Currently Viewing:
Evidence-Based Oncology October 2017
Formulary Considerations: The Past, Present, and Future
Molly Billstein Leber, PharmD, BCPS, FASHP
Pharmacy's Changing Role as Cancer Care Transitions From Infused to Oral Therapies
Stacey McCullough, PharmD, and Ricky Newton, CPA
Currently Reading
Pharmacy Team Engagement in Navigating the Revenue Cycle for High-Cost Medications in Patients With Cancer
Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS
PBMs: Their Role, the Problems, and How Practices Can Work With Them
Ray Bailey, RPh, and Ricky Newton, CPA
Positive Quality Interventions: An Innovative Platform for Oncology Practice Collaboration
Joshua Nubla, PharmD; Neal Dave, PharmD; and Michael Reff, RPh, MBA
Medical World News®, October 2017
AJMC Staff
AJMC®tv Interviews, October 2017
Produced by Laura Joszt and The Center for Biosimilars®

Pharmacy Team Engagement in Navigating the Revenue Cycle for High-Cost Medications in Patients With Cancer

Brandon R. Shank, PharmD, MPH, BCOP; Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS; and Emily C. Pherson, PharmD, BCPS
With the clinical and financial implications of high-cost medications, and their impact on health system revenue, it is of utmost importance for all key stakeholders to be engaged in the complex revenue cycle.
2. Setting patients up for success by facilitating coverage via outpatient prescription insurance.

Outpatient prescription insurance plans also have a formulary to optimize medication use for their members. Often, medications and criteria for their use differ between the hospital formulary and the outpatient insurance formulary. Additionally, preferred drugs may differ from institutional pharmacies based on contracting or rebates received from a pharmacy bene t manager (PBM). In order to best assist patients in navigating the outpatient prescription formulary, it is first necessary to access and interpret the outpatient formulary and then meet any requirements necessary to access the formulary medication.

One method to determine outpatient prescription coverage is to process a test claim through an outpatient pharmacy. This practice will adjudicate the prescription to make a coverage determination but then immediately cancel the claim to prevent the prescription from processing completely. To use this method, it is important to clarify the intention of the test claim to the outpatient pharmacy—safety and insurance issues can arise if prescribers are attempting to ll the same prescription multiple times. If one does not have access to a test claim process, some outpatient insurance plans will post their formulary information online. It is important to note that updates to these documents are determined by the individual insurance plans and may not correlate in real-time with decision changes.

For the most accurate information, it is best to contact the company via phone. Also, what is listed on the online formulary will not be specific to the patient in terms of any deductible or other patient-specific plan information, so contacting the insurance company directly or having the patient use their online portal to obtain the most accurate patient-specific information about coverage may be necessary. Several test claims of different drugs in a therapeutic class may be needed to help determine the preferred drug with the most affordable cost. It is important to remember that the test claim result is only an estimate specific to that pharmacy as the co-pay may differ at another pharmacy due to various insurance and pharmacy acquisition cost factors.

Once outpatient insurance coverage has been determined, it may be necessary to facilitate PA of the medication. The PA process typically requires the prescriber to review the patient’s medical history and ensure that they meet certain criteria for medication use. PA approval can take place over the phone, even online in some instances, and an immediate determination could be made. Other cases require forms to be submitted via fax or online, and coverage determination may take 24 to 72 hours. Once issued, it is important to note that the standard timeframe for the PA is 1 year, but that it may be a shorter period in other instances and re-authorization must be obtained to ensure continuity of care.

An area of growing complexity, especially when navigating from the inpatient to the outpatient setting, is the realm of biosimilar medications. Although a hospital formulary may include one brand of a biologic, the outpatient PBM formulary may prefer another. An example of this is filgrastim, where a hospital formulary may include filgrastimsndz (Zarxio), while the outpatient plan prefers filgrastim (Neupogen). This is also common with the new follow-on biologic for insulin glargine, Basaglar, which is becoming more common for outpatient formularies even though many hospitals still have Lantus or another basal insulin as their preferred product. Being aware of these different formulary preferences can help patients safely transition from inpatient to outpatient, avoiding interruptions in treatment or duplications in these high-risk medications.

3. Assisting patients to obtain drugs with no coverage or high co-pays.

Patient assistance programs, private grants, and medication replacement programs are a few mechanisms that support patient access to medications.10 Pharmaceutical manufacturers can provide assistance to obtain insurance approval and help patients get coverage for their medications. The provision of this assistance is often outsourced to a third-party company that oversees the disbursement of funds and/or free medications.

Most insurance plans have strict guidelines outlining which medications are covered within their plan. There are specific clinical scenarios with limited treatment options where a medication may need to be used off label or its FDA approval may be pending. In these situations, obtaining reimbursement from the insurance company can be challenging. Free distribution programs offered by pharmaceutical manufacturers provide an alternative to procuring expensive medications. However, the approval process can take several days to weeks, so starting early can prevent delays in treatment initiation. Submission of specific income documentation and copies of insurance denial is often required, which can be time-consuming to collect.

On an institutional level, many pharmacy departments have hired reimbursement coordinators/specialists, who may be pharmacy technicians or nonhealthcare individuals with a background in finance or health insurance. These individuals focus on PAs, drug replacement, co-pay assistance, and denial management and they work closely with the PBM and insurance companies to find alternatives and investigate co-pays for high-cost medications. They serve as a liaison to the financial offices at the hospital and coordinate with replacement drug programs to recover medications. Upon obtaining the power of attorney from patients, reimbursement coordinators can request co-pay assistance from manufacturers on the patients’ behalf and provide valuable assistance, especially for patients who may be too ill or overwhelmed by the reimbursement process. The addition of pharmacy reimbursement coordinators/specialists has significantly reduced the amount of time pharmacists and other health- care providers spend on getting drugs reimbursed for patients.2 These programs often lead to increased outpatient prescription capture rates for institutional pharmacies. One institution increased its outpatient pharmacy’s capture rate from 57% to 73% for the general pediatric service.11

There are exclusions for some programs, such as federal or state Medicare and Medicaid programs, where patients may not be allowed to receive co-pay assistance. This can be particularly di cult for patients who cannot afford high co-pays or for those who must first meet their deductible. Additionally, several private programs offer grants to cover out-of-pocket costs for patients undergoing cancer treatment. Being on funding cycles and considering their high demand, these grant programs are at risk of quickly exhausting their capital. It is important to have a backup plan in place and understand the extent of assistance that a patient may require so an entire treatment is covered.

4. Navigating patient registration for drugs requiring REMS programs.

The FDA Amendments Act of 2007 gave the regulatory body authority to require a REMS from manufacturers to ensure that the benefits of a medication outweigh its risks (Table).12,15 The drugs selected for REMS programs have been found to have safety risks, such as teratogenic effects; special initiation requirements; or communication mandates to the patient beyond a black box warning.13 These programs often require the physician to undergo additional training to gain the privileges to pre- scribe these drugs. Patients also have to complete a survey, undergo education, and sometimes obtain the medication through a designated pharmacy. Medications such as thalidomide, lenalidomide, and pomalidomide, which can cause severe birth defects, require female patients to undergo pregnancy testing and all patients to agree to contraceptive use. While these added steps improve safety, the process significantly slows down drug procurement and complicates their use in the inpatient setting.14

In scenarios where the medication is distributed directly to the patient, patients must use their own supply during hospitalization. Outpatient pharmacies are required to adapt to the increasingly complex monitoring requirements of specialty medications that have limited distribution and high costs, require close monitoring or specialty handling, need patient or provider education, and are used in a unique patient population. This has resulted in a shift to higher utilization of specialty pharmacies, which are equipped to distribute specialty medications as they maintain adequate training and necessary procedures. PBMs often have preferred pharmacies, and it is time consuming to determine what the preferred pharmacy is for each patient. 

Copyright AJMC 2006-2020 Clinical Care Targeted Communications Group, LLC. All Rights Reserved.
Welcome the the new and improved, the premier managed market network. Tell us about yourself so that we can serve you better.
Sign Up