CVS/Caremark had a change of heart…

An update to our post from October 1, 2016:

COA has recently learned that CVS Health is indicating it will not proceed with restricting cancer patients from receiving their medications from oncology practices that dispense medications.
Previously, CVS had notified patients that, beginning January 1, 2017, their oncologists’ pharmacies would be considered “out of network” and medications would only be available from pharmacies CVS deems in network, such as its own (learn more in the COA white paper).

According to a statement from CVS to COA’s attorneys, “Oncologists who dispense medications will remain in our Medicare Part D networks pending future dialogue with CMS. We are in the process of communicating this information to affected dispensers and beneficiaries.” We are hopeful that this decision will be officially communicated to all patients who have been unnecessarily shocked and worried over this ill-conceived proposal and the poor way in which it was rolled out and communicated to cancer patients and others.

COA and its Community Oncology Pharmacy Association (COPA) will continue to monitor and provide more updates on this averted patient crisis. We also continue to fight for patients and their providers on outstanding issues with pharmacy benefit managers (PBMs), such as restrictive formularies and DIR fees.



Posted October 1, 2016:

The pharmacy benefit manager (PBM) CVS/Caremark, a division of CVS Health, has announced that effective January 1, 2017 it will declare all cancer care clinics dispensing oral cancer drugs as “out-of-network” despite the fact that for the past 13 years they have been “in network.”

This recent action will force cancer patients—many of them among our most vulnerable seniors—to obtain drugs away from their site of cancer care. We expect CVS/Caremark will attempt to steer these patients to its own specialty and mail-order pharmacies. The immediate impact of this is a dangerous disruption in seniors’ cancer care, likely increasing treatment non-adherence and errors, as well as increasing costs. Perhaps most importantly, this decision does not benefit patients—it only serves CVS Health by pushing more business towards its specialty and mail-order pharmacies.

Background on PBMs and New York State

Health insurers today frequently outsource administration of prescription drug benefits to PBMs, which are third-party entities responsible for contracting with pharmacies, negotiating rates, and processing drug claims. Since 2011, the PBM marketplace has seen rapid consolidation – just five national PBMs now control prescription drugs for 80% of all Americans. CVS/Caremark is one of the nation’s largest PBMs, second only to Express Scripts. In addition, CVS/Caremark and all of the major PBMs have their own specialty and mail-order pharmacies. These wholly-owned providers serve to maximize profits by vertically integrating the payor and provider, and by controlling access to specialty drugs like oral cancer therapies. We expect CVS/Caremark to leverage its vertical integration to drive patients needing such drugs to their own specialty/mail-order pharmacy.

It is important to note that in New York State physicians are not allowed to have on-site pharmacies, unlike many other states, but oncologists and HIV providers can operate in-office dispensing (IOD) facilities due to a special exception in NYS Education Law authorizing them to dispense medications to their patients beyond a 72-hour supply.

Benefits of In-Office Dispensing of Medications

As cancer treatment has expanded beyond physician-administered chemotherapy infusions to include oral cancer drugs, the ability to dispense these complex, potentially toxic specialty drugs is essential in effective, coordinated cancer care. Providing these drugs at the point-of-care provides greater assurance that patients will receive their drugs, be instructed on how to take them, and can communicate any medication issues with their providers. It also means less time-to-treatment, less difficulty in adjusting dosage-to-disease progression, and less overall drug wastage, all of which we document.

In contrast, when cancer patients must obtain cancer drugs from specialty and/or mail-order prescriptions, run by PBMs, it often:

•Delays patient access to chemotherapy drugs and treatment;
•Disrupts the coordination of care, such as the infusions, radiation, and/or laboratory testing, frequently prescribed in conjunction with oral therapies;
•Disrupts care management, including the opportunity for physicians to monitor for adverse events, compliance, tolerance, and efficacy;
•Sets a dangerous precedent for the patient to potentially receive different dosing and treatment directions from the mail-order pharmacy versus what is intended by the prescriber (careful dosing titrations and adjustments are frequently made at the site of care);
•Increases cost to the patient by limiting split-filling, a process that can be implemented at the physician dispensing level, which avoids significant drug waste, as well as access to patient assistance programs for patients in need;
•Increases the stress and inconvenience on patients fighting a life-threatening illness; and
•Increases waste when dosage and therapies are changed to meet the needs of the patients. Extremely costly drugs (for new oral cancer therapies, a 30-day supply costs on average $10,000) already received by the patient from mail-order pharmacies are unusable if there is a change in the patient’s status. That means they are thrown away. This is very common, and a substantial issue for all payers, including Medicare and private insurers.

Today, when a patient is treated at one of our cancer clinics and is prescribed an oral cancer drug, they can often receive it the same day during a single, integrated visit. When PBMs require patients to mail-order cancer drugs there can sometimes be a delay of weeks, even up to over a month as the facility processes the claim and ships it out. For example, one patient recently faced a delay of 32 days before receiving their cancer medication. The typical turnaround time for a cancer medication to reach the patient from a mail-order pharmacy is 7-10 days.[i]

In-office dispensing also gives patients in-person counseling by an oncology certified pharmacist or nurse about how to take the drug appropriately and how to manage potential side effects. In addition, the in-office dispensing staff works directly with the patient and their caregivers to help them overcome any financial issues that are all too common with acquiring these expensive drugs. A study found that more than half of people who believe they take their medications properly are not – and with cancer drugs especially, patients need clear direction and intense counseling to assure appropriate use to maximize therapeutic outcomes.[ii]

In-office dispensing saves our health care system billions of dollars. Compliance with drug therapy has been shown to be as much as 70% better when medications are delivered at the point of care.[iii] Ironically, according to a study by CVS/Caremark itself, patients not taking their prescribed medications cost the health care system as much as $200 billion a year.[iv]

Despite having credentialed, contracted, and paid for in-office dispensing as “in-network” providers for 13 years, CVS/Caremark is suddenly taking the position that dispensing physicians are “out- of-network” providers and are now subject to network exclusion. This is clearly motivated by their intent to control a major portion of the specialty drug dispensing market. No other PBM or major payor has taken this position.
Please ask CVS/Caremark to delay implementation of this change until a more thorough examination of its impact on cancer patient care and the overall health care market can take place. The decision to begin implementation on January 1, 2017 is arbitrary and should be reconsidered given that this will create a crisis for cancer patients by negatively impacting patient care while increasing costs.

We understand that CVS/Caremark is currently distributing a very confusing form letter to patients that is wreaking havoc and causing confusion. We fear most of our vulnerable senior patients do not understand this letter or have not been made aware of these sweeping pharmacy network changes. A delay is critical for New York’s cancer patients.

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