1. Pharmaceutical Safety Net Programs Jon Rosmann, Executive Director Jon.rosmann@iowapdc.org

2. IOWA PRESCRIPTION DRUG CORPORATION Safety Net Services Address issues of pharmaceutical access through innovative, non-traditional partnerships. Leverage scarce resources and create value for all stakeholders in our health delivery systems. Short-term, Gap Assistance Focus: Safety Net Patients – High cost users Uninsured and Underinsured Medicare eligible Iowans Individuals with Chronic Behavioral Health Disorders State and Local Offenders 501(c)(3) Established in 2001 to provide pharmaceutical access to Iowans who cannot afford prescription drugs. Serve Iowa’s Safety Net Patients - uninsured or underinsured Iowans with incomes 200 percent of the federal poverty level or below

3. PHARMACEUTICAL SAFETY NET DRUG DONATION REPOSITORY PROGRAM

4. CASE STUDY – PATIENT SAVINGS Rates based on data received from the Iowa Hospital Association in 2011.

5. IOWA DRUG DONATION REPOSITORY Overview: Iowans in need of assistance can receive medications and medical supplies for little or no cost. Donations are received from long-term care dispensing pharmacies, medical facilities, and individuals. The medications and supplies are inspected by a pharmacist, distributed to medical facilities or pharmacies, and dispensed to Iowans in need. Eligibility: Iowans at or below 200% of the federal poverty level who are uninsured or under-insured are eligible to receive donated drugs. Any organization or individual in the country can donate medications in their original sealed container or in tamper-evident packaging. Any pharmacy or medical facility with authorization to dispense per State administrative rules may re-dispense donated medications. Administrative Rules established in 2007 Public Health Department 641-Chapter 109 Regulated by the Iowa Board of Pharmacy

6. PATIENT ELIGIBILITY IPDC’s drug donation repository helps redistribute medications and supplies to safety-net patients who cannot afford their prescriptions Safety-net patients Uninsured or underinsured Iowans with incomes 200 percent of the federal poverty line or below Patients who use high-cost medications but are unable to access them Medicare eligible Iowans State and local offenders Patients with chronic conditions (ex. psychiatric conditions)

7. DONOR ELIGIBILITY Any organization or individual in the country can donate medications Most common donors Long-term care dispensing pharmacies Retail pharmacies Medical facilities Community Mental Health Centers Federally Qualified Health Centers Medication Requirements: Must be in original sealed container or in tamper-evident packaging No controlled substances No expired medications No medications requiring refrigeration

8. DRUG DONATION REPOSITORY PROCESS Receiving & Sorting InspectionInventoryProcessing Filling & Shipping

9. RECEIVING & SORTING Once medications are received from a facility, medications are sorted prior to inspection Drugs not kept: Tablets with no markings Broken/split tablets Controlled substances (CS) Drug/label do not match Short-dated or expired medications Unusable packaging Unused medications are sent to incinerator, CS sent back to facility Drugs kept are sorted by name, strength, and dosage form

10. INSPECTION Once sorted, the pharmacist inspects each card to determine whether the drug is correctly labeled Drug is identified using Facts and Comparisons Pharmacist looks at pill color, shape, imprint codes, and NDC Disposal of cards Cannot use split/broken pills Foil backing of card is ripped, damaged, punctured

11. INVENTORY Following inspection, the number of tablets or capsules on each card is counted and entered into inventory Medication and supply inventory is available online using a username and password An average retail value is assigned to each unit Inventory is then organized and put on the shelf

12. PROCESSING After inventory, all medications are processed in accordance with Iowa Code 135M.4 and Iowa Administrative Rule Chapter 109 All patient information is removed from each card per HIPAA compliance Drug name, strength, quantity, expiration and NDC remain on card Medications and supplies in bottles and all other forms undergo same process

13. FILLING & SHIPPING Licensed as a Wholesale Distributor Medical facilities submit orders to IPDC online or via email and fax (http://www.iowapdc.org/drugdonationrepository.aspx)http://www.iowapdc.org/drugdonationrepository.aspx Approximately 220+ orders are filled each month All orders are filled and shipped via UPS and USPS. In the event of an emergency, an order will be hand-delivered Orders are generally received 1-3 days after being placed

14. DRUG DONATION REPOSITORY – FISCAL YEAR PERFORMANCE YearUnits DonatedDonated ValueUnits ShippedShipped Value FY 2007-2008768,311$786,400.15492,686$475,591.62 FY 2008-2009890,986$1,316,051.73629,573$935,697.87 FY 2009-20101,106,003$1,492,565.20850,559$1,234,449.75 FY 2010-20111,166,447$1,634,592.67931,431$1,430,735.10 FY 2011-20121,075,950$1,924,487.711,095,934$1,877,496.06 FY 2012-20131,230,200$2,593,314.011,147,464$2,477,716.43 FY 2013-20141,395,640$2,605,365.991,105,153$2,319,463.90

15. FISCAL YEAR PERFORMANCE Over 47,000 Iowans have benefitted from donated medications and supplies! Fiscal YearPatients Served 2007780 20083,011 20095,732 20106,237 20117,300 20127,567 20138,222 20148,605

16. DRUG DONATION REPOSITORY – PATIENTS SERVED Since 2008:  Over $13.1M in free medication and supplies  Over 47,000 Iowans served *Totals based on number of patients served quarterly as reported by participating medical facilities and pharmacies.

17. DRUG DONATION REPOSITORY RETURN ON INVESTMENT Iowa’s Drug Donation Repository Program is the largest drug repository in the country. Over 47,000 Iowans have been provided medication and supplies since the program was established in 2007.* Over $13.1 million in free medical supplies and medications has been shipped to participating medical facilities and pharmacies. Over 200 medical facilities and pharmacies receive medications and supplies from the Drug Donation Repository Program. Every $1 used to administer the program yields over $5 in donated medications and supplies. *Total based on number of patients served quarterly as reported by participating medical facilities and pharmacies.

18. A BEHAVIORAL HEALTH FOCUS Although IPDC receives a wide variety of donated medications, there is a deficit in behavioral health medications Anxiolytics: Buspirone, Antipsychotics: Latuda, Seroquel, Zyprexa Antidepressants: Sertraline, Cymbalta, paroxetine Behavioral health medications are in high demand, but because of low inventory, many orders go unfilled Most frequent form of assistance requested from safety-net patients

19. A BEHAVIORAL HEALTH FOCUS Goal: Significantly increase the inventory of behavioral health medications in the drug donation repository program Outreach and education to community mental health centers and behavioral health providers Development of educational materials to support effort Regional meetings with area behavioral health providers Participation in behavioral health stakeholder meetings and conferences Technical assistance to integrate repository into behavioral health facilities

20. BENEFITS OF BECOMING A DONOR Increase medication management Pharmacist will ensure medications are correctly labeled, appropriately packaged, and within the expiration date Healthcare professionals on site will not have to worry about inspecting medications Improve patient safety Patient will get medications that are inspected by a pharmacist Increase ease of dispensing medications to patients All dispensed medications come from a central location No need to keep stock of medications on site

21. SIGNING UP WITH THE PROGRAM Visit www.iowapdc.orgwww.iowapdc.org Click “Drug Donation Repository” Under Program Resources, click “Medical Facility Donor Participation Form” to make donations. Under Program Resources, click “Medical Facility Dispensing Form” to dispense medications. Fax or email completed form to 515-327- 5422 or barbara.horn@iowapdc.org Call 515-327-5405 for assistance or additional information

22. PHARMACEUTICAL SAFETY NET BEHAVIORAL HEALTH MEDICATION VOUCHER PROGRAM

23. A BEHAVIORAL HEALTH CASE STUDY Case Study: A young female with bi-polar disorder was recently released from the Polk County Jail. Prior to release, the individual was advised that she could obtain primary care services and up to 90 days of behavioral health medications at no cost. Three days after being released the individual was seen at Primary Health Care’s outpatient clinic. She was in need of Risperidone and was worried about her ability to effectively participate in an upcoming job interview. The individual was seen immediately and was provided a 30-day supply of medication. She has stabilized her condition and is currently working part-time as a Certified Nurse Assistant. Without access to primary care and behavioral health medications, the individual’s disorder may have gone untreated, resulting in a subsequent non-violent offense. In Polk County the average length of stay for individuals with behavioral health disorders is 36 days at a cost of $2,160. As an alternative, the individual is employed and positively contributing to her community. This savings is greater than the cost of providing 340B behavioral health medications to all eligible released offenders in Polk County for one month.

24. BEHAVIORAL HEALTH VOUCHER PROGRAM Overview: Provides free access to behavioral health medications for safety net patients living in Iowa. The program is designed to help supplement an FQHC’s capacity to serve safety net patients with behavioral health disorders. Provides patient access to critical behavioral health medications until a patient can be transitioned to community mental health center or medical center Prescription assistance for Iowans between 135-200 FPL with high deductible (Bronze) plans purchase on the Exchange Temporary assistance for patients transitioning to Medicaid or state and federal programs

25. BEHAVIORAL HEALTH VOUCHER PROGRAM Patient Eligibility: Any safety net patient living in Iowa with a household income up to 200% of the Federal Poverty Level that is uninsured or underinsured will be able to use this program. Patient must seek care at the local FQHC No limit on the number of prescriptions/vouchers each patient is eligible to use. Valid only for non-controlled medications prescribed to treat a behavioral health illness. Dispensed in 30 day quantities

26. BEHAVIORAL HEALTH VOUCHER PROGRAM FQHC Requirements: The program is available to any of Iowa’s FQHCs with an in-house or contracted 340B pharmacy The FQHC’s 340B pharmacy will be reimbursed at 340B rates for the cost of medications dispensed to eligible safety net patients Reimbursements will be made on a monthly basis. FQHC enrollment in the program will begin on February 1, 2015

27. PHARMACEUTICAL SAFETY NET IPDC PRESCRIPTION DISCOUNT CARD

28. Provides 70-80% cash discount on generic prescriptions and 10-14% cash discount on brand prescriptions Managed by MedOne Health Systems – Division of Hartig Drug, Dubuque Low processing fee to pharmacies - $2.00 - $2.50 range Supported by Iowa Collaborative Safety Net Provider Network

29. PRESCRIPTION DISCOUNT CARD PERFORMANCE 2014 – Average Savings per RX = $58.01 or 69% Savings

30. TO REQUEST MEDICATION DISCOUNT CARDS Contact: Vicky Witt Vicky.witt@iowapdc.org 515-327-5405

31. LOCAL AND STATE CORRECTIONS PROGRAMS PROGRAMS TO ADDRESS HIGH RATES OF RECIDIVISM

32. Iowa DOC: Individuals are given a 30-day supply of all current medications upon release. County Jails: No supply provided at time of release. Does not provide an adequate amount of time for the individual to achieve the following: Locate a medical provider. Be evaluated by a medical provider to receive new RXs. Establish financial and medical assistance. Establish source or continuous medication assistance such as Medicaid, Medicare, Patient Assistance Program, etc. Average waiting period to see a behavioral health provider in Polk County, IA is 80-100 days. In rural shortage areas, waiting period could be greater. Corrections Revolving Door. ADDRESSING HIGH RATES OF RECIDIVISM

33. Provide immediate primary care services and up to 90 days of behavioral health prescription drug coverage for transitioning offenders in Polk County. Upon Release: 1.Individuals directed to Primary Health Care, Inc. to be seen on walk-in or appointment basis. 2.Medical home is established if not present. 3.30-day Behavioral Health RX (w/ two 30-day refills) filled at Primary Health Care 340B Pharmacy. 4.Individual transitioned to Eyerly Ball Community Mental Health Services or Broadlawns Medical Center for long-term services. Program launched March 4, 2013 Polk County Jail Behavioral Health Medication Assistance

34. Preliminary findings: 1) To effectively reduce the rates of recidivism in Polk County, offenders identified as mentally ill should be targeted. 2) A significantly smaller percentage of program participants are returning to jail (recidivating) than non-participants with mental illness who are released from the Polk County Jail. 3) The longer program participants utilize the program the lower the rate of recidivism is among that group. 4) Persons with mental illness in the Polk County Jail who use the program when they reenter society stay out of jail longer than persons with mental illness in the Polk County Jail who do not. Polk County Jail Behavioral Health Medication Assistance

35. IOWA DEPARTMENT OF CORRECTIONS MODEL Provide 90 days of behavioral health prescription drug coverage for transitioning State offenders. Upon Release: 1.Individuals given a 30-day supply of all current medications. 2.Eligible behavioral health prescriptions (30-day RX with one 30-day refill) are transferred directly from DOC Pharmacy to a participating local pharmacy. 3.Extends behavioral health medication benefit period to a full 90 days. Program launched April 1, 2013

36. IOWA DEPARTMENT OF CORRECTIONS MODEL April 1, 2013 – December 15, 2013: 5 of 119 offenders (4.2%) had new charges entered in the Iowa Department of Corrections database (ICON). Preliminary data is promising: Significant number of offenders were medication compliant Mental health adjustment among participating offenders is positive Positive mental health adjustment among participating offenders is strongly associated with success under supervision Recidivism Analysis

37. County Jail Model: Funding Secured for Years 2, 3 and 4 Recidivism Analysis: Post 90 Days from Release Cost Savings Analysis Attorney General’s Office: Multi-county Integration Iowa Department of Corrections: Funding Secured for Years 2, 3 and 4 Recidivism Analysis: Three Year Study Cost Savings Analysis University of Iowa: Multi-state Demonstration Project ADDRESSING HIGH RATES OF RECIDIVISM NEXT STEPS

38. QUESTIONS OR ASSISTANCE Contact: Jon Rosmann, Executive Director Jon.rosmann@iowapdc.org 515-327-5405 Laura Sands, Senior Program Director Laura.sands@iowapdc.org 515-327-5405

39. Telepharmacy January 2015 Iowa CCC Update Kate Gainer, PharmDBrett Barker, PharmD Executive Vice President/CEOV.P. of Operations Iowa Pharmacy Association NuCara Pharmacies

40. Telepharmacy Opportunities Remote Order Verification Remote Dispensing Pharmacist Services (pharmacist as specialist) Long term Care Other

41. Current Landscape – Iowa Iowa Code 155A.33 and IC 147.107 – Requires AMDS for a remote dispensing site to operate without a pharmacist physically present Board Of Pharmacy rules IAC 657 – Chapter 9 (AMDS and Telepharmacy Services) – Definitions, PIC responsibilities, QA, P&P, system/site/process requirements, records, AMDS Board of Pharmacy rules IAC 657 – Chapter 7 (Hospital Pharmacy Practice) – Verification by a remote pharmacist

42. Current Landscape Remote Order Verification – Widely accepted, implemented statewide Telepharmacy as Remote Dispensing – 5 sites approved by Board of Pharmacy under 3 pilot project applications – AMDS requirement seen as barrier by providers Telepharmacy for pharmacist services – Some applications today (eg MTM) – Greater opportunities exist (eg specialist pharmacists) – Need for regulation (?) (BOP or broader telehealth rules?) LTC and other – Opportunities exist, growing

43. 2014 Iowa Telepharmacy Task Force IPA and BOP convened joint task force in early 2014 Consensus recommendations: 1. To pursue legislative changes in 2015 to IC chapters 147 and 155A, amending the current requirement for AMDS in telepharmacy practices. 2. To revise telepharmacy rules in 657 IAC, re-defining telepharmacy services and establishing necessary criteria. 3. To state the purpose and intent of telepharmacy rules, providing that telepharmacy is intended to increase access to pharmacist and pharmacy services, and enhance the care and communication between patients and pharmacists. 4. To create an application form and process for telepharmacy practice sites to be approved by the Board of Pharmacy for each applicant. 5. To recommend continuing education and training for pharmacists and pharmacy technicians providing patient care services through telepharmacy. 6. To maintain rules relating to hospital pharmacy remote order verification in board rules regarding hospital pharmacy practice (657 IAC Chapter 7). 7. To further explore opportunities for telepharmacy applications in other pharmacy practice settings.

44. Next Steps 2015 Legislative Priority for IPA Board of Pharmacy pre-filed language – Amend 147.107 and 155A.33 (add language “when a pharmacist is remotely supervising a certified pharmacy technician practicing in a telepharmacy site approved by the board of pharmacy” Advocate for broad language in statute Subsequent rules by BOP Monitor activity / success in other states

45. NuCara Zearing Telepharmacy Pilot Operated by NuCara Management Group Community telepharmacy remote dispensing site – Located on Main Street in Zearing – Strongly supported by and located adjacent to Story Medical Zearing rural health clinic – City of Zearing purchased and renovated building – Approved by Board of Pharmacy in 2012 – Opened in permanent location July 2013

46. Landscape before NuCara Zearing (pop. 554) located in rural Story County Story Medical Clinic – Zearing operated an Instymed robotic dispensing system – Limited formulary – Operated at a financial loss to the organization – Lack of pharmacist interaction Story Medical Clinic – Zearing employed one full time nurse practitioner Empty building on Main Street Nearest pharmacy was NuCara in Nevada more than 20 miles away Many patients served by mail order services

47. Zearing Overview 1000 Square Feet Open Monday through Friday Staffed with Certified Pharmacy Technicians Provides access to prescriptions, OTC products, immunizations (e.g. shingles), Medication Therapy Management (MTM), home medical equipment, prescription compounding, and respiratory therapy through NuCara network of Story County locations

48. Telepharmacy process Working with Iowa based technology start-up Telepharm to provide telepharmacy system Pharmacist verification, oversight, and counseling provided by NuCara in Nevada Pharmacist receives an array of images alongside patient information for verification All prescriptions dispensed require the patient to visit the counseling station Pharmacist counsels patient through secure audio / visual connection. Goal is to provide same high level of pharmacist – patient interaction and patient centered care as traditional NuCara Pharmacies.

49. Current experience 3 rd Quarter 2014 data: – Daily average of 36 prescriptions dispensed – 2 errors were corrected by the pharmacist in the verification process – To date, zero errors known errors have reached a patient Clinic hired second full time provider in 2014

50. NuCara’s Next Steps Continue to improve process and increase accepted counseling rates Continue to work with Telepharm on technology improvements Expansion of clinical services provided Modest volume growth to reach long-term sustainability Engage with stakeholders and policymakers to continue to evolve unique and innovative care delivery models

51. Next Steps – Hybrid Model NuCara Hybrid Telepharmacy Model Pilot Project in State Center Begins May 2015 Allows for partial on-site pharmacist while providing full-time business hours Tool to grow pharmacist presence in the community Long-term goal to expand pharmacist on-site availability

52. Questions Brett Barker VP of Operations NuCara Management Group bbarker@nucara.com

53. Medication Access

54. Discussion points  What is working for regions?  What challenges do regions face?  How are regions addressing the gap coverage concerns?

55. Contact Information John Swegle, PharmD, BCPS, BCACP Clinical Associate Professor University of Iowa College of Pharmacy Mercy Family Medicine Residency 641-428-7182 sweglej@mercyhealth.com