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Partial Fill Programs for Oral Oncolytics

Peter L. Salgo, MD; Steven L. D’Amato, RPh, BSPharm; Noa Biran, MD; Arturo Loaiza-Bonilla, MD, MSEd, FACP; and Carl T. Henningson, MD, debate the advantages and disadvantages of using partial fill dispensing of oral oncolytics.
Published Online: Feb 07,2018

Peter L. Salgo, MD: I heard that there was this 90-day supply that suddenly is appearing because you’re taking half the dose? On the other side, there’s a phrase that’s out there—“partial fill programs.” What are partial fill programs?

Steven L. D’Amato, RPh, BSPharm: Partial fill, I think, is a great idea if you’re allowed to do it. We can’t do it for all medications or for all patients. Sometimes, the payer and the benefit plan drive some of that. But, from a point-of-care dispensing perspective, if you have a drug that you know is going to require a dose adjustment within the first week or 2 in most of your patients—we see that with some of the newer oral agents for breast cancer and so forth)—you don’t dispense 30 days of that product to the patient. We might dispense 7 to 10 days of product, because we’re going to bring the patient back in to see us in 7 days. We’re going to assess the toxicity. If they’re fine, we may continue that for another period of time and adjust as necessary. That decreases waste and cost in the long run.

Noa Biran, MD: Well, it also decreases convenience.

Steven L. D’Amato, RPh, BSPharm: It does.

Noa Biran, MD: We have ways of dealing with our dose reductions, but the problem is, let’s say we need to dose reduce—we’ll switch it to every other day, but at least we’ll have the drugs that we have. Now, you give 10 days of a drug. They need to be on it for 21 days. You have another delay. You have another treatment interruption.

Steven L. D’Amato, RPh, BSPharm: It may not be with Revlimid (lenalidomide).

Noa Biran, MD: No, it’s based on insurance. Insurance determines how many drugs your patient will get—if they’ll get 7 days, 14 days, or the whole month’s supply. I think that they need to leave it to the physician to deal with dose reductions and not take it upon themselves to give you half a month’s supply.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Again, flexibility. If we were the ones making the prescription, we should get the call from the specialty pharmacy saying, “This patient may be labeled for a partial refill. Will you feel comfortable doing that? Yes or no?” Then, we’ll say, “Yes, sure.” We say this because we will probably dose escalate next week. Then, they have the next one ready for the patient. So, if that’s done in that frame, I’m 100% into that. But then again, I agree with you—that’s not the way it’s working right now.

Peter L. Salgo, MD: What you read is that these partial fill programs decrease hospitalizations. They decrease cost.

Noa Biran, MD: Who is saying this?

Peter L. Salgo, MD: I’ve got it here.

Noa Biran, MD: I’m just curious: How are they decreasing hospitalizations by supplying 7 pills instead of 21 pills?

Peter L. Salgo, MD: Is it decreasing overdoses? Is that what’s going on?

Arturo Loaiza-Bonilla, MD, MSEd, FACP: I can go from the article standpoint. I’ve seen it.

Peter L. Salgo, MD: I was being facetious. Yes, it’s here, but it’s here for a reason.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: So, in theory, the rationale for partial refills was because we require those doses to be escalated up. If we give the full dose, the patient may have side effects. We were having the patient come in earlier to see us. Then again, I see that the system doesn’t work that way. We’re not doing in-house dispensing, so we have a third party trying to give us drugs when we really need them right away.

Noa Biran, MD: Right. We need these drugs right away. When patients are in renal failure with newly diagnosed myeloma, every day that they are not taking a pill or the chemotherapy can result in irreversible kidney damage. These patients need their drugs.

Steven L. D’Amato, RPh, BSPharm: To be clear, I was talking about in-office dispensing and the partial fill.

Noa Biran, MD: That’s different.

Peter L. Salgo, MD: I don’t mean to say they’re limiting the amount of drugs for financial reasons; I’m saying that there is a compliance reason to partial fill.

Noa Biran, MD: Oh, OK.

Peter L. Salgo, MD: Because it brings patients back, yes?

Noa Biran, MD: Fair enough.

Steven L. D’Amato, RPh, BSPharm: From my perspective, from in-office, yes.

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Yes—and it decreases waste.

Carl T. Henningson, MD: What some drug companies do is, if you are having a side effect with the full dose, you send the drug back to the company and they’ll actually give you the lower dose without an additional co-pay.

Noa Biran, MD: Oh, that’s great.

Peter L. Salgo, MD: Really?

Carl T. Henningson, MD: Yes. Not a lot of companies do that, but some do.

Peter L. Salgo, MD: Do you think that these partial fill programs with an in-office dispensary reduce cost? Does the cost stay the same, or does it go up? What happens?
Steven L. D’Amato, RPh, BSPharm: From an in-office dispensing perspective, I would say that the cost goes down.

Peter L. Salgo, MD: Why?

Steven L. D’Amato, RPh, BSPharm: Because there is less waste.

Peter L. Salgo, MD: Oh, it’s waste?

Steven L. D’Amato, RPh, BSPharm: Yes.

Peter L. Salgo, MD: So, if you’ve got 30 days, and they don’t take the right number of pills, there’s waste going on? Whereas if they have to come back, you can count the pills up?

Steven L. D’Amato, RPh, BSPharm: There’s less waste with a close monitoring program.

Noa Biran, MD: Yes.

Peter L. Salgo, MD: So, what are the best practices for increasing adherence with these oral oncolytics, in terms of managed care and providers?

Arturo Loaiza-Bonilla, MD, MSEd, FACP: Well, I think the key is communication with the patient and having utilization of the resources that the specialty pharmacies are supposed to provide us with, as physicians. They get well compensated by manufacturers and hub services, so we should actually use 100% of those resources of monitoring, utilization process, and reimbursement. They shouldn’t be a burden to us. That’s the best way we can utilize their system as it is right now. I don’t want to change the whole thing, because it’s not going to happen. The big specialty pharmacies are there to stay. They’re just going to become even bigger by the day. But we should, as providers, have access to these people and have all of this information available. And at the same time, we should have the flexibility, when we’re doing the in-house dispensing, to have that option from any manufacturer.