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FUNGISAI NOTA, PHD. * ANDREW WELSH ANDREW LOFURNO AIDS CARE GROUP RYAN WHITE ALL TITLES MEETING, WASHINGTON DC NOVEMBER 27 TH -29 TH, 2012 *CONTACT INFORMATION:

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Presentation on theme: "FUNGISAI NOTA, PHD. * ANDREW WELSH ANDREW LOFURNO AIDS CARE GROUP RYAN WHITE ALL TITLES MEETING, WASHINGTON DC NOVEMBER 27 TH -29 TH, 2012 *CONTACT INFORMATION:"— Presentation transcript:

1 FUNGISAI NOTA, PHD. * ANDREW WELSH ANDREW LOFURNO AIDS CARE GROUP RYAN WHITE ALL TITLES MEETING, WASHINGTON DC NOVEMBER 27 TH -29 TH, 2012 *CONTACT INFORMATION: 340B AND YOUR ORGANIZATION

2

3 340B Program Evolution

4 Creation of the 340B Program

5 Intent of the 340B Program 1. HR Rep No. 102–384, pt 2, at 12 (1992).

6 Patient Definition

7 340B Eligible Entities * 340B eligible through Section 7101 of the Affordable Care Act

8 Hospital Eligibility Criteria * 340B eligible through Section 7101 of the Affordable Care Act

9 Hospital Outpatient Facilities In order for outpatient facilities to become eligible for the 340B Program:  The outpatient facility must be an integral part of the hospital  The outpatient facility must be included as reimbursable on the covered entity’s most recently filed Medicare Cost Report  To register additional outpatient facilities, complete the online Register an Outpatient Facility registration at:

10 340B Enrollment Procedure

11 340B Implementation

12 1. History of 340B 2. The Intent of 340B Program 3. Who is eligible 4. Key dates Part 1 - Summary

13 340B Prohibitions and Requirements

14 340B Covered Drugs

15 340B Prohibitions and Requirements

16 Duplicate Discount on 340B Drugs

17 Examples of Duplicate Discounts

18 Examples of Duplicate Discounts Cont’d 1. CMS. Letter re: medication prescription drug rebates. April 22, Available at: ​ SMD.pdf. Accessed November 22, 2011.

19 Billing Medicaid

20 Medicaid Exclusion File and 340B Contract Pharmacies

21 The Medicaid Exclusion File

22 CE Decision to Use 340B Drugs Carve-In

23

24 Avoiding Duplicate Discounts

25 Diversion Prohibition

26 GPO Exclusion

27 The Orphan Drug Exclusion The Orphan Drug Product Designation Database can be found at:

28 Part 2 - Summary 1. Determining which drugs are covered under 340B 2. Diversion / Exclusion / Duplicate discounts 3. Carving – in or Carving - out Medicaid 4. GPOs and Orphan drugs

29 OPTIMIZING YOUR 340B PROGRAM

30 340B Prime Vendor Program PVP Mission and Goals Improve access to affordable medications for covered entities and their patients Primary goals:  Lower participants’ supply costs by expanding the current PVP portfolio of sub-340B priced products  Provide covered entities with access to efficient drug distribution solutions to meet their patients’ needs  Provide access to other value added products and services meeting covered entities’ unique needs

31 Estimated Prices For Selected Public Purchasers as a Percent of AWP Stephen Schondelmeyer, PRIME Institute, University of Minnesota (2001) 100.0% 80.0% 67.9% 60.5% 51.7% 49.0% 47.9% 34.6% 0%20%40%60%80%100% AWP AMP Medicaid (Min.) Medicaid Net FSS 340B FCP VA Contract Private Sector Pricing

32 The 340B Price 25% – 50% of the average wholesale price Drug Manufacturers Drug Pricing Program 340B The 340B price is actually considered a “ceiling” price Can offer sub- ceiling prices

33 Benefits of PVP to Participants Ease of enrollment and activation of pricing by wholesaler Access to 340B sub-ceiling prices for covered drugs Access to discounts on other value added outpatient products such as vaccines and diabetic supplies Participant communications Support of DSHs and HRSA grantees by funding 340B education and networking opportunities

34 Value of PVP to Participants Savings - average sub-ceiling savings on PVP contract purchases for all participants = 16% in 2007 Diminishes the need for Independent Sub-Ceiling contracts and the resources that they require to manage Provides a “One Stop Shopping” model for outpatient pharmacy services such as 340B split-billing software Access to lowest priced vaccines in the marketplace Access to market reports to help cut formulary costs

35 Cost Savings Analysis Summary Current Annualized Purchases = $538,576 Projected Annualized Purchases if the participant takes advantage of all categories of savings (1:1, generic exchange, and therapeutic exchange = $331,131 Annualized Savings of $205,455 Percent Savings of 38% This analysis was for a FQHC switching from a GPO Model to a 340B plus Prime Vendor Model

36 Supplier Agreements Allendale Pharmaceutical Alliant Pharmaceuticals AMO (pending) Astra-Zeneca Pharmaceuticals Abraxis Pharmaceutical Akorn Inc. ASD (flu vaccine) Bayer Diagnostics Bedford Labs Can-am Care LLC Caraco Pharmaceutical Labs Cytogen Dabur Pharmaceuticals FFF (flu vaccine) G&W Laboratories Geritrex Corporation GlaxoSmithKline Hawthorne Pharmaceuticals, Inc Home Diagnostics Inc. Early Detect Lilly & Company Major Pharmaceuticals Medicure Morton Grove Pharm Inc. NitroMed Inc. Novartis Vaccines Novo Nordisk Okomoto USA Inc. Organon USA, Inc. Paddock Labs RD Plastics Co Inc. Rx Elite Holdings, Inc. Sandoz Pharmaceutical Teva Health Systems Total Pharmacy Supply Tri State Distribution Stratus Pharmaceuticals Trinity Biotech X-Gen Pharmaceuticals Watson Pharma Inc. Wyeth Pharmaceuticals

37 Other Products and Services Vaccines PAP software Split billing software Auditing/overcharge recovery services Repackaging services Prescription vials/labels/printer cartridges Diabetic/TB syringes PBM services OTC diagnostic test kits HIV rapid test kits Pharmacy automation/technology

38 Manufacturers & 340B Pricing Must provide 340B pricing if their drug(s) is covered by Medicaid Cannot sell covered drug above 340B ceiling price to covered entity Are not prohibited from selling outpatient drugs at below 340B ceiling price Prices offered covered entities are exempt from “best price” but not Non-FAMP calculation Are not required to offer sub-ceiling price to other covered entities or Medicaid Can obtain Non-FAMP pricing exemption for sub-ceiling pricing through HRSA’s 340B Prime Vendor Program

39 Manufacturers – 340B Pricing and Medicaid Rebate Programs Medicaid and 340B entities receive prices based on either “Best Price” OR Average Manufacturer Price (AMP) – 15.1% for branded drugs Additional discounts are applied if price increases exceed the Consumer Prime Index (CPI) Generics – AMP minus 11% “Best Price” is not part of generic calculation Pricing - recalculated quarterly Discounts are upfront. No backend rebates

40 PRIME VENDOR CONTRACTING Contract methodology - build upon existing supplier relationships - new supplier contracting - savings vs. revenue - target high dollar/ proprietary drugs - negotiations vs. bidding on select drug classes - value added products and services

41 Positive (+) Negative (- ) Entity pays flat fee per claim Stop-loss function (prevents 3 rd party transmission is loss to entity) Entity does not pay fees on claim reversals Entity pays lowest of U&U, MAC, and 340B Entity pays fees based on % of revenue or drug cost Entity does not keep Medicaid/3 rd party reimbursement Vendor recruits patients to its mail order pharmacy Early cancellation fees Entity not allowed to select wholesaler Entity might end may end up purchasing partial bottles at high rates due to non-replenishment CHOOSING A CONTRACT PHARMACY

42 Part 3 - Summary 1. Understanding PVP 2. Expected gains from joining the PVP 3. Choosing contract pharmacies

43 340B POLICIES

44 Guidelines Regulations (proposed) Patient Definition* Contract Pharmacy* Audits* Dispute Resolution* Outpatient Facilities Duplicate Discounts Manufacturer Civil Monetary Penalties Administrative Dispute Resolution Orphan Drugs 340B Policies

45 340B Guidance and Policy

46 340B Proposed Regulations

47 Drug Delivery Contract Pharmacies

48 340B Usage Considerations

49 340B Program Support

50 Office of Pharmacy Affairs (OPA)

51 340B Program Integrity Resource

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53 Functions of OPA

54 Clinically and Cost-Effective Pharmacy Services

55 MAKING 340B PROGRAM WORK 1. Maintain updated records on OPA website. 2. Choose your contact pharmacy wisely 3. Conduct regular internal audits 4. Devote adequate quality personnel for 340b 5. Develop and update your organization’s 340B standard operating procedures (SOPs) 6. If you deliver the medication – combine it with case management to increase adherence

56 GETTING READY FOR AN AUDIT Have Policies and Procedures - do not create them for the purpose of the audit - detail entire process Be proactive - get information to the auditor when requested in an easily digestible format Audit Now - trace clinically significant encounters monthly - involve social workers, patient financial services, and medical records. Understand state Medicaid managed care - get to know your Medicaid office that processes claims for your entity Stand your ground with C-suite, do not be pressured into risky practices.

57 QUESTIONS

58 MAIN SOURCES USED OPA HRSA APEXUS – 340B PVP


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