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DoD Pharmacy Enterprise

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Sustained Excellence. ... 1 MAY 2015FORMULARY SEARCH TOOL. The TRICARE Formulary Search Tool will transition from the current DHA Pharmacy Website to ESI Website. – PowerPoint PPT presentation

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Title: DoD Pharmacy Enterprise


1
For Office Use Only
Pharmacy Workgroup
DoD Pharmacy Enterprise Operations Update April
1, 2015
Medically Ready ForceReady Medical Force
2
Opening Remarks
  • Pharmacy Shared Service Full Operating
    Capability
  • 3 March 2015 7 months ahead of projection!
  • Chartered Work Group Service Consultants, DHA
    Pharm
  • Guiding DoD Pharmacy Enterprise to Sustained
    Excellence
  • Uniform Priorities Standardized Process
    Metrics
  • Full Agenda

Medically Ready ForceReady Medical Force
3
Agenda
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
PT 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
4
Update on DHA Pharmacy Initiatives Dr. George
Jones, Chief Pharmacy Operations Division
  • 2014 Stood up operations 3 Primary
    Initiatives
  • Retail 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 Pilot
  • NDAA 2015 terminated Pilot
  • Implement Same MTF/Mail approach for all
    beneficiaries
  • Pharmacy Savings Index Update

Medically Ready ForceReady Medical Force
5
Pharmacy Savings Index (PSI) FY15 Overall
Target 208M
208M 85M DHP 123M MERHCF
Good
Target 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
5
6
Initiative 1 - Retail Rxs to Mail/MTF Estimated
Cost Savings
Good
6
7
Initiative 2 - Formulary Management Estimated
Cost Savings
Monthly cost savings reported for therapeutic
classes evaluated by DoD PT with decisions
implemented in the last year does NOT include
potential cost increases in other therapeutic
areas associated with market approval of new drugs
Good
7
8
Initiative 3 - Generic Contracting Compliance,
Estimated Cost Savings
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.
Good
9
TPharm4 Changes 1 MAY 2015 SPECIALTY DRUGS
  • Express Scripts, Inc. (ESI) will implement a
    select retail pharmacy network for some specialty
    drugs
  • List approved by PT at the November 2014 meeting
    (79 items) and subject to change based on PT
    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 ESIs 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

Medically Ready ForceReady Medical Force
10
TPharm4 Changes 1 MAY 2015 SPECIALTY 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

Medically Ready ForceReady Medical Force
11
TPharm4 Changes 1 MAY 2015 FORMULARY SEARCH TOOL
  • The TRICARE Formulary Search Tool will transition
    from the current DHA Pharmacy Website to ESI
    Website

12
TPharm4 Changes 1 MAY 2015 EXPLANATION OF
BENEFITS (EOB)
  • Explanation of Benefits (EOB) will now include
    MTF dispensed prescriptions as well as TMOP drug
    costs

Medically Ready ForceReady Medical Force
13
TPharm4 Changes 1 MAY 2015 DEPLOYMENT
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

Medically Ready ForceReady Medical Force
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TPharm4 Changes 1 MAY 2015 MTF 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/Specialt
    y Leaders
  • Some ProDUR messaging under ESIs 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

Medically Ready ForceReady Medical Force
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TPharm4 Changes 1 MAY 2015 MTF 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 Report List 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 Report List 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 Report List of completed MTF claims that generated the following ProDUR warnings High Dose Alerts and Invalid Provider.
Medically Ready ForceReady Medical Force
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TPharm4 Changes 1 MAY 2015 MTF 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
  • 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
  • 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)

Medically Ready ForceReady Medical Force
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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.

Medically Ready ForceReady Medical Force
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Increased Adherence to Pharmacy Business Rules
MTF Provider adherence to business rules is an
enabler of savings for three major pharmacy
initiatives
  • 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 PT 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

Medically Ready ForceReady Medical Force
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Increased Adherence to Pharmacy Business Rules
There are five guiding principles for achieving
high levels of provider adherence
Medically Ready ForceReady Medical Force
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Increased Adherence to Pharmacy Business Rules -
Example from the field
  • 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

Medically Ready ForceReady Medical Force
21
Playbook of Enhancing Communications of Business
Rules to Providers
RECAPTURE SAVINGS
A C C U R A C Y
A C C E S S
S E R V I C E
Medically Ready ForceReady Medical Force
22
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

23
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

24
Service
  • Patients
  • Have a choice of what Point of Service to fill at
  • Incentive to fill at the MTF built in with copay
    structure
  • Must make utilizing MTF appealing
  • Wait-times
  • Personalized care
  • Additional services (refill synchronization)
  • Providers
  • Must be advocates for utilizing MTF pharmacies
  • Access is key

25
Access
  • MTF providers must feel like they have the
    ability to order what they feel they need to
    treat their patient
  • Non-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

26
Access
  • Leverage robust non-formulary process with BCF
    optimization
  • Drug 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.

27
Access
  • Provide regular communication to providers
    regarding pharmacy business rules
  • Provide cost data on formulary
  • decisions
  • Recognize providers with high
  • BCF utilization
  • Call providers to recommend
  • changes to BCF items (leverage pharmacist/tech
    students)
  • Every provider in-processes through pharmacy and
    receives on-boarding packet with formulary
    guidance

28
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

29
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/Site
    Pages/Default.aspx
  • Use email certificate for access
  • Permission based access currently via 3G link and
    follow prompts https//carepoint.afms.mil/CAREPOI
    NT/
  • 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)

Medically Ready ForceReady Medical Force
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November 2014 PT Committee Update
39
Uniform Formulary Class Review
  • Self Monitoring Blood Glucose System Test Strips
    (SMBGS) Test Strips
  • Multiple Sclerosis Drugs

40
SMBGS Test Strips Formulary Status
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
Step therapy applies to all new users and
current users of a test strip must try
Precision Xtra or FreeStyle Lite first
40
41
(SMBGS) Test Strips Formulary Status
  • Precision Xtra test strips remain on the Basic
    Core Formulary (BCF). FreeStyle Lite test strips
    were added to the BCF
  • These 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
42
(SMBGS) Test Strips Prior Authorization Criteria
  • 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 meter
  • Contour NEXT strip with CONTOUR NEXT Link meter
    for Medtronic pump
  • Nova Max strip with Nova Max Link meter for
    Medtronic pump
  • Accu-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
43
(SMBGS) Test Strips MTF Conversion
  • 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
    carole.hamm_at_abbott.com
  • Tom Tveit, Senior Government Account Manager
    (949) 244-7348 tom.tveit_at_abbott.com
  • The BCF decision is for the test strips, not the
    glucometers, however, Abbott will continue to
    provide glucometers at no charge to the MTFs
  • Precision Xtra meter is for the Precision Xtra
    test strips
  • FreeStyle Freedom Lite meter is the workhorse
    meter for the FreeStyle Lite test strips

43
44
(SMBGS) Test Strips MTF Conversion
  • For Meter replenishment
  • Please contact the Abbott Inside Sales Team at
    800-401-1183 (ext below) fax 866-222-3715
  • Patty NcNett Patty.mcnett_at_adc-insidesales.com ext
    8006
  • Dawn Rayens Dawn.rayens_at_adc-insidesales.com 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
45
Multiple Sclerosis Formulary Status
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
Prior Authorization criteria apply to Tecfidera
and Gilenya (updated for cardiovascular toxicity)
45
46
Multiple Sclerosis Oral Drugs Key Points
  • 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
47
Multiple Sclerosis Injectables Key Points
  • 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
Medically Ready ForceReady Medical Force
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New Drugs in a Previously Reviewed Class Summary
  • 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
  • Decision
  • UF Umeclidinium/Vilanterol (Anoro Ellipta)
  • Encourage pts to fill Rxs at Mail or MTFs
  • Justification
  • Offers the patient convenience of two
    bronchodilators in one inhaler, dosed once daily
  • Anoro 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

52
Brinzolamide 1/Brimonidine 0.2
(Simbrinza) Background
  • 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

Generic Brand (Manufacturer) Concentration Dosing Mechanism of Action
Brinzolamide/ brimonidine Simbrinza (Alcon) 1/0.2 TID alpha-adrenergic receptor 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

54
DoD PT 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

55
DoD PT Committee Upcoming Evaluations
  • August 2015
  • May 2015
  • UF Class review
  • CML
  • SGLT-2 Inhibitors
  • GLP-1 Receptor Agonists
  • Narcotic Analgesics
  • New Drugs
  • COPD drugs umeclidinium (Incruse Ellipta)
  • 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)

56
Specialty Rx Filled by Point of Service Jan-14
to Feb-15
  • Interventions began in August 2014 (PT
    education working with DLA formulary expansion
    reimbursement)

Based on Clinical Services Drug List
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Specialty Rx Filled by Point of Service Jan-14
to Feb-15
  • Decreasing the Retail market share

Based on Clinical Services Drug List
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Top 20 Rx written by MTF providers and filled at
Retail Point of Service, Jan-14 to Feb-15
Sum of RX Sum of Net Cost to Government Mean Cost/RX Target 30 Recapture
NOVOSEVEN RT 30 792,002 26,400 237,601
GLEEVEC 57 457,084 8,019 137,125
COPAXONE 102 804,815 7,890 241,445
SPRYCEL 33 241,858 7,329 72,558
REBIF 45 321,844 7,152 96,553
GILENYA 72 509,058 7,070 152,717
REBIF REBIDOSE 36 240,985 6,694 72,296
AVONEX 20 122,734 6,137 36,820
BETASERON 36 205,413 5,706 61,624
TECFIDERA 414 2,306,524 5,571 691,957
SIMPONI 24 117,425 4,893 35,227
AUBAGIO 18 86,866 4,826 26,060
HUMIRA 436 1,688,256 3,872 506,477
CIMZIA 38 132,286 3,481 39,686
ENBREL 198 625,942 3,161 187,783
BENEFIX 25 69,638 2,786 20,892
ORENCIA 24 66,494 2,771 19,948
XELJANZ 13 27,442 2,111 8,233
LEUPROLIDE ACETATE 124 29,736 240 8,921
RIBAVIRIN 15 2,466 164 740
Grand Total 1,760 8,848,868   2,654,660
Based on Clinical Services Drug List adjusted
for refunds copays
59
New Resources Tab under DOD PT Committee
Based on Clinical Services Drug List
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Brand to Generic Update
FY15 10.8M Cost Avoidance
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National Contract Compliance Update
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Nexium NDC Transition Plan
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Prime Vendor Credits Update
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64
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

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Prime Vendor Global Status Go Live Dates
Region Go-Live
Designated Providers April 1, 2015_at_
Other Government Agencies April 1, 2015_at_
Upper Prairie (DMLSS) April 1, 2015
North (DMLSS/Web Ordering) North (TEWLS) May 1, 2015 May 4, 2015
South (DMLSS/Web Ordering) South (TEWLS) May 8, 2015 May 11, 2015
West (Hawaii and Alaska) (DMLSS/Web Ordering) West (TEWLS) May 15, 2015 May 18, 2015
North OCONUS (Europe) (All) June 1, 2015
West OCONUS (Pacific) (All) June 1, 2015
_at_Non-DMLSS/TEWLS The Back-up Supplier will go
live with the Primary for Each Region
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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

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Overview Compounds
  • Lack of Scientific Evidence lack of peer
    reviewed clinical research evaluating the safety
    and effectiveness of many compounded products
  • Costs DoDs 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, TRICAREs
    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 (PT)
    Committee Recommendation Prior Authorization
  • Express Scripts Network Agreements
  • HA request for Service/eMSM support

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Compound Pharmacy Expenses
Actual for January 2015 194M
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Management Strategy
  • In November 2014, DoD Pharmacy Therapeutics
    (PT) 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 PT recommended
    implementation period and review of other cost
    containment options
  • The Director, Defense Health Agency considered
    recommendations of both the DoD PT 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 PT recommendations that will
    ensure beneficiaries have sustainable access to
    compound medications while addressing safety and
    efficacy concerns

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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 TRICAREs coverage standards

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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.

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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

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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

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Key Messages
  • DoDs 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.

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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

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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

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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 eRxs 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

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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

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Questions
  • Questions?
  • For additional information, please reach out to
    one of the following
  • DHA Pharmacy Operations Division Chief Dr.
    George Jones, george.e.jones48.civ_at_mail.mil
  • Air Force Pharmacy Consultant Col Scott
    Sprenger, scott.a.sprenger.mil_at_mail.mil
  • Army Pharmacy Consultant COL John Spain,
    john.spain1.mil_at_mail.mil
  • Navy Pharmacy Consultant CAPT Thinh Ha,
    thinh.v.ha.mil_at_mail.mil
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