Drug Topics - February 2009 - (Page 28)

SPECIAL REPORT ONCOLYTIC AGENTS Oral oncology drugs Navigating dispensing, billing, and reimbursement challenges is a daunting but not insurmountable task F Maude Campbell, Clinical Managing Editor, Michele B. Kaufman, PharmD, and Jeffrey Bendix, Senior Editor how to bill it. Most pharmacists don’t bill Medicare Part B and never have. They were never taught how to do it,” Lofholm said. Oral oncolytics that aren’t billable under Medicare Part B often are covered by MediIntricacies care Part D. Then the health of dispensing There are extraordinary plans weigh in. In fact, the barriers to dispensing some advent of Medicare Part D is of these drugs,” Lofholm thought to have speeded the said. For example, ﬁlling a development of oral cancer prescription for aprepitant drugs to its current dizzy(Emend; Merck) may seem ing pace. (See “The pipeline: Oral antineosimple enough, plastic agents,” but it can be page 32.) dispensed only As the numwith dexaPOWER POINTS ber of available methasone and oral cancer only when the Oral agents with a parenteral counterpart medications patient has had can be billed under continues to methotrexate Medicare Part B. increase, pharadministered in macists must the oncologist’s Oral oncolytics that work to navioffice. Furtheraren’t billable under gate the dismore, all three Part B often are covered by Medicare pensing, billing, agents must be Part D. and reimbursebilled on the ment challenges same day. that come with “So if the patient goes to get their che- them. There is also concern motherapy we cannot bill about the safety of handling their antinausea medication cytotoxic drugs on a regular until the oncologist bills for basis. “There are multiple drugs, the methotrexate,” Lofholm said. If the physician failed accessing of multiple bento write the dexamethasone efits and patient assistance prescription or if the timing programs, and a disease that of the billing is off, Lofholm’s is continuously morphing patient is left nauseated with the shortest durations while the pharmacy techni- of therapy. There is also a sense of urgency to get the cian tries to sort it out. Oral agents with a par- drug to the patient,” said enteral counterpart can be Burt Zweigenhaft, CEO of billed under Medicare Part Oncomed, a New York-based B, “if the pharmacist knows bio-oncology pharmacy. “It is Lofholm and other community and retail pharmacists, and even some specialty pharmacists, ﬁnd that ﬁlling these prescriptions can be daunting. not unusual to have multiple agents, and the reimbursement is the toughest out there.” He added that since the margins on these drugs are so slim, pharmacies want to make sure they will be reimbursed. Some of the agents are under limited distribution and may be difﬁcult for community and retail pharmacies to obtain. “Manufacturers don’t put limited distribution agreements in place so they can restrict the drug and raise the margins. They are trying to deﬁne competency, and if you don’t have those competencies, they are not going to give you the drug,” Zweigenhaft said. The packaging of some agents also presents a challenge. According to Lofholm, he may have a patient who needs the ﬁrst 14- or 21-day cycle of a drug that comes only in 100-count packages. If the physician changes that patient’s regimen or the drug isn’t tolerated, Lofholm is stuck with the remainder. “When we dispense orals we look at dispensing weekly rather than monthly,” Zweigenhaft said. If the patient pays $4,000 for a month of treatment only to ﬁnd out the drug isn’t tolerated after a week, $3,000 of the patient’s drug beneﬁt is wasted. Additionally, as the average cost of oral cancer treatment approaches $43,000 and some drugs, W W W.D R U GTO P I C S .C O M ew pharmacies can afford to have unused and/or outof- d a t e m e d i c a t i o n s sitting in their inventories. If the medications are oncolytic agents such as temozolomide (Temodar; Schering-Plough) or erlotinib (Tarceva; Genentech/OSI Pharmaceuticals), the problem is that much more acute. Paul Lofholm, PharmD, who operates a 2500-squarefoot pharmacy in Marin County, Ca., deals with this issue. Oncolytic agents might be included in the Ross Valley Pharmacy inventory two or three times a year. “Erlotinib comes in a bottle of 30 and if I dispense 14 of them I have $1500 worth of drug sitting on a shelf,” he said. Ross Valley Pharmacy is near the local hospital and an oncology group, said Lofholm, who is also a professor of clinical pharmacy at the University of California, San Francisco. “We are a community pharmacy and 90 percent of our business is prescriptions,” he said. Of that prescription business, only 1 percent involves oral oncology drugs, up to 5 percent if hospice patients are included. “We are trying to take care of the patients who need help. We have developed a relationship with the oncologists so they will refer patients to us,” Lofholm said. They do refer patients, but 28 DRUG TOPICS Februar y 2009 http://WWW.DRUGTOPICS.COM

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Drug Topics - February 2009 Contents Health-System Edition Group Attempts to Resurrect Pain Care Act HSE Business Management HSE Clinical Letters Up Front Up Front in Depth Community Practice Niche Pharmacies Serve Special Populations Special Report Oral Oncology Drugs New Drugs Update 2008 Approvals OTC New Products Viewpoint

Drug Topics - February 2009

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