 45% of distributors don’t plan to establish a direct connection with dispensers.  This indicates many distributors have a significant amount of work to do over the next two years to meet the November 2023 deadline.  Some survey respondents said COVID-19 has curtailed adoption of the standard.  There is also a question as to the number of business partners that prefer a direct connection versus a portal connection. The top distributor obstacle identified was a lack of trading partner understanding or commitment.

Currently, the only “widely recognized”[3] international standard developed to comply with the Track-and-Trace law is GS1’s Electronic Product Code Information Services (EPCIS), which allows trading partners to exchange the transaction data required to comply with the law.  Responses from the survey indicate that industry movement to implement EPCIS is slow possibly due to a lack of IT resources for testing and implementation, the obligation to make IT upgrades required before implementation, or the need to concentrate on error resolution stemming from this process.

Implementation of DSCSA processes has been difficult based on the survey responses.  If funding exists, the Foundation plans to conduct more surveys over the next two years to gauge progress.  Based on the progress still required for a November 2023 implementation, there is a possibility that this deadline, established in 2013, will be extended.  In the meanwhile, PHSL encourages organizations to talk with their software vendors or IT support to determine if the requisite steps are being taken to address this issue.

PHSL has written about Track-and-Trace since President Obama signed this Act in 2013. Please see the below publications for more information:

http://phsirx.com/news-events/publications/computertalk-januaryfebruary-2015

http://phsirx.com/news-events/publications/computertalk-marchapril-2014

http://phsirx.com/blog/update-track-and-trace-enforcement-delayed

http://phsirx.com/blog/track-and-trace-staggered-deadlines-may-lead-to-workflow-disruption

[1] https://www.hda.org/resources/epcis-implementation-benchmarking-survey EPCIS Implementation Benchmarking Survey (hda.org)

[2] https://www.hda.org/~/media/pdfs/industry-relations/hda-foundation-epcis-report.ashx

[3] https://www.hda.org/~/media/pdfs/industry-relations/hda-foundation-epcis-report.ashx

Posted January 5, 2022

Winter 2022 Newsletter:

National Drug Price Reduction Plan

On September 9, 2021, the U.S. Department of Health & Human Services (HHS) published their Comprehensive Plan for Addressing High Drug Prices.  This plan was established in accordance with an executive order from President Biden and focuses on three principles:

1. Make drug prices more affordable and equitable
2. Improve and promote competition
3. Foster innovation to promote better health care and improve health

This review will focus on certain ideas from the HHS Plan and does not opine upon every specific target action.

HHS Drug Rebate Negotiation

One focus of the report is the legislation that currently prohibits the HHS Secretary from negotiating directly with drug manufacturers for Medicare rebates.  The report briefly describes how this portion of the law and Medicare program contrasts with the Veteran’s Affairs (VA) drug procurement program and mandatory rebates in Medicaid.  The report indicates that HHS could negotiate lower prices (greater rebates) that reduce patient out-of-pocket costs and premiums; those lower prices could be extended to employer coverage, the ACA marketplace, and other individual market health coverage.  This description lacks the detail to answer questions around how this potential change would impact the current commercial pricing and administration system, i.e., what could be the unintended consequences of this action?

In the current Medicare Part D system, drug manufacturer rebates are negotiated through plan sponsors/PBMs and passed on to the Centers for Medicare & Medicaid Services (CMS).  If the HHS Secretary were to gain the ability to negotiate drug rebates, how might this impact Medicare Part D plan sponsors?  PHSL has identified the following four scenarios:

1. HHS/CMS intervention would dictate formulary selections and limit options for plan sponsors to differentiate between covered drugs, making most plans very similar and reducing the plan options to beneficiaries
2. HHS/CMS continues to permit unique formularies, and lower pricing would only be invoked when CMS rebate is greater than the plan obtains
3. New HHS rebates may be a supplemental rebate for CMS only, permitting unique plan sponsor formularies
4. New HHS rebates may be a required rebate on all negotiated drugs, similar to the Medicaid Rebate system, permitting unique plan sponsor formularies and cost profiles

Proposals being discussed are focused on limiting negotiations to 10 drugs in 2025 and increasing to 20 drugs in 2028.  The maximum price Medicare pays would be the non-federal average manufacturer price.  The focus will be the top 50 high-cost drugs but exempts small-molecule drugs for their first 9 years and biologic drugs for their first 13 years after approval or licensure.  The implementation and impact to Medicare Part D plan sponsors is still unclear.

For Medicare Part B, where there are no current rebates and no current method to direct treatment to discounted options (formulary and utilization management), PHSL sees two main options for HHS to lower drug prices through negotiation:

1. Allow formulary/utilization management edits in Medicare Part B to direct therapy to lower cost drugs (due to newly negotiated rebates)
2. Require mandatory rebates on all negotiated drugs, similar to the Medicaid Rebate system

Lowering costs for Medicare Part B has already encountered one hurdle, as the U.S. House of Representatives Energy and Commerce Committee did not pass this legislation. The debate continues in the House Ways and Means Committee and in the Senate.

Biosimilars and Generics

The HHS plan also advocates for reforms to reduce delays and barriers to introducing additional competitors, including generics, biosimilars, and competing brands prior to generic entry.  PHSL agrees that generics, biosimilars, and competing brands all offer competition and help to reduce net drug prices to payers, pharmacies, and patients.

The HHS plan advocates for the FDA to work with the Federal Trade Commission (FTC) to identify and address efforts by parties to impede generic and biosimilar competition.  This is already an existing function of the FTC, but any efforts to streamline the process and curtail false, misleading, or deceptive statements about generic and biosimilar products could have a meaningful impact.

Drug Pricing

There are several points focused directly on drug pricing, including an idea to stop unreasonable price increases by applying an excise tax.  This is a general action that would impact all stakeholders (payers, pharmacies, and patients) and would be opposed by drug manufacturers.  This option does not impose price restrictions and continues to permit drug price changes with taxes/penalties for larger price increases.  We would expect this provision to be challenged in court by the pharmaceutical industry.  What other industries face an excise tax based on their pricing behavior?  Why is the government targeting the pharmaceutical industry?

Specifically for patients, the plan describes caps on catastrophic and out-of-pocket spending, using an example for insulin products.  Depending on the implementation of this option, government and payer costs could increase, unless price concessions are shared by manufacturers to offset the difference between the previous uncapped patient cost and the new capped patient cost.

There are current efforts to increase price transparency, which allow market pressure to be exerted to influence prices.  The discussed legislation would require many health plans to annually report currently confidential information about prescription drug and other medical costs to the Departments of HHS, Labor, and the Treasury.  This information will inform leadership, and potentially the public, on prices experienced in the market.  Similarly, CMS is also implementing Affordable Care Act (ACA) provisions that require issuers of Marketplace plans or their PBMs to provide drug, rebate, and spread pricing information.

Testing New Models

The report also notes that the Medicare Part B payment methodology may be a potential area to test new models to determine if drug savings can be achieved.  The report identifies that a single payment limit, applicable to the reference biological product and the biosimilar product(s) of that reference biological product, could spur price competition and drive down average sales prices (ASP) for all products included in the payment limit calculation, resulting in savings for Medicare and supplemental insurers.

Conclusion

The HHS plan offers many targets to impact competition and drug pricing.  It offers a guide for legislators and policy makers to investigate and consider.  The probability of implementation and impact will vary for each target.  PHSL has reviewed several of these options and proposes some alternatives where a more meaningful impact could be achieved.  Of the options that PHSL has reviewed, which do you think are most likely to occur?

Posted January 5, 2022

2022 Winter Newsletter:

Track-and-Trace Implementation Update

Nebraska is the first state to leverage the capabilities of a Prescription Drug Monitoring Program (PDMP) to require pharmacies to report all prescriptions using the ASAP standard format.  A PDMP helps healthcare providers identify patients at risk of drug misuse or abuse, prevent drug overdoses due to taking multiple prescriptions for the same condition, and flag patients who have been prescribed multiple drugs with abuse potential.  Most states currently only utilize PDMPs for tracking controlled substance prescriptions.

Nebraska’s PDMP, a public health model focusing on patient safety, is a statewide tool that collects dispensed prescription medication information that is housed on the CyncHealth (formerly known as the Nebraska Health Information Initiative or NeHII)[1] Health Information Exchange (HIE) platform.  DrFirst, an electronic health records (EHR) and health information systems IT company, manages the pharmacy data by capturing it and moving it to the PDMP.[2]

The Nebraska PDMP was launched in the beginning of 2017 as a stand-alone medication query platform.  Starting January 1, 2018, all dispensed prescriptions filled in the state have been reported to the PDMP so that clinicians can better monitor the care and treatment of their patients.  The PDMP is integrated within the CyncHealth HIE with the query platform to facilitate improved workflow for providers.[3]  DrFirst has focused efforts on integration with EHRs in Nebraska.[4]  This information is housed in a secure database and is available to healthcare professionals as authorized by law.  The PDMP allows prescribers and pharmacists to view those prescriptions to prevent the misuse of controlled substance prescriptions.[5]

If a prescription is dispensed by a pharmacy, it will be reported to the PDMP and show for other healthcare providers with access to review.  However, pharmaceuticals administered in a healthcare provider’s office or in the hospital will not be on the PDMP.  Also, anything administered in the pharmacy, such as vaccines, will not be on the PDMP.  Medical marijuana, CBD, and illicit drugs will also not be on the PDMP.[6]  Patients cannot opt out of the PDMP, and all prescriptions must be entered into the PDMP, even if the patient pays cash for the prescription and does not use a third-party payer.[7]

For healthcare providers, the PDMP provisioning and related registration processes may take approximately two weeks to complete.  Registration requires that all correct information is received and mandatory PDMP training is completed.[8]  In addition, healthcare providers must complete one-half hour of continuing education covering PDMP.  This requirement can be satisfied by watching the PDMP video on the Nebraska Department of Health and Human Services’ website and completing the training acknowledgment form and prescriber CME assessment.[9]

CyncHealth cites that the overall value of their PDMP process is in providing a comprehensive medication history of dispensed prescriptions from all dispensers within one day of dispensing.  The database will contain ten times the data compared to a normal PDMP used only for controlled substances.  This could allow healthcare providers to identify potential drug interactions involving medications from multiple prescribers filled in multiple pharmacies, although the ease of accessing this information will play a key role in its use.  There is no cost for healthcare providers to access and query the PDMP.  Its ease of access and the ability to integrate the PDMP into workflow will promote informed decisions by healthcare providers and encourage better conversations with patients to improve patient safety.[10]

In 2019, lawmakers in Nebraska began work to allow sharing patient prescription data between states and to improve interoperability between EHRs.  They also were working to add information like the number of refills to the data, which would benefit pharmacists.[11]

Based on the success of Nebraska’s PDMP expansion, PHSL expects that additional states could follow suit in the future, but data storage space requirements and patient privacy concerns may be a limiting factor.  Nebraska mentioned that they expect to use ten times more storage space for the PDMP expansion; for more populous states, this may be prohibitive.  Furthermore, getting all stakeholders to trust each other with access to this information will be a challenge.  Based on how the PDMP is configured and what safeguards are implemented, retailers may have concerns that the data they share could be used to identify their customers or what products they are dispensing.  Before more widespread PDMP usage is adopted, users will want to ensure their data is protected and cannot be used by competitors.

[1] https://cynchealth.org/

[2] https://www.psychcongress.com/article/technology/nebraska-finds-success-expanded-pdmp

[3] https://cynchealth.org/nebraska-prescription-drug-monitoring-program/

[4] https://www.psychcongress.com/article/technology/nebraska-finds-success-expanded-pdmp

[5] https://cynchealth.org/nebraska-prescription-drug-monitoring-program/

[6] https://neana.org/file_download/inline/89ace5ea-0bc4-4e19-8484-3b508e509425

[7] https://oig.hhs.gov/oas/reports/region7/71806080_Factsheet.pdf

[8] https://dhhs.ne.gov/Pages/Drug-Overdose-Prevention-PDMP-Access.aspx

[9] https://www.nebmed.org/about/news/new-nebraska-laws-regarding-opiates-prescribing-and-continuing-ed

[10] https://neana.org/file_download/inline/89ace5ea-0bc4-4e19-8484-3b508e509425

[11] https://www.beckershospitalreview.com/opioids/nebraska-legislature-advances-bill-to-enhance-pdmp-limit-opioid-abuse.html

Posted August 18, 2021

2021 Summer Newsletter:

340B Market Dynamics: Role of Systems and Strategic Tactics presented at ASAP by Ann Johnson

It’s that time of year again, PHSL’s annual review of the PBM formulary exclusion list updates!  Express Scripts (ESI), CVS Caremark, and OptumRx have published their formulary exclusion lists for 2021.  Based on PHSL’s calculations, ESI leads the way with 117 new formulary exclusions. CVS Caremark added 62 new exclusions.  OptumRx will exclude an additional 38 drugs.  The new 2021 exclusions, as researched by PHSL, are as follows:

During the review, PHSL made the following observations:

• OptumRx focused more attention on the respiratory class this year, excluding an additional 9 agents. Examples of excluded agents include ProAir Respiclick, Incruse Ellipta, and Xopenex HFA.
• ESI seemed to focus on the oncology class for formulary exclusions in 2021, with products such as Avastin, Rituxan, and Herceptin no longer included on the formulary.  For Avastin, ESI prefers the biosimilars (Mvasi and Zirabev).  Similarly, ESI prefers the biosimilar Ruxience, instead of innovator Rituxan and biosimilar Truxima.  ESI also selected two biosimilars (Kanjinti and Trazimera) instead of innovator Herceptin and biosimilars Ogivri and Ontruzant.
• CVS focused on women’s health, in particular the menopausal symptom category, with seven formulary exclusions.  Examples include Premarin Cream and Estring.
• Although initially only available as authorized generics, additional generic manufacturers are now producing albuterol sulfate inhalers.  Because of these generic launches, all three PBMs are now excluding brand agents ProAir, Proventil, and Ventolin, and this once brand-competitive space is now genericized.
• All three major PBMs have chosen to exclude Udenyca (biosimilar to Neulasta) in 2021.  CVS and ESI also included Neulasta as exclusions in 2021.  ESI prefers two biosimilars (Fulphila and Zietenzo), OptumRx prefers brand Neulasta and biosimilar Ziextenzo, and CVS prefers Zienxtenzo as well.  Sandoz’s Ziextenzo is benefiting from these changes, but with the volume of pegfilgrastim billed through the medical benefit, these changes may represent only a fraction of the total market.
• As mentioned in our 2020 Exclusion List Review, ESI continues to use indication-based management for the “inflammatory conditions” drug class. Reviewing the updates to that category, Cosentyx is no longer a preferred agent for 2021.

Each of the major PBMs has taken a different approach to managing drug spend in 2021, and formulary exclusions continue to play a major role.  PBMs exclude products because of clinical, financial, and humanistic reasons.  They are making value judgments and have decided covering these products is no longer warranted.  This article represents PHSL’s analysis of publicly available information regarding the three PBMs’ formulary exclusion lists for 2021.  Readers are encouraged to assess the lists for themselves.  Links to the exclusion list source information are provided below.

• CVS Health 2021 Exclusion List
• Express Scripts 2021 Exclusion List
• OptumRx 2021 Exclusion List

Posted January 2021

2021 Winter Newsletter:

Rare Disease Drugs Led the Way for 2020