dod pharmacy enterprise operations update april 1, 2015 pharmacy workgroup “medically ready...

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


∎ 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

Apr-

15

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

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

Mill

ions

Over 65 Under 65 FY 15 Cumulative Total FY15 Target

$13.3 $12.7 $13.2 $12.4

6

Initiative #1 - Retail Rxs to Mail/MTF Estimated Cost Savings

Goo

d

Source: PDTS Data; Pharmacy POS Cost Analysis Data

6

$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

-14

Dec

-14

Jan-

15

Feb-

15

Mar

-15

Apr-

15

May

-15

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

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

7

$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

Jun-

15

Jul-1

5

Aug-

15

Sep-

15

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

d

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.

8

TPharm4 Changes: 1 MAY 2015SPECIALTY DRUGS


∎ 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


∎ 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

https://host1.medcohealth.com/static/formularySearch/1.0/

∎ Explanation of Benefits (EOB) will now include MTF dispensed prescriptions as well as TMOP drug costs

TPharm4 Changes: 1 MAY 2015EXPLANATION OF BENEFITS (EOB)


TPharm4 Changes: 1 MAY 2015DEPLOYMENT PRESCRIPTION PROGRAM (DPP)


∎ 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


∎ 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)


∎ 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


∎ 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


∎ 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

18

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:


Increased Adherence to Pharmacy Business Rules

19

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


Increased Adherence to Pharmacy Business Rules - Example from the field

20

• 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?


Playbook of Enhancing Communications of Business Rules to Providers


$ RECAPTURE SAVINGS $

AC

CE

SS

AC

CU

RA

CY

SERVICE

Recapture Savings


• 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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-15

$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


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


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


∎ 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.


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


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


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)


https://carepoint.health.mil/SitePages/Default.aspx

https://carepoint.afms.mil/CAREPOINT/


November 2014 P&T Committee Update

39

Uniform Formulary Class Review

∎ Self Monitoring Blood Glucose System Test Strips (SMBGS) Test Strips

∎ Multiple Sclerosis Drugs


SMBGS Test Strips: Formulary Status


40

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


41

∎ 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

41

(SMBGS) Test StripsPrior Authorization Criteria


42

∎ 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

42

(SMBGS) Test StripsMTF Conversion


43

∎ 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;

[email protected]

∎ 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

43

mailto:[email protected]


(SMBGS) Test StripsMTF Conversion


44

∎ 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


45

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


46

∎ 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


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


New Drugs in a Previously Reviewed ClassSummary


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)


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


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


Based on Clinical Services Drug List

59

Brand to Generic Update


FY15 $10.8M

Cost Avoidance

National Contract Compliance Update


Nexium NDC Transition Plan


Prime Vendor Credits Update


Narcotic Order Review and Approval (NORA)


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


Prime Vendor Global Status: Catalogs


∎ 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


∎ 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


$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


∎ 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


∎ 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


∎ 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


∎ 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


∎ 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


∎ 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


∎ 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

75

e-Prescribing Update


∎ 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


∎ 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



∎ 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





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