Over the past several months, PAAS National® has been chiding the MedImpact Clinical Services team about this reimbursement decision and the correct biosimilar terminology and DAW utilization.
As pharmacies may be aware, Semglee® (YFGN) is not a brand, but an interchangeable biosimilar. As such, it does not require a DAW code and requiring a DAW 9 for Semglee® (YFGN) would be incorrect according to NCPDP guidance.
NCPDP description of a DAW 0:
This is the field default value that is appropriately used for prescriptions for single source brand, single biologic, cobranded/co-licensed, generic or interchangeable biosimilar products. DAW 0 is not appropriate for a multi-source branded product with available generic(s) or for a reference product with interchangeable biosimilar(s).
NCPDP description of a DAW 9:
This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic or interchangeable biosimilar substitution is permitted, but the plan’s formulary requests the brand or reference product. This situation can occur when the prescriber writes the prescription using either the brand, reference product, generic or interchangeable biosimilar name and the product is available from multiple sources.
While MedImpact considers Semglee® (YFGN) a brand for reimbursement purposes, it is classified by the FDA as an interchangeable biosimilar. The DAW code definitions (pasted above) from NCPDP state that DAW 0 would be appropriate. Pharmacies should not be negatively impacted financially for failing to use the DAW 9 code. This is not consistent with the industry and is an inappropriate use of DAW 9. DAW 9 states that an interchangeable biosimilar is permitted, but the Plan wants a brand or reference product. Semglee® is not a reference product in this definition (in reference to biologic drugs), Lantus would be.
After months of back and forth, PAAS was just informed by MedImpact that at the end of August, the POS message referencing DAW 9 for Semglee® (YFGN) was removed from all 2023 and 2024 Part D formularies. They are removing all messaging related to DAW 9 for insulin glargine and referencing “Please Dispense Brand for Generic Copay” with no requirement for a DAW 9 reference.
Biosimilar Advancements: Understanding the Latest Updates on Humira® with Cyltezo® and Abrilada™
At the time our April 2023 Newsline article Biosimilar Adoption for Humira® in 2023 was published, eight FDA biosimilars for Humira had been approved, and five more were pending approval. As of June, three additional biosimilars are in the market and three are still pending FDA approval. In October, Abrilada™ was granted FDA approval as an interchangeable biosimilar. Now, Abrilada™ along with Cyltezo® are the only two biosimilars that are interchangeable with Humira® without the intervention of the prescribing physician, depending on state pharmacy laws. The chart below
FDA Approved
Ingelheim
Pending Approval
PAAS Tips:
Audit Target: Linzess® Prescriptions
PAAS National® analysts have noticed an increase in audits targeting Linzess®. Linzess® is a focus of PBM audits not only because of the high cost, but also the manufacturer dispensing requirements. Not following FDA approved guidelines when dispensing this medication will likely result in full recoupment.
Allergan, the manufacturer of Linzess®, has not provided evidence to the FDA for the safety and efficacy of this medication outside the original container. PAAS has reached out to Allergan looking for additional stability information to appeal audit recoupments; however, they have only confirmed the current requirements. Pharmacies can visit DailyMed for medication information, including How Supplied/Storage and Handling requirements under Section 16 of the drug label information.
While Linzess® is not the only medication required to be dispensed in the original container, it is frequently prescribed for patients in long-term care and for those who have medications in compliance packaging. Unfortunately, there are no exceptions for these situations, and the original container must be given.
Billing Linzess® for quantities other than increments of 30 capsules will make the claim an easy audit target for any PBM to identify the medication was not dispensed in the original container. This is true for many other medications with specific dispensing requirements as well. PAAS has created our Dispense in Original Container Chart, based on the medications we frequently see audited. You can find this and many other Day Supply Charts and Proactive Tips available on the PAAS Member Portal.
PAAS Tips:
NEW PAAS Resource – Printable Signature Logbook
Many pharmacies have made the switch to electronic signature log capture, but paper signature logs have not gone away. Some pharmacies choose to maintain all signature logs through a paper log but those with an electronic signature capture system may still find themselves with the need for a paper signature log. Common reasons for paper logs include:
To aid our member pharmacies in having appropriate documentation on their paper signature logs, PAAS National® is now offering a free printable signature book. To access this new tool, log onto the PAAS Portal, visit the Forms tab then download and the 400+ page Signature Logbook. Send the pdf to your local print shop and have them create a bound book. The form includes a place to document the date filled, acceptance or refusal of a consultation, prescription number, third party program, date picked up, signature, and more!
PAAS Tips:
OTC COVID-19 Test Prescribing Authority
Some pharmacies are wondering if they are allowed to continue prescribing OTC COVID-19 tests. The eleventh amendment to the Public Readiness and Emergency Preparedness Act (PREP Act) was issued on May 12, 2023 and extends PREP Act coverage through December 31, 2024 to allow licensed pharmacists to order and administer COVID-19 countermeasures including COVID-19 vaccines, seasonal influenza vaccines, and COVID-19 tests.
Coverage for OTC COVID-19 tests varies by payer. See summary below:
PAAS Tips:
PAAS Battles MedImpact for DAW 0 Reimbursement on Semglee®
MedImpact sent a memo to network pharmacies dated May 22, 2023, with the subject line Semglee-YFGN (Preferred U-100 Long Acting Insulin). For their participating Medicare Part D plans, MedImpact requested pharmacies to dispense Semglee® (YFGN) at the brand reimbursement. Other insulin glargine products were considered non-formulary with a claim rejection response. The memo goes on to indicate that this ‘brand’ claim must be submitted with a DAW of 9 to get correctly reimbursed, meaning pharmacies that use a default DAW 0 could be incorrectly paid!
Over the past several months, PAAS National® has been chiding the MedImpact Clinical Services team about this reimbursement decision and the correct biosimilar terminology and DAW utilization.
As pharmacies may be aware, Semglee® (YFGN) is not a brand, but an interchangeable biosimilar. As such, it does not require a DAW code and requiring a DAW 9 for Semglee® (YFGN) would be incorrect according to NCPDP guidance.
NCPDP description of a DAW 0:
This is the field default value that is appropriately used for prescriptions for single source brand, single biologic, cobranded/co-licensed, generic or interchangeable biosimilar products. DAW 0 is not appropriate for a multi-source branded product with available generic(s) or for a reference product with interchangeable biosimilar(s).
NCPDP description of a DAW 9:
This value is used when the prescriber has indicated, in a manner specified by prevailing law, that generic or interchangeable biosimilar substitution is permitted, but the plan’s formulary requests the brand or reference product. This situation can occur when the prescriber writes the prescription using either the brand, reference product, generic or interchangeable biosimilar name and the product is available from multiple sources.
While MedImpact considers Semglee® (YFGN) a brand for reimbursement purposes, it is classified by the FDA as an interchangeable biosimilar. The DAW code definitions (pasted above) from NCPDP state that DAW 0 would be appropriate. Pharmacies should not be negatively impacted financially for failing to use the DAW 9 code. This is not consistent with the industry and is an inappropriate use of DAW 9. DAW 9 states that an interchangeable biosimilar is permitted, but the Plan wants a brand or reference product. Semglee® is not a reference product in this definition (in reference to biologic drugs), Lantus would be.
After months of back and forth, PAAS was just informed by MedImpact that at the end of August, the POS message referencing DAW 9 for Semglee® (YFGN) was removed from all 2023 and 2024 Part D formularies. They are removing all messaging related to DAW 9 for insulin glargine and referencing “Please Dispense Brand for Generic Copay” with no requirement for a DAW 9 reference.
Your membership in PAAS helps us continue to advocate and fight for fair treatment of independent pharmacies.
Use As Directed – What is Your Attack Plan?
The top audit discrepancy year after year is invalid days’ supply or refill too soon – which are essentially the same issue. Submitting prescription claims with an accurate days’ supply is often the responsibility of a pharmacy technician doing data entry, while pharmacists are focused on clinical accuracy and may not be paying attention to this “clerical” issue. It is important that all pharmacy staff members (technicians and pharmacists) understand the audit implications of submitting an incorrect days’ supply and how each staff member can contribute to success. With that in mind, the pharmacy team can develop an attack plan to be both accurate and consistent.
First, understand …
Second, staff must be trained how to perform the mathematical calculations. How would your staff estimate the days’ supply for an insulin or topical cream prescription with a sig of “use as directed”? If each staff member gives you a different answer, then you have an audit problem waiting to happen. In general, days’ supply is simply the total quantity dispensed divided by the daily (or weekly, monthly) dose. Data entry staff should perform the calculations and document, while dispensing technicians and/or verifying pharmacists can double check those calculations for accuracy.
Third, you must have a plan for how to address certain dosage forms where the basic calculation does not come so easily. Common examples include topical creams, vaginal creams, insulin, diabetic test strips, bowel prep kits, migraine meds, starter kits and pancreatic enzymes.
PBM auditors will expect that any clarifications regarding instructions for use end up on the dispensing label to communicate instructions to patients – see this month’s article Auditor’s Latest Trick for Flagging “Misfilled” Prescriptions.
PAAS Tips:
$32 Million Kickback Scheme Involving Medicare and TRICARE
According to an August 18, 2023 press release from the U.S. Attorney’s Office, District of New Jersey, a former president of a pharmacy business pleaded guilty to a scheme that violated the Federal Anti-Kickback statute. For a little over 3 years, this individual engaged in fraudulent activity by paying marketing companies to direct prescriptions for expensive medications with high reimbursement to his pharmacies. The marketing companies would identify Medicare and TRICARE beneficiaries and convince them over a recorded phone call to try expensive creams and migraine medications. Then they forwarded these recorded phone calls with a pre-printed prescription pad for the medications with high margins to telemedicine companies. For every beneficiary referred for a prescription, the marketing company would provide a kickback and the telemedicine company would pay the doctors to approve the prescriptions. These prescriptions were then filled at the pharmacies in which they had a kickback agreement. The pharmacies received payment and sent part of each reimbursement to the marketing companies as a kickback. This scheme caused a loss of over $32 million dollars billed to Medicare, TRICARE, and other federal health benefit programs. This violation of the Anti-Kickback Statute has a potential penalty of five years in prison and a maximum fine of $250,000, or twice the gross gain or loss that occurred, whichever is greatest.
Ensure your pharmacy has a robust Fraud, Waste, and Abuse Compliance Program in place for employees to understand the repercussions of violating laws and regulations such as the False Claims Act and the Anti-Kickback laws. Contact PAAS National® for more information on our comprehensive program that is easy to set-up, web based and customized for your pharmacy.
PAAS National® Announces USP 800 Compliance Program
PAAS National® is excited to announce the USP 800 Compliance Program for community pharmacies. Developed by community pharmacists, PAAS brings you a community pharmacy tailored approach to USP 800 operational needs.
“Empowering community pharmacies with best-in-class, web-based programs to ensure employee safety and maintain pharmaceutical standards are at the forefront of our priorities. Compliance with USP 800 reinforces our commitment to community pharmacies in reducing their liability while improving patient safety and upholding the highest industry standards in handling hazardous drugs,” stated Carmen Fusselman, Vice President at PAAS National®. “PAAS will provide you with the information necessary to implement a fully functional USP 800 Compliance Program with the least necessary interruption to your day-to-day business.”
The PAAS USP 800 Compliance Program will reduce a pharmacy’s exposure to hazardous drugs through physical processes, written policies and training to ensure compliance with USP 800.
If you would like more information about PAAS USP 800 Compliance Program, please visit paasnational.com/usp800 or contact PAAS National® at (608) 873-1342 or info@paasnational.com.
Breyna™ – The First FDA Approved Symbicort® Generic With a 0.1 Gram Problem
Breyna™, like Symbicort® is approved as a maintenance therapy for people with COPD and for asthma patients ages 6 and older. For Breyna™ to become a regular generic, the manufacturer (Viatris) had to submit an Abbreviated New Drug Application (ANDA) to the FDA. Viatris had to prove that Breyna™ is comparable to Symbicort® in dosage form, strength, route, quality, performance characteristics, and intended use. Below is a chart comparing Symbicort®, its authorized generic and the new “regular” generic Breyna™ (also known as an ANDA generic).
Size (gm)
PAAS Tips:
Signature Required – Proving Patient Receipt
The Public Health Emergency for COVID-19 ended on May 11, 2023, and PBMs notified pharmacies that they would once again be requiring signatures for proof of patient receipt of medications. Since then, PAAS National® analysts have taken questions about what format signatures logs should take. The following tips should help your pharmacy stay compliant.
PAAS Tips: