The Dispensing Capabilities of Pharmacies

2019-06-21 14:50:00
Tags: practice pearls,specialty pharmacy


Peter Salgo, MD: All right, let’s talk about pharmacies for a minute. Who determines which pharmacies have dispensing capability for these new drugs? Is it the manufacturer, is it the payer? How do you go about assessing these pharmacies and deciding, “You, you get to do this, and not so fast for you?”

Cheryl Allen, BPharm, MBA: Well, if we’re talking about multiple myeloma drugs in the oral space, it’s the immunomodulatory drugs, the IMiDs, that are in limited distribution. I think across the space what you can say is payers will look to certain pharmacies to contract with for their specialty book of business. So even though the manufacturer didn’t limit the distribution of the drug to certain pharmacies, the payer is calling out who the dispenser of the drug will be.

Peter Salgo, MD: How does a prescriber keep abreast of which pharmacy is OK for this drug?

Cheryl Allen, BPharm, MBA: All those people she has on the phone calling the insurance companies.

Peter Salgo, MD: That army of people you’ve got. It sounds like a massive challenge. Is this a changing playing field month by month? This pharmacy could do this drug, this pharmacy can’t? The payer says it’s OK here, but the manufacturer won’t let them do it?

Noa Biran, MD: For us, it’s about whoever can get us the drug as efficiently and as cost-effectively as possible. And we have relationships with specific specialty pharmacies that are able to provide us with excellent service. A lot of community practices and any practice may have their own specialty pharmacy, and they might be more partial to send prescriptions to them.

Peter Salgo, MD: What’s an override contracting process?

Cheryl Allen, BPharm, MBA: An override.

Peter Salgo, MD: Yes.

Cheryl Allen, BPharm, MBA: Oh, that’s a good question.

Peter Salgo, MD: I know, I just asked it.

Cheryl Allen, BPharm, MBA: That happens on the pharmacy benefit, now you’re really getting into the weeds.

Peter Salgo, MD: I was afraid of that.

Cheryl Allen, BPharm, MBA: Yes. When we send a claim for adjudication to the payer. We’re sending all of the information over to the payer. The payer doesn’t recognize either the pharmacy or the drug and we call, pick up the phone.

Peter Salgo, MD: Whoa, low tech.

Cheryl Allen, BPharm, MBA: Yes, it’s still very low tech, for the most part, the majority of time. Some efficiencies there, but not across the board. It’s still phone-driven. And we as the pharmacy or if it’s the physician dispenser who’s running the claim through, they may be given a one-time override on that drug.

Peter Salgo, MD: A one-time override.

Cheryl Allen, BPharm, MBA: One-time override to put that through.

Peter Salgo, MD: Then what happens?

Cheryl Allen, BPharm, MBA: Well, that means that possibly the next time if it’s the pharmacy that’s not recognized, the next time the patient needs that drug product, they’ll likely have to go to the payer’s designated pharmacy or pharmacies.

Noa Biran, MD: Oh.

Peter Salgo, MD: Why would the payer choose one pharmacy over another?

Cheryl Allen, BPharm, MBA: Because payers will contract with certain pharmacies to be in the payer network. Payers generally will select a handful of pharmacies for their insured patients to fill those prescriptions with, and then they’ll write the contract. There may be a carve-out for specialty, may be a carve-out for a specific infusion contract, but definitely that type of contracting is driving things forward.
One would also say that the payer is looking for a pharmacy that they can contract with that has service level agreements and has a standard of care.

Peter Salgo, MD: OK, so you’re looking also for quality of care.

Cheryl Allen, BPharm, MBA: Yes, quality care.

Peter Salgo, MD: All right. Now let’s take a look at something else, which is the 7-day-off treatment plans. Which medications are on that, and what is a 7-day off?

Noa Biran, MD: I believe you’re referring to receiving a 7-day supply of the drug?

Peter Salgo, MD: I hear 7-day off. I get the sense it was a 7-day off, like a 1-week holiday, 3 weeks of treatment.

Cheryl Allen, BPharm, MBA: Oh, OK.

Noa Biran, MD: Almost all of the IMiDs are a 21-day-on, 7-day-off cycle. And actually ixazomib is dosed the same way. Almost all of the oral drugs have a week break, and that’s generally for the purposes of count recovery, because their blood counts drop, and then it takes a week for them to recover.

Peter Salgo, MD: Does that affect reimbursement in any meaningful way, the fact that they’re off for a week and then back on?

Cheryl Allen, BPharm, MBA: No.

Peter Salgo, MD: So that’s built in.

Cheryl Allen, BPharm, MBA: Built in.

Noa Biran, MD: It’s a 28-day cycle.

Cheryl Allen, BPharm, MBA: It’s cycled.

Noa Biran, MD: It’s a 28-day cycle. So you need 21 pills for a 28-day cycle. There are some cycles that are a 14-day supply in a 21-day cycle. So 2 weeks of drug, 1 week off would be a cycle.

Peter Salgo, MD: OK.

Noa Biran, MD: The price is, I believe, the same. I’m pretty sure the price of the drug is the same, whether you take it for 21 days or 14 days.