The scope of the clinical pharmacist is discussed in switching a patient over to a preferred biosimilar along with the role of specialty pharmacy.
Anthony Mato, MD, MSCE: From a clinician’s perspective—from the perspective of dosing a drug or ordering it in the EMR [electronic medical record]—how is the EMR flagged for all these different agents at each institution? I’m curious about that. Dose should be the same, right?
Marc Earl, PharmD, BCOP: Correct. Each of the biosimilars does have its generic name and a different suffix, so you can tell which biosimilar is ordered in the EMR. We try to make a decision about what the preferred biosimilar product in that class is, and that’s going to be preferred in the EMR. A lot of times you’ll pull up a protocol, and that product will automatically be defaulted in. The issue becomes if the patient for some reason needs to use a different biosimilar, and now you have to go in and change the EMR and update that which can be complicated. That’s why we try to prefer 1 agent and prefer that in EMR.
Bhavesh Shah, RPh, BCOP: We actually have authority from the P&T [pharmacy and therapeutics] committee that we could actually substitute for the provider. This is because providers have such a significant time burden that they don’t have the time to go and see which 1 they need to order or which 1 is preferred by a given payer. We have a protocol where the pharmacist can go and choose the 1 that’s covered by the patient’s insurance or that’s the formulary agent for the hospital, whichever is basically approved.
Anthony Mato, MD, MSCE: Then what happens? Does the provider have to sign the order?
Bhavesh Shah, RPh, BCOP: Correct.
Anthony Mato, MD, MSCE: So you write the order, and then it’s cosigned by the provider?
Bhavesh Shah, RPh, BCOP: Exactly.
Anthony Mato, MD, MSCE: Got it. Anything else to add about that?
Tim Peterson, PharmD, BCOP: It’s basically similar. On the inpatient and outpatient clinic settings, the pharmacist does have the ability to change to a preferred biosimilar based on the payer’s preference with the financial services.
Bhavesh Shah, RPh, BCOP: I’m glad you mentioned inpatient because that’s another thing that we are actually always very involved in. This is because a lot of times patients get started on therapy on the inpatient side, and we may actually give 1 of the drugs. But we have to be conscious of what their insurance is and what’s going to be covered by that when they’re outside the hospital. Sometimes patients are coming into our system, but they’re not really our patients, or we don’t know what their insurance is going to cover.
That’s another aspect that you need to be aware of, because you don’t want to have the patient getting the drug in the hospital and then going to another hospital that’s their main hospital, where they have a different drug on the formulary. Then, of course, the insurance covers a different drug. It’s definitely challenging when you have inpatient and outpatient.
Anthony Mato, MD, MSCE: The other challenge that I would perceive, and I’d be curious to hear about this from a specialty pharmacy perspective, is most of the agents that we’re talking about are ordered by a physician, delivered by the pharmacy, their infusions. But specialty pharmacies will become more and more involved. If I were ordering a GCSF for a patient, and I put in the reference product, I’m not sure I would know what the preferred agent was and whether that could result in delays for patients. This is because if it’s denied, and then it takes a few days to find out that we have to switch to a biosimilar, we don’t know whether that could actually impact patient care.
Bhavesh Shah, RPh, BCOP: That’s a great question, and obviously PBMs [pharmacy benefit managers] have a formulary that they go by.
Anthony Mato, MD, MSCE: Just for the audience, what is a PBM?
Bhavesh Shah, RPh, BCOP: It’s a pharmacy benefit manager, and basically they run the claims and the adjudication and formulary for the health plan. If there were issues like that, we’d know up front because every single 1 of these agents has to go through a prior authorization. So we would know before what’s covered before it’s ordered.