, when health system formularies were created, they were simply a current list of medications stocked in the pharmacy, along with some related information about each drug.

 In the 1980s, the clinical and economic value of well-controlled and managed formularies were highlighted.

 Today, Pharmacy and Therapeutic (P&T) committees are considered a critical tool for healthcare organizations to ensure safe, appropriate, and cost-effective use of pharmaceuticals for patient care. A guideline on P&T committees and formulary systems, developed by the American Society of Health-System Pharmacists, summarizes the best practices and techniques that should be implemented for optimal formulary system management.

 Policies and procedures for procuring, dispensing, administering, and appropriate utilization of medications are also included in the formulary management process.

To promote evidence-based medicine, there must be a systematic approach to the evaluation of biomedical literature and its application to clinical practice, which should be applied to formulary decision making.

 This often goes beyond the FDA approval process. The most important decision at hand for a P&T committee is the definition of a formulary drug. Typically, formulary agents are deemed urgent or used with sufficient frequency that they are stocked in the pharmacy in appropriate quantities to ensure patients have sufficient access to safe, efficacious, and cost-efficient drugs.

A formulary agent may be restricted or unrestricted, with restrictions defined by indication, service, or specialty group (eg, infectious disease); medical staff hierarchy (eg, attending only), or patient population (eg, cystic fibrosis, pediatric). Off-criteria uses of formulary agents constitute a nonformulary use. Ideally, medication utilization evaluations should be conducted on a regular basis to assess compliance with formulary restrictions. When multiple agents within a therapeutic category are available on the market (such as low-molecular weight heparins or histamine-2 receptor antagonists), drug class reviews are often conducted in an attempt to declare therapeutic equivalence and maintain only 1 preferred agent on the formulary. An increasing number of medications within a therapeutic category can lead to greater price variation among the medications, which creates potential for significant cost savings through declaring agents therapeutically equivalent and allowing them to be interchanged. 

In addition to cost savings, patient safety is enhanced by minimizing look-alike sound-alike medications through streamlined inventory and the medication reconciliation process. Minimizing the number of agents available on a formulary also improves staff competency and knowledge about specific medications. 

Selecting an agent for inclusion in a formulary requires numerous operational considerations: 

		With respect to purchasing, it is important to determine if a drug is supplied by the organization’s pharmaceutical distributors or if it is a specialty/limited-distribution drug requiring direct shipment. Not all pharmaceutical wholesalers are able to supply the drug product, particularly high-cost specialty medications. Since most pharmacy departments purchase products from wholesalers at a cost minus discount, the pharmacy will be charged a higher price if the drug being reviewed comes from another source, potentially resulting in a significant increase in drug expenditures due to the loss of the cost-minus discount. Manufacturers can switch between different distribution strategies to best fit the needs of patients and providers as the marketplace changes. 

		Drugs with a limited distribution are not shipped as frequently as deliveries from wholesalers. Under these circumstances, additional storage space may be needed, such as a refrigerator or a freezer, to ensure timely patient care. Packaging of the pharmaceuticals is also important to take into consideration, especially with increased usage of barcode medication administration (BCMA). BCMA can improve medication safety by verifying that the right drug is being administered to the right patient. BCMA technology has been proven to reduce medication administration errors.

 To ensure BCMA is being used effectively, compliance rates should be evaluated regularly and any potential barriers to compliance should be investigated. 

Often, the barrier identified is the lack of a barcode. The FDA currently requires barcodes on containers, but does not require that unit dose containers be available for all medications. Since not all manufacturers provide barcoded unit-of-use dosage forms, pharmacies are often required to prepare dosage forms through automated repackaging equipment. The barcodes are also used to ensure the correct drug is loaded into the automated dispensing cabinet (ADC) and in compounded sterile products (CSP)—all in an effort to improve patient safety. Technology-assisted CSP preparation uses computerized workflow processes that require barcode scanning of containers and ingredients. 

The stability of the CSP also plays a role in formulary management. For medications that require refrigeration, the refrigerator must be connected to an ADC on the patient care unit where the patient room is located. Ensuring there is space to appropriately store the medication is crucial; size and product classification determine storage conditions and how medications can be dispensed. ADCs ensure secure storage of drugs, but require careful inventory management so that all of the needed drugs in adequate quantities are available for patient use. Compliance with USP <800> is vital to determining what drugs can be stored in an ADC or compounded at the organization. USP <800> describes hazardous drug handling related to the receipt, storage, compounding, dispensing, administration, and disposal of both sterile and nonsterile products and preparations.

When selecting a preferred formulary agent, the cost of the drug and the reimbursement amount should also be considered. However, the cost of a drug should only be considered after its clinical efficacy and safety are established. For health systems that are 340B-eligible, providing a competitive 340B price is critical to the formulary decision. Created by Congress through the Veterans Health Care Act of 1992, 340B is a drug discount program that allows safety-net providers with large shares of low-income patients to access discounted drug pricing.

Reimbursement should also be an important consideration in the formulary evaluation. For hospitalized patients (in-patients), drugs are reimbursed as part of a Diagnosis-Related Group (DRG), so the best-priced product is the preferred product. However, on the outpatient side, the price of the product is as important as the reimbursement. With rising medication costs, pharmacy benefit managers are increasing the number of tiers in a formulary, changing co-payment structures, and dictating the brand, where, and how patients can receive their medications. These decisions often conflict with the final hospital formulary decision and require a routine audit process to compare the actual reimbursement with what was projected. Insurance companies often change their preferred formulary agent to match changes within pricing structures or rebates. 

Protocol to Incorporate Formulary Changes 

When planning for formulary additions and changes, the medication’s integration into technology should be carefully coordinated: 

		Dosage forms, concentrations, and ordering options should be limited and standardized. 

		Required monitoring for efficacy and toxicity should be built into computerized prescriber order entry (CPOE) panels or sets whenever possible. 

		If a drug is infused through a smart pump, it should be programmed with a standardized concentration and volume and the appropriate limits. 

		All formulary drugs should be available for ordering in the CPOE system, minimizing the need for verbal orders. 

In addition to the clinical and operational considerations necessary for formulary evaluation, the focus of health systems has changed. Healthcare organizations now focus on value-based reimbursement models and participating in accountable care organizations. These changes are simultaneously forcing P&T committees to change. There has been a transition to ensuring compliance with regulations and meeting publicly reported quality metrics.

 P&T committees have also expanded their focus to include the oversight of CPOE and the associated medication orders and order sets and building the necessary clinical decision support. However, the most significant change in healthcare that has impacted P&T committees and formulary management is the focus on cost containment and reimbursement while being able to provide high-quality patient care. As the healthcare payment structures continues to change, the structure and oversight of P&T committees will continue to transform, too. 

One of the most notable drivers of this change is the high cost and complicated treatment regimens of oncology drugs. It is now essential for health systems to, in addition to input from the medical staff, consider the patient mix and chief insurance provider when making a formulary decision. To make this transition, P&T committees will need to transform how they have historically conducted business. 

Traditional drug monograph reviews are solely based on safety, efficacy, and acquisition cost. After a request for formulary addition is received, the monograph is created by a clinical pharmacist and reviewed by physician stakeholders. The recommendations are often based on a published consensus statement or guideline, which may not consider the overall cost within the recommendation. In the future, health systems will be looking at P&T committees to take different factors into consideration to determine how best to utilize drugs to provide the most value to their patients, weighing efficacy, safety, cost, and outcomes. 

Cancer care accounts for 5% of total US healthcare costs, and these costs continue to rise. Estimates suggest that the annual rate of spending will rise to $158 billion in 2020 from $120 billion in 2010, and the expenditures for oncology drugs are rising more rapidly than any other facet of healthcare.

 There continues to be an increasing financial burden associated with chemotherapeutic agents. The rising cost of cancer treatment is a significant contributor resulting in personal bankruptcy.

To start the discussion around value and to determine the best way to include pharmacoeconomic analyses into formulary management, several initiatives have been undertaken in an attempt to define the value of drugs used for cancer care, including the American Society of Clinical Oncology’s Value Framework, the European Society of Medical Oncology’s Magnitude of Clinical Benefit Scale, the National Comprehensive Cancer Network’s Evidence Blocks, Memorial Sloan Kettering Cancer Center’s Drug Abacus, and the Institute for Clinical & Economic Review’s Value Assessment Framework. These frameworks display similarities, but differ in their purpose, focus, and means of assessment. The final objective of all of these initiatives is to assist with the assessment of value in cancer care; however, most of these frameworks are relatively new and a significant amount of work remains to be done to determine how best to integrate these assessments into the ultimate formulary decision.

Although the costs of drugs continue to rise, the question of the relative value of the drug itself is left unanswered by our current healthcare system. We cannot continue to review drugs in silos based only on safety, efficacy, acquisition costs, and outcomes. Healthcare systems also need to be aware of all the current regulations and intricacies of their CPOE system to ensure safe delivery of drugs that are added to the formulary. 

Molly Billstein Leber, PharmD, BCPS, FASHP, is manager, Medication Policy and Formulary Management, Yale New Haven System, New Haven, Connecticut. 

Molly Billstein Leber, PharmD, BCPS, FASHP 

200 Orchard St. Scranton (SRC)-Department of Pharmacy 

1. Tyler LS, Cole SW, et al; ASHP Expert Panel on Formulary Management. ASHP guidelines on the pharmacy and therapeutics committee and the formulary system. 

2. Poon EG, Keohane CA, Yoon CS, et al. Effect of bar-code technology on the safety of medication administration. 

. 2010;362(18):1698-1707. doi: 10.1056/NEJMsa0907115. 

3. Seibert HH, Maddox RR, Flynn EA, Williams CK. Effect of barcode technology with electronic medication administration record on medication accuracy rates. 

. 2014; 71:209-218. doi: 10.2146/ajhp130332. 

4. <800> Hazardous drugs—handling in healthcare settings. United States Pharmacopoeia website. usp.org/compounding/general-chapter-hazardous-drugs-handling-healthcare. Published February 1, 2016. Accessed August 23, 2017. 

5. § 602; PHS Act § 340B; 42 U.S.C. § 256b. Government publishing office website. gpo.gov/fdsys/pkg/USCODE-2010-title42/pdf/USCODE-2010-title42-chap6A-subchapII-partD-subpartvii-sec256b.pdf. Accessed August 23, 2017. 

6. Boucher B. Formulary decisions: then and now. 

. 2010;30(6 Pt 2):35S-41S. doi: 10.1592/phco.30.pt2.35S. 

7. Meropol NJ, Schrag D, Smith TJ, et al; American Society of Clinical Oncology. American Society of Clinical Oncology guidance statement: the cost of cancer care. 

. 2009;27(23):3868-3874. doi: 10.1200/JCO.2009.23.1183. 

8. Schnipper LE, Davidson NE, Wollins DS, et al. Updating the American Society of Clinical Oncology Value Framework: revisions and reflections in response to comments received. 

. 2016;34(24):2925-2934. doi: 10.1200/JCO.2016.68.2518. 

9. Cherny NI, Sullivan R, Dafni U, et al. A standardised, generic, validated approach to stratify the magnitude of clinical benefit that can be anticipated from anti-cancer therapies: the European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS). 

. 2015;26(8):1547- 1573. doi: 10.1093/annonc/mdv249. 

10. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) with NCCN Evidence Blocks. National Comprehensive Cancer Network website. nccn.org/evidenceblocks/. Published 2016. Accessed August 23, 2017. 

11. Drug Abacus. Memorial Sloan Kettering Cancer Center website. https:// drugpricinglab.org/tools/drug-abacus/. Accessed August 31, 2017. 

12. Ollendorf D, Pearson SD. ICER evidence rating matrix: a user’s guide. Institute for Clinical and Economic Review website. icer-review.org/wp-content/ uploads/2016/01/Rating-Matrix-User-Guide-FINAL-v10-22-13.pdf. Published 2016. Accessed August 23, 2017. 

Articles

Evidence-Based Oncology

The hospital formulary system is an ongoing process that evaluates and selects the safest, most effective, and most economical care for hospitalized patients. As healthcare continues to change, so will the formulary management process.  



Formulary Considerations: The Past, Present, and Future

drugs are now delivered in oral formulations, with an estimated 25% to 35% in the research pipeline being orals. Increasingly, patients prefer to receive their oral cancer drugs and ancillary oral therapies in a safe, reliable, accessible, and affordable environment, tightly integrated with their overall cancer care. Depending on state pharmacy laws, community cancer clinics have established facilities to dispense oral drugs operating either under the physician’s license or as in-practice closed-door pharmacies.

With the advent of oral oncolytics, a pharmacy’s role has expanded far beyond compounding chemotherapy drugs for infusion. This evolution has created a beneficial physician extension for oral therapies in the care and management of patients treated in a home environment. Today’s pharmacy teams are comprehensive, including patient access coordinators, financial counselors, and clinical staff to help navigate prescription benefits, secure co-pay assistance, educate patients on what can be complex dosing schedules, and provide specific information on potential side effects. Through strategically scheduled inter- actions, based on drug care plans, pharmacy staff routinely engage patients, assessing both adherence and tolerance to therapy. 

As the role of pharmacies in providing care increases in prominence, so does the corresponding need to ensure quality standards and best practice benchmarks, both in general operations and patient outcomes. Pharmacy accreditation is an important way to achieve those needs.

Accreditation is an external and independent review that pro- vides an imprimatur of a pharmacy’s current policies, procedures, overall operations, and quality assurance programs. In seeking accreditation, pharmacies demonstrate their commitment to providing the highest quality service by complying with stringent national regulations and industry best practices. Common specialty pharmacy accreditations include:

		Accreditation Commission for Health Care (ACHC)

		Utilization Review Accreditation Commission

Most insurers require specialty pharmacy accreditation for application to their network, which is a means of demonstrating to the patient and payer that pharmacy services are on par with other pharmacy providers. 

The Community Oncology Pharmacy Association (COPA) and ACHC have partnered to create educational resources and a customized suite of specialty pharmacy accreditation offerings.

 In addition, standards for an oncology-specific accreditation have been jointly established by ACHC and COPA.

 Undergoing both ACHC specialty pharmacy and oncology sub-specialty accreditation demonstrates proficiency in operations and patient-centric care plans specific to the complex care of oncology and hematology patients.

Oral oncolytics are powerful chemotherapeutic agents and have the same bene ts and risk as intravenously administered drugs. With the convenience of patients taking the medication at home comes responsibilities for both the patient and the oncology practice. Patients must fully engage and commit to their care plan, including adherence to taking their medication(s) exactly as prescribed. Additionally, the oncology practice must create a remote “chemo suite” environment. Just as nursing and clinic staff establish relationships and dialogue with patients while receiving infused therapy, pharmacy staff have a similar opportunity and responsibility for patients receiving oral therapy. Because oral drugs are not taken under the direct, watchful eye of the physician, patient education and understanding of their medication is paramount to successful outcomes. Important areas for discussion include medication names (both trade and generic); how the medication works; when to begin taking the medication and how to take it, including details on days of the week and best time of day; how to take medication in relation to food and other medications; what to do if a dose is missed; and who to call if you have questions.

Patient education must also include an in-depth discussion of potential side effects and adverse reactions. Patients and/or caregivers must be taught to recognize symptoms as early as possible and be equipped with information to mitigate or manage side effects. Knowing how, when, and who to call to report the occurrence of any side effects and reactions helps minimize missed doses, discontinuation of therapy, or poor outcomes to therapy. This may require 24/7 on-call staff to address patient concerns or questions and access to both their complete pharmacy pro le and electronic health record (EHR).

The efficacy of many oral agents allows a pharmacy’s relationship with patients to continue for several years. Monthly refill calls, especially when performed by the same pharmacy staff member, establish a rapport that allows a congenial exchange while ensuring medication adherence and tolerance.

Innovation in the development of new cancer treatments has significantly increased the number of oral treatment options and expanded opportunities for the pharmacy’s role in patient care and management. Today’s pharmacy team understands the various aspects of oral therapies, from benefits investigation to co-pay assistance and initial education to long-term adherence. Both, community oncology practices with in-house physician dispensing and licensed pharmacies can access complete patient charts within EHRs. Pharmacy staff working directly with the oncologist and their care extenders are poised to provide best management and better outcomes for patients receiving oral oncolytic treatments. For many patients on oral cancer drugs, pharmacy staff have become a regular contact and the most frequently accessible resource in their cancer care. 

Stacey McCullough, PharmD, is senior vice president, Pharmacy, at Tennessee Oncology; member, Community Oncology Pharmacy Association Board of Directors. 

Ricky Newton, CPA, is treasurer and director of financial services and operations for the Community Oncology Alliance; advisor, Community Oncology Pharmacy Association. 

Director of Financial Services and Operations 

1634 I Street NW, Suite 1200, Washington, DC 20006 1. ACHC accreditation. Community Oncology Pharmacy Association website. coapharmacy.com/ achc-accreditation/. Accessed September 5, 2017.

2. ACHC launching new Distinction in Oncology program [press release]. Cary, NC: Accreditation Commission for Health Care; April 27, 2016. achc.org/pdf/Distinction_in_Oncology_PR.pdf. Accessed September 5, 2017. 

The advent of oral oncolytics has changed the pharmacy's role in patient care beyond compounding infusions. Pharmacy staff now routinely engage patients, assessing adherence and tolerance to therapy as well as helping them navigate prescription benefits.

Pharmacy's Changing Role as Cancer Care Transitions From Infused to Oral Therapies

today’s evolving healthcare landscape shoulder the responsibility of delivering high-quality care while reducing costs throughout the entire revenue cycle. This cycle encompasses several key steps to appropriately bill patients and third party providers and capture revenue. The major components of the revenue cycle include patient access, clinical documentation, coding, billing processes, denial management, and reimbursement.

 To optimize the revenue cycle, key stakeholders, including clinicians, financial staff, and institutional leadership, need to be engaged in the process to maximize reimbursement for the health system and minimize patient costs and burden. Pharmacists and pharmacy staff play a pivotal role in cost containment through optimization of medication regimens and engagement in the revenue cycle, particularly for high-cost medications (

 The high-cost medications referred to in this article are those commonly used in the treatment of patients with cancer, such as oral antineoplastics, immunosuppressants, antifungals, and select anticoagulants.

To facilitate the billing process, the medications must be appropriately coded. Every hospital has a charge description master, which includes the general ledger number, product description, billing units, Healthcare Common Procedure Coding Systems (HCPCS) codes, revenue codes, and pricing information.

 With constant updates to CMS’ billing requirements and rapid changes in the drug market of new brand and generic medications, there is a high possibility that HCPCS codes can easily become out- dated or incorrectly associated with a medication. For example, blinatumomab (Blincyto), approved in 2014 for the treatment of Philadelphia chromosome—negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia, had different HCPCS codes for 2015 (J7799) and 2016 (J9039)

 It is essential for hospital and pharmacy leadership to understand the financial implications of such changes. These leaders should include individuals well-versed in charge coding and actively engaged in the ever-changing drug market and insurance industry.

In addition to the complexities associated with billing, the problem of sky-rocketing drug prices has garnered much attention in recent years and made budget management more complex. In its annual report on national trends in prescription projections and spending, the American Society of Health-System Pharmacists (ASHP) showed a 6% increase in US prescription sales between 2015 and 2016, totaling $448.2 billion in 2016.

 Overall, adalimumab was associated with the highest overall spend in 2016 with $13.6 billion in expenditures; in clinics and nonfederal facilities, in iximab had the highest expenditure with $5.3 billion in spending.

Nonfederal facilities are de ned as licensed hospitals that are not owned by the government, including inpatient treatment and rehabilitation facilities. Nonfederal facilities also include general and specialty acute care institutions. Federal facilities refer to US ships or hospitals that belong to the Public Health Service, the Veterans Health Administration, and other federal branches. Higher drug prices and more prescribing were primarily responsible for the growth in expenditure in nonfederal hospitals and clinics.

 Drug expenditures in 2017 are projected to increase 6% to 8% overall and by 3% to 5% in hospitals.

 Therefore, health-system pharmacy leaders and clinicians should be actively engaged in the revenue cycle process and develop strategies that emphasize cost containment and ensure optimal medication reimbursement.

Top 5 Opportunities for Pharmacy Team Engagement in Containing Drug Costs and Maximizing Reimbursement in Patients Undergoing Cancer Treatment 

Pharmacists caring for patients undergoing cancer treatment are in a unique position to help other providers and patients navigate the convoluted reimbursement structure. Strategies include finding suitable therapeutic alternatives to meet the needs of formulary restrictions or obtaining approval for off-label use of agents. Starting upon admission and continuing post discharge, transitions-of-care pharmacy team members provide continuity of care and enhance medication adherence. Transitions-of-care pharmacy team efforts, starting upon admission and continuing through discharge, can ensure coverage and enhance medication adherence.

Many antineoplastic and supportive care medications are expensive and/or challenging to obtain. Timely acquisition is essential in order to initiate cancer treatment expeditiously. This article reviews key strategies that pharmacy team members can utilize to optimize medication-related revenue cycle compliance, including prior authorizations (PAs), hospital formulary management, patient assistance programs, accessibility of medications, and risk evaluation and mitigation strategies (REMS) programs.

1. Managing inpatients who are taking medications outside of the hospital formulary as outpatients.

Hospital formularies ensure safe, efficacious, and cost-effective medication use in the inpatient setting, especially for high-cost medications.

 Medications included on a hospital formulary vary based on an institution’s patient population and contracting options, among other factors. Strategies to appropriately manage admitted patients who continue to take medications as outpatients that are not included on the inpatient hospital formulary include therapeutic interchanges, nonformulary review processes, and using the patients’ own medication(s) during their hospital stay.

A therapeutic interchange is a tool that provides a roadmap to transition patients from an outpatient medication that is not on the hospital formulary to a medication that is included, and this often presents healthcare providers with a medication that has an equivalent dosage as the formulary medication.

 For example, if a patient was taking candesartan 8 mg by mouth once daily as an outpatient and losartan was the hospital formulary angiotensin receptor blocker, a therapeutic interchange would direct prescribers to order losartan 50 mg orally once daily. These interchanges are most effective when the electronic health record (EHR) automatically directs prescribers to this alternate choice when the nonformulary drug is ordered. This strategy alerts prescribers that they are attempting to order a non-formulary medication and presents them instantly with alternatives. Some institutions utilize automatic therapeutic interchanges whereby the pharmacist, upon order verification, would automatically make the switch to the appropriate formulary medication. Developing therapeutic interchanges requires appropriate research and evidence supporting the specific interchange so that the healthcare team has information readily available.

For a medication that is not a part of an institution-approved therapeutic interchange, most institutions have a process in place whereby pharmacists are responsible for reviewing non- formulary medications and providing formulary alternatives, when appropriate.

 Depending on the specific institutional practice, this may be built into the role of the pharmacist who is verifying orders or a pharmacist with specialized training in the particular therapeutic area may be consulted for reviewing and approving nonformulary medication use, if needed. By having a review process in place, prescribers can become accustomed to discussions with the pharmacist when ordering nonformulary medications to assist with providing formulary alternatives.

When it may not be appropriate to transition a patient to a hospital formulary medication, the hospital may elect to order the medication and dispense it from their inventory. In certain circumstances, if a patient brought the medication with them to the hospital, that may be used during the hospital stay. This may occur if waiting for the hospital to acquire the nonformulary medication poses a safety risk to the patient or if the medication requires a patient-specific distribution channel, such as a REMs program or clinical trial. Ensuring safe use of a medication brought in by a patient requires appropriate practices for ordering and verifying these medications. Many EHRs have an option to allow the prescriber to indicate that a patient’s own medication may be used. This acts as a trigger for the verifying pharmacist to check the product by confirming identity and appropriate dating. When applicable, appropriate barcoding of the patient’s own medication also needs to be accounted for using institution-specific practices.

An example of this in oncology practice is the tyrosine kinase inhibitor, dasatinib. If a hospital did not have this medication on formulary, it would not be clinically appropriate to substitute another agent during the hospital stay. If the patient brought his or her own supply to the hospital, it would be important to not interrupt therapy, to continue the medication using the patient’s supply. Many hospital formularies do not include all oral antineoplastic agents; this becomes an important education point when prescribing oral chemotherapy in the outpatient setting by informing patients that they should be prepared to bring their own supply in the event of hospitalization.

Using a combination of the above strategies will prepare institutions to appropriately manage patients that are taking medications outside of the hospital formulary as they transition to being inpatient.

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.

 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.

 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.

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 (

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.

 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.

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.

In certain circumstances, it may be urgent to start cancer treatment. However, we often experience delays with obtaining high-cost novel targeted medications. PAs delay drug procurement in addition to identifying the patient’s preferred pharmacy, which is more often a mail order pharmacy (

) so that these medications need to be directly shipped to the patient. Providers and support staff spend a large amount of time on the phone with insurance representatives to obtain PA and ensure timely drug delivery, and specialty pharmacies work to ensure prompt delivery of medications as soon as approval is obtained. It is important to communicate with the pharmacy when urgent delivery is needed so the drug can be overnighted to the patient, if necessary. 

Due to drug shortages or restricted use, some medications undergo limited supply distribution. For example, procarbazine, a drug used in combination treatment for lymphoma in the brain, is not carried by all pharmacies. There also have been instances where a patient’s insurance required a specific specialty pharmacy, but that pharmacy was unable to obtain a supply of the drug. These circumstances take a significant amount of time to manage and ensure patient access to the medication.

It can be logistically challenging, especially for patients from out of town, to have their drugs delivered to a hotel or temporary residence. They often need someone to sign for the package, which requires the caregiver to leave the patient’s bedside to obtain medications. Some medications require special handling, such as refrigeration, which adds complexity. Mail order prescriptions may have lower co-pays for chronic medications. If caregivers know medications will be delayed, they can defer the start of cancer treatment until the entire regimen can start at the same time—unless the patient’s clinical situation prevents this. It is often difficult to predict what other medication needs may arise during a course of chemotherapy; therefore, a local community pharmacy is often necessary for obtaining medications to manage symptoms in a timely fashion. In addition, patients often have to rely on caregivers, friends, and relatives to ensure timely delivery of their medications, which may include personally carrying or mailing the medications to the patient’s temporary location.

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. Tackling PBMs’ insurance formularies and the reimbursement process can be dynamic and complex. It is crucial for the pharmacy team to collaborate with other providers, hospital financial team members, PBMs, and hospital leadership and leverage their skill sets to manage costs and optimize reimbursement for the health system. Overall, this collaboration will maximize benefits for both institutions and patients, ultimately ensuring the most optimal use of medications. 

Brandon R. Shank, PharmD, MPH, BCOP, is a clinical pharmacy specialist, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX.â€¨

Phuoc Anh (Anne) Nguyen, PharmD, MS, BCPS, is a clinical pharmacy specialist, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX.

Emily C. Pherson, PharmD, BCPS, is a clinical pharmacy specialist, Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD. 

Brandon R. Shank, PharmD, MPH, BCOPâ€¨

Clinical Pharmacy Specialist, Division of Pharmacy,

The University of Texas MD Anderson Cancer Center

1515 Holcombe Blvd - Unit 377, Houston, TX 77030. 

1. Arends-Marquez A, Knight N, Thomas-Flowers D. ICD-10’s impact reaches far beyond coding: examining the new code sets’ revenue cycle implications. 

2. Loyd LM. Optimizing pharmaceutical reimbursement: one institution’s approach. American journal of health-system pharmacy. 

3. Jarrett AT, Patel KR, Babbitt R. Understanding pharmacy department billing and the charge master. American journal of health-system pharmacy. 

. 2008;65(23):2213-2214. doi: 10.2146/ajhp070675.

4. Blincyto - Coverage and correct coding — revised. CGS website. cgsmedi- care.com/jc/pubs/news/2015/0215/cope28409.html. Updated January 7, 2016. Accessed August 4, 2017.

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.

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

the drug manufacturer Novartis became the first company to receive a green light from the FDA to market its chimeric antigen receptor T (CAR T)-cell gene therapy treatment. Tisagenlecleucel (Kymriah) has been approved for the treatment of B-cell precursor acute lymphoblastic leukemia (ALL) in a pediatric population (

™), Brandon R. Shank, PharmD, MPH, BCOP, clinical pharmacy specialist, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, shared his experience with this treatment in his clinic. He explained the changes he anticipates may be needed for a safe, effective adoption of this new treatment modality in the oncology clinic.

Can you start by giving us a clinical understanding of the CAR T-cell therapy?

 CAR T-cell therapy is a specific kind of therapy for patients in which T cells are trained to attack a specific antigen. One specific group so far is in ALL [acute lymphoblastic leukemia], and the specific product developed has an anti-CD19 on it. So, the patients undergo leukapheresis and then they are infused with cells that have been trained to attack the cancer, specifically leukemia—either acute or chronic. There are trials currently underway [that are testing] these cells in lymphoma and also in multiple myeloma with a different target. There are also trials evaluating different antigens on these CAR T cells.

This treatment has revolutionized cancer [care] because we have moved away from standard chemotherapy—although there is a place of CAR T cells getting a conditioning regimen with fludarabine or cyclophosphamide. [Overall, though,] we are moving away from the actual chemotherapy and instead, training the body’s immune system to fight the cancer.

What specific role do you play in delivering CAR T-cell infusion to patients?

: My role is in the inpatient lymphoma service, specifically, with managing the logistics of the pharmacotherapy and toxicities of CAR T cells. On the formulary management side, hospitals now have to deal with adding 2 expensive medications—anti—IL-6 [interleukin-6] medications called siltuximab and tocilizumab&mdash;which are used to manage CRS [cytokine release syndrome]. So, from a formulary standpoint, institutions will need to develop order sets and make appropriate restrictions for the use of these agents.

Currently, most of my role on the service is to provide the supportive care and to manage the CRS and the CRES [CAR T-cell—related encephalopathy syndrome]. The pathophysiology of CRES overlaps with CRS, but this is specifically divided out to having encephalopathy. It’s a related but separate toxicity that’s been described recently by Neelapu, et al.

Can you describe the coordination among the various care providers when managing the toxicities associated with CAR T-cell infusion?

 An interdisciplinary team [includes] the oncologist, the attending physician, the nurse practitioner, emergency [department] physicians, neurologists, ICU [intensive care unit] physicians, and other specialties. Many consult services, such as the neurology team, will assess the patients daily. As soon as I hear of an adverse effect, most commonly fever, we [begin] our sepsis work-up, starting intravenous antibiotics, and all this has to be done in a rapid manner as CRS can be a rapidly progressing syndrome.

We ensure that we avoid medications that would overlap or have overlapping toxicities, such as central nervous system suppressants, which could affect the differential assessment of the patients who develop CRS. We also avoid contraindicated medications, such as steroids. We have to monitor patients’ blood pressure, fluids, and electrolyte status, and also ensure that their home medications are continued or held if appropriate, as well as to start our standard prophylaxis.

Certain protocols may include Neupogen, which is fairly controversial; we have to work on the insurance coverage for this drug and then facilitate the transition to outpatient after they have completed treatment and are out of their window of CRS toxicities.

What is the duration for which patients are monitored for CRS toxicities?

We are more conservative in our assessment and management of these patients. When most of our patients are admitted following their conditioning chemotherapy, we monitor their ferritin and their C-reactive protein, which is an inflammatory marker used to help predict CRS. Depending on the [CAR T-cell] product that the patients have received, the time of T-cell expansion may vary following infusion. Depending on the product, we may keep the patients longer because we have to wait for the [T-cell] expansion to occur—as soon as there’s expansion, that’s when the CRS is most likely to occur. Other factors with possible association with CRS risk include the cell dose, extent of disease, or the patient’s age.

There’s also been new research out of the Fred Hutch Cancer Center [which concluded] that if a patient had a larger cell dose, high marrow tumor burden, or bulky disease, it increased the risk of CRS.

Were there specific work ow changes needed for more efficient team management of patients receiving CAR T-cell treatment?

 I’d say that the acuity of when a CRS happens...it’s an emergency, which is different from some other chemotherapy toxicity. The patient decompensate faster. Another thing that is very di cult, and for which we have systems in place, is a mechanism to avoid administration of corticosteroids. It’s a common pre-med for blood products and platelets, but these [CAR T-infusion— treated] patients can’t receive any, and so e orts were made to educate staff to make sure that they don’t receive steroids.

As more patients undergo treatment with chimeric antigen receptor T cells, we will learn to better manage cytokine release syndrome.

Our standard admission orders needed to be altered for CAR T cells, because they include medications like zolpiderm or promethazine, which are medications that we try to avoid in this patient population.

These are some of the things we need to consider. I had one patient who was on a chronic, long-acting opioid medication, which gets tricky when you have to stop [the medication] abruptly if they have CRS, because they may develop withdrawal symptoms. So, there are many logistical barriers that are coming up now—we are learning how to manage the drugs in our arsenal when we are administering CAR T-cell infusion.

Going forward, what kind of infrastructure changes would you like to see in the way CAR T-cell treatment is currently delivered in the clinic to make it easier to manage these patients? 

One of the needs would be the capacity of the drug companies to quickly amplify the modified T cells. The financial toxicity is a problem. One article estimated the cost at between $450,000 and $475,000 per treatment. The high cost will have a significant financial impact on our healthcare system. As more patients undergo treatment, we will learn to better manage CRS. We have made great strides in the last year or two managing these patients, but we can do better and focus on risk strati cation to determine which patients are at high risk.

If this proves to be the trajectory of cancer treatment, select therapies may be given in the outpatient setting or inpatient, with a potential 2- to 3-week stay. [It’s] similar to a stem cell transplant, but this will be done on a lymphoma service. There’s a lot that we will learn along the way, and there is a high likelihood of logistical challenges initially since a lot of patients are waiting to receive therapy.

With respect to formulary management, billing is another important question—will this treatment be billed as a medication or a blood product? What would be the role of the pharmacy? Those are some of the current unknowns with this treatment.

CAR T cells have had a profound impact and will have a tremendous impact on oncology care, for non-Hodkgin’s lymphoma and leukemia. As we learn more, and more trials are available, this will be a unique treatment option for patients who have failed chemotherapy. 

Brandon R. Shank, PharmD, MPH, BCOP, is a clinical pharmacy specialist, The University of Texas MD Anderson Cancer Center. 

Evidence-Based OncologyTM sat down with Brandon R. Shank, PharmD, MPH, BCOP, clinical pharmacy specialist, Division of Pharmacy, The University of Texas MD Anderson Cancer Center, to understand a pharmacist's role in administering chimeric antigen receptor (CAR) T cells.

In Conversation With a Pharmacist: Management of CAR T-Cell Treatment

 benefit managers (PBMs) and community oncologists has not been an easy one. With the increasing prevalence of oral oncolytics, PBMs and community oncologists have seen a concurrent increase in their mutual interaction. Each can rail against the other, claiming better, faster, and more cost-effective care, or community oncologists can find a way to co-exist with and manage PBMs in a manner that would benefit patients and their practice.

In many areas of medicine, the role of PBMs is established. PBMs can be a beneficial part of the patient care team, especially for chronic conditions such as hyperlipidemia, hyperglycemia, and hypertension. However, the role of PBMs in cancer care is less clear. For acute, severe, and often life-threatening conditions like cancer, the community oncologist is better able to provide the intense, rapid-response, personalized, and familiar care that is necessary.

Adverse reactions and dosing refinements are common in oncology care and require prompt attention by someone familiar with patient history. PBMs do not have access to patient medical records and are, therefore, hampered in their ability to understand and resolve problems. In contrast, community oncology pharma- cists and pharmacy technicians, working under the supervision

of their community oncologists, have access to patient medical records and are familiar with the 50-plus oral anticancer agents, the most frequent and expected reactions, and the most prompt and effective response.

Community oncology-based pharmacists, pharmacy technicians, and oncologists know their patients and the drugs in ways PBMs do not. PBMs are very much on board with dispensing many drugs, but they may have less experience with the more varied and critical care cancer drugs. PBMs are well-suited to manage the orals process, to adjudicate claims, and to manage the process of obtaining drugs, but they are not experts in determining drug access options.

During traditional chemotherapy, patients are very closely monitored by clinic staff —from the lab technicians, pharmacists, pharmacy technicians, nurses, nurse practitioners, and chemotherapy nurses to the physicians. This changes with oral drugs, placing a much greater responsibility on the pharmacist and pharmacy technicians.

In most practices, it is the responsibility of the dispensing pharmacist, lab technician, and oncologist to manage the patients receiving oral chemotherapy. These chemotherapy agents often carry the same risks and reactions as an intravenous chemotherapy agent. In the absence of a linear connection between dispensing and patient management, there is a disconnect that affects treatment, compliance, outcomes, and the cost of care for patients.

It is not only the standard of care, but also required by law in most states, that the dispensing pharmacist, pharmacy technicians, and oncologists are responsible for patient education and management. For oral cancer drugs, this includes dosing plan explanation (eg, should the drug be taken with or without food, drug storage and handling, possible adverse reactions, how to mitigate those reactions, monitoring compliance, and when to provide medical intervention). Based on their knowledge of the agents, community oncology pharmacists and pharmacy technicians are prepared make recommendations to the oncologist for OTC medications or supportive care medications that can ameliorate common reactions, such as diarrhea or skin toxicities, rather than discontinuing treatment. They are familiar with options such as dosing changes and/or drug holidays, and they recognize signs of toxicity and know when lab testing, in-office hydration, or other supportive care may be warranted. Recognition of these signs can avoid disruptive occurrences, such as trips to the emergency department.

Community oncology-based pharmacists, pharmacy technicians, and oncologists have access to patient records and can more closely monitor patients which empowers them to provide the most coordinated care. These tools are not available to anyone outside the practice, including PBMs.

Patients receiving their oral drugs from a community oncology practice have access to those drugs within 24 hours of prescribing, and they begin treatment immediately. Patients receiving their oral cancer drugs through a PBM, on the other hand, often have a much longer wait, sometimes 14 days or more. Common causes of delays include:

		More complicated or cumbersome internal PBM protocols that require more time to process a prescription

		Multiple back-and-forth conversations between the PBM and the practice

		Time needed to confirm and re-confirm patient information, including addresses and insurance coverage, as well as additional information requests

		Transferring prescriptions for processing between facilities for actual dispensing

Some PBMs force patients currently receiving their oral drugs from the community oncologist to switch to pharmacies that the PBM owns. However, PBMs are often disconnected from the patients and may invoke internal systems that make presumptions about the preferred method of care and attempt to dispense drugs without evaluating what might be the best care, from the patient’s perspective.

For drug prior authorization, PBMs document all of the information necessary for subsequent prescriptions, including the physician and patient names, payer information, drug name, dosage, and authorization. Some PBMs will automatically create a prescription and fax it to the physician. Without scrutiny from the oncologist or staff, patients may be directed away from the practice’s pharmacy.

Physician dispensing has become increasingly popular in the United States and has expanded to include a variety of medications in both the retail and specialty spaces. This growth in popularity has largely bene ted overall patient care. William Shell, MD, in 

, reports that patient compliance with drug therapy is 60% to 70% higher from a dispensing physician than a pharmacy.

Patients cannot be compelled to fill their prescription from a specific dispenser; however, many report receiving correspondence from their PBM that implies they must use a pharmacy owned by the PBM. These letters often explain that the insurance company has its own pharmacy, from which the patient may already be receiving other prescribed drugs, and offer for the patient to also get their oral cancer drug from this same source. Many patients find this confusing and do not understand the repercussions that jeopardize the monitoring, care control, and care management that they receive at their community oncology pharmacy, and they mistakenly, or unintentionally, switch their drug dispenser.

A community oncology pharmacist will recognize drugs that may be di cult to tolerate or patients whose conditions may require multiple dosing refinements. In these cases, in anticipation of modifications, practices will often dispense a 15-day supply rather than a 30- or 90-day supply. PBMs can lack the expertise for such forethought or do not have the experience with care management to know when a smaller supply might be the wiser, more economical choice. In-house pharmacies are often able to lower medication waste in cases when a patient’s drug dose is expected to be reduced or when drug tolerance is a consideration.

Although PBM problems are not guaranteed, patient care is enhanced when a practice is aware of what may happen and is prepared to handle problems as soon as they arise. Practices that have coping systems in place and have developed ways of dealing with the PBM problems can enhance patient care and avoid treatment delays.

PBMs may delay shipping a drug because they require address confirmation; they often send a letter requesting address confirmation to the very address they wish to con rm. Other times patients wait, often too patiently, for overdue drugs. Paper work problems, red tape, and conflicting or missing information are often easily resolved with a short conversation. Relatively simple problems that can cause unnecessary delays can usually be resolved just by picking up the phone.

Community Oncology Pharmacy Association Support

The Community Oncology Pharmacy Association (COPA), within the Community Oncology Alliance (COA), was formed in response to the increasing number of community cancer clinics dispensing oral cancer drugs and ancillary therapies. COPA is a nonprofit entity that has established standards; provides information, education, and resources; enhances information exchange; and advocates for the patient-centric model of integrated, high-quality cancer care. Due to the increasing costs of cancer drugs, there are commercial interests, such as PBMs and specialty pharmacies, attempting to separate oral cancer therapy from the point-of-care and oncologist control, thus interfering with the physician-patient relationship. As a nonprofit focused on enhancing patient care, COPA is in the unique position of serving as a noncommercial organization dedicated to addressing a variety of pharmacy-related issues, all in the sole interest of patient care.

COPA provides tools that can assist practices in resolving issues with PBMs and benefit patients, including:

		Letter templates when challenging, usually in cases of steering, PBM violation of the Health Insurance Portability and Accountability Act and other laws

		Access to State Boards of Pharmacy consumer complaint forms to report incidents of interference in the physician-patient relationship over drug dispensing

		Access to HHS’ Office for Civil Rights (OCR) forms to file a Health Information Privacy Complaint

Many larger practices are developing internal protocols to deal with some of the most common problems. Rapid referral systems establish procedures for follow-up—daily, when necessary&mdash;if a delay of the onset of treatment due to drug delays could be detrimental to the patient’s prognosis. Follow-up systems enable practices to track prescriptions as they move through a PBM system, avoiding potential delays and preventing intentional or unintentional poaching, trolling, or steering.

COPA has also developed a system to document incidents of PBM abuses by collecting data on PBM and specialty pharmacy-related incidents to identify trends, patient care issues, and pricing issues and to provide tools that can ensure maximum patient benefit. These data are also available to support proposed regulatory or legislative action. COPA also maintains a chronology of actual patient stories of PBM abuses. Go to 

to review the complete listing in Real Life Impact of Pharmacy Bene t Managers: April 2017, May 2017, September 2017.

Community oncologists expect their pharmacists to make sure patients have their prescribed drugs— whether from the practice or a PBM&mdash;and are fully educated and compliant and properly monitored and managed. PBMs can be both part of the problem and the solution to meeting those expectations. When they are part of the problem, community oncology pharmacists and pharmacy technicians are not alone and have tools to help them help patients. 

Ray Bailey, RPh, is pharmacy director for Florida Cancer Specialistsâ€¨and Research Institute’s clinical sites and a member of the Board of the Community Oncology Pharmacy Association.

Ricky Newton, CPA, is treasurer and director of nancial services and operations for the Community Oncology Alliance and an advisor to the Community Oncology Pharmacy Association. 

Director of Financial Services and Operations

1634 I Street NW, Suite 1200 Washington, DC 20006 

October 2017

Formulary Considerations: The Past, Present, and Future

Pharmacy's Changing Role as Cancer Care Transitions From Infused to Oral Therapies

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

In Conversation With a Pharmacist: Management of CAR T-Cell Treatment

PBMs: Their Role, the Problems, and How Practices Can Work With Them

Positive Quality Interventions: An Innovative Platform for Oncology Practice Collaboration

Medical World News®, October 2017

AJMC®tv Interviews, October 2017