Financial impact of integrated specialty pharmacy efforts to avoid oral anticancer medication waste

Abstract

BACKGROUND:

The growing number of oral anticancer medications represents a significant portion of pharmacy spending and can be costly for patients. Patients taking oral anticancer medications may experience frequent treatment changes following necessary safety and effectiveness monitoring, often resulting in medication waste. Strategies to avoid medication waste could alleviate the financial burden of these costly therapies on the payer and the patient.

OBJECTIVE:

To evaluate the impact on waste and cost avoidance of reviewing the amount of medication patients have on hand and the presence of upcoming follow-up (ie, provider visit, laboratory testing, or imaging) before requesting a prescription refill renewal for patients taking oral anticancer medications through an integrated health system specialty pharmacy.

METHODS:

We performed a retrospective review of patients filling oral anticancer medications prescribed by a Vanderbilt University Medical Center provider and dispensed by Vanderbilt Specialty Pharmacy between January 1, 2020, and December 31, 2020. Specialty pharmacists received a system-generated refill renewal request for oral anticancer medications when the final prescription refill was dispensed, prompting the pharmacist to review the patient’s medical record for continued therapy appropriateness and to request a new prescription. If the patient had a sufficient supply on hand to last until an upcoming follow-up (ie, provider visit, imaging, or laboratory assessment), the pharmacist postponed the renewal until after the scheduled follow-up. Patients were included in the analysis if the refill renewal request was postponed after review of the amount of medication on hand and the presence of an upcoming follow-up. Medication outcomes (ie, continued, dose changed, held, medication changed to a different oral anticancer medication, or discontinued) resulting from the follow-up were collected. Cost avoidance in US dollars was assigned based on the outcome of follow-up by calculating the price per unit times the number of units that would have been unused or in excess of what was needed if the medication had been dispensed before the scheduled follow-up. The average wholesale price minus 20% (AWP-20%) and wholesale acquisition cost (WAC) were used to report a range of costs avoided over 12 months.

RESULTS:

The total cost avoidance over 12 months associated with postponing refill renewal requests in a large academic health system with an integrated specialty pharmacy ranged from $549,187.03 using WAC pricing to $751,994.99 using AWP-20% pricing, with a median cost avoidance per fill of $366.04 (WAC) to $1,931.18 (AWP-20%). Refill renewal requests were postponed in 159 instances for 135 unique patients. After follow-up, medications were continued unchanged in only 2% of postponed renewals, 56% of follow-ups resulted in medication discontinuations, 32% in dose changes, 5% in medication changes, and 5% in medication holds.

CONCLUSIONS:

Integrated health system specialty pharmacist postponement of refill requests after review of the amount of medication on hand and upcoming follow-up proved effective in avoiding waste and unnecessary medication costs in patients treated with oral anticancer medications at a large academic health system.

Plain language summary

Medicines that treat cancer can be expensive. Patients often change or stop taking medicines because the medicine is not working for them or they have side effects. This can lead to patients having too much medicine on hand that cannot be used. Pharmacists can prevent waste and save money by not refilling unneeded medicines when a patient is about to see their doctor, who may change their therapy.

Implications for managed care pharmacy

Pharmacist review and postponement of refill renewal requests for oral anticancer prescriptions is a novel method to reduce medication and financial waste. This process resulted in cost avoidance of more than half a million dollars over 12 months, benefiting patients and insurers that would have paid for these medications. This method of waste avoidance is replicable at other health centers and presents an opportunity for insurers to work with health system specialty pharmacies to improve care and reduce waste.

Oral anticancer medication use has increased in recent years, becoming a frequent treatment route for cancer therapy.¹ Novel oral therapies and expanded indications gain approval each year, providing more options to patients for self-administered oncology treatment.² Between 2011 and 2018, the US Food and Drug Administration approved 44 individual oral oncolytic agents, and current estimates show that oral anticancer drugs comprise up to 35% of all oncologic treatments in the pipeline.^3,4 Along with increased use of oral chemotherapy comes worries of increased financial burden to both patients and health systems.^5,6 Financial toxicity occurs when patients experience distress and have a diminished quality of life because of the burden of cancer care.⁷ The mean monthly point of sales cost per oral anticancer agent was nearly $14,000 for Medicare Part D customers in 2018.⁸ Because of the complexity of cancer regimens, patients receiving oral anticancer therapy require frequent follow-up with scans, laboratory tests, and clinic visits for health care providers to monitor efficacy, disease response, and drug safety.⁹ Changes in treatment regimens that occur during prescription overlap (ie, refilling a prescription before the current supply is exhausted) can result in patients accumulating unused medication, leading to waste and financial toxicity.^9,10

Novel strategies are needed to minimize medication and financial waste resulting from unused oral anticancer agents.⁹ Quantitative methods, such as split-fill and repository programs, have been successful in reducing waste and cost to the health care system and to patients. Split-fill programs reduce dispensing of oral anticancer agents to 14-to-16-day supplies in an attempt to prevent waste if a treatment modification were to occur before the end of a month supply.^11,12 In a study by Staskon et al, a split-fill program model was shown to have a per member per month savings of $1,012.¹² However, split-fill programs may not be suitable if patient copays cannot be split.⁹ Additionally, pharmacies have implemented drug repository programs to redistribute unused oral anticancer agents in certain states to reduce waste, although these programs may be limited by state regulations and the cost of increased pharmacy workload.^9,13 A medically integrated specialty pharmacy was able to offset $55,000 of $250,000 (average wholesale price [AWP]) accumulated oral chemotherapy waste over 3 years using a state repository program.⁹ These select opportunities for waste avoidance have shown success; however, given the high cost of oral anticancer medications, more research is needed to identify additional effective methods to minimize prescription overlap and reduce waste through clinical pharmacist intervention.¹⁰

Patients taking oral anticancer medications may accumulate an oversupply of medication because of missed doses or dose changes that occur because of side effects or response to therapy.¹⁴ A study by Li et al found that 31% of patients with a dose change experienced medication overlap averaging 11 days of medication waste estimated at $5,471 (wholesale acquisition cost [WAC]) per patient.¹⁵ When a patient fills their last prescription of a medication, the pharmacy typically sends the prescriber a request for a new prescription. The prescriber or their representative then determines if a refill renewal will be authorized.¹⁶ Often, the prescriber has limited visibility into the prescription fill data and is unaware if the patient may have an oversupply of medication on hand. Similarly, the pharmacy has limited access to medical data regarding upcoming appointments or clinical follow-up. This lack of data transparency can lead to medication waste if the prescriber authorizes a refill but the therapy is changed at an upcoming follow-up appointment.

As integrated members of the oncology care team, health system specialty pharmacists have a unique opportunity to connect prescription refill information and electronic health record (EHR) data to offer clinical and financial interventions that improve patient care and reduce waste. Health system specialty pharmacists have demonstrated several benefits of integrating into outpatient oncology clinics, including increasing oral anticancer medication adherence,¹⁷ improving patient understanding of new oral anticancer treatments,¹⁰ increasing symptom collection and risk stratification in patients with myelofibrosis,¹⁸ reducing patient costs,¹⁹ decreasing time to medication receipt,² and achieving high patient satisfaction.²⁰ However, the potential impact of health system specialty pharmacists on avoiding medication waste has not yet been explored. Therefore, this study’s objective was to describe and evaluate the efforts of an integrated health system specialty pharmacy (IHSSP) to avoid medication waste by implementing a proactive refill renewal review program for oral anticancer medications.

Methods

SETTING

This study was conducted in a tertiary academic medical center cancer clinic that provides comprehensive, interdisciplinary care and a full range of cancer treatments for patients. As part of the interdisciplinary team, IHSSP specialty pharmacists and pharmacy technicians managed specialty medications for the oncology and hematology outpatient clinics, filling more than 1,000 prescriptions for more than 700 patients monthly. Specialty pharmacists were physically integrated into the clinic and practice alongside medical and nursing clinic staff. IHSSP staff assisted patients in accessing specialty medications by completing insurance authorizations and navigating financial support as needed. Once treatment was approved, specialty pharmacists provided medication counseling and monitored patients while they received therapy, including mitigating adverse effects, supporting medication adherence, and evaluating response to treatment. When patients receiving treatment filled their last refill of a medication, specialty pharmacists requested a new prescription from the prescribing provider through the EHR (refill renewals) to ensure patients did not experience gaps in therapy.

In 2020, a formal process was implemented for specialty pharmacists to review all refill renewals including assessing the amount of medication the patient should have on hand and any upcoming follow-up before sending requests to the prescriber’s office. An electronic refill renewal request was generated by the specialty pharmacy software when a patient’s final prescription refill was dispensed and sent to the pharmacists. Pharmacists reviewed the requests 8 to 10 days before the patient was anticipated to run out of (exhaust) their current medication supply. The specialty pharmacists evaluated each request to determine the appropriateness of continued therapy, reviewing the EHR for an upcoming clinic appointment, imaging, or laboratory monitoring (henceforth referred to as follow-up) that may have resulted in a change to the treatment regimen. If the patient had an upcoming follow-up before the exhaust date, the pharmacist reviewed the prescription claims data from the prior dispensing to determine if the patient had a sufficient supply of medication on hand. Patients were contacted if the estimated quantity on hand was unclear to determine if they had a sufficient supply to last until after their next follow-up. If the patient was at risk for missing doses before the follow-up or because of a missed follow-up, the pharmacist sent the refill renewal request to the provider, and the prescription was filled. If the patient had an adequate supply of medication on hand to last until after the follow-up date, the refill renewal request was postponed. The specialty pharmacist reviewed the EHR on or after the follow-up date to assess the outcome of the follow-up and whether the treatment regimen was renewed, discontinued, held, or changed.

Before this formal process, refill renewal requests were generated in the same manner and the specialty pharmacist would forward the request to the prescriber’s office. The specialty pharmacist could decline to forward a request if they knew the patient was not continuing therapy. However, there was not a standard process for determining when to decline or defer requesting a refill renewal, and the clinic staff was relied on to assess and accept or decline requests. In the year before implementation, 97.6% of all refill renewal requests sent by the oncology specialty pharmacy resulted in a prescription being issued for the patient.

STUDY DESIGN AND DATA

This was a single-center, retrospective review of patients filling oral anticancer medications prescribed by a Vanderbilt University Medical Center provider and dispensed by Vanderbilt Specialty Pharmacy between January 1, 2020, and December 31, 2020. Patients were included if they had a refill renewal request for an oral anticancer medication postponed after pharmacist review because of an upcoming follow-up. Patients were excluded if they did not attend the scheduled follow-up, care was transferred to another facility, or death occurred between refill renewal postponement and the follow-up appointment. This study was approved by the center’s institutional review board.

The primary outcome was the total cost avoidance associated with postponing refill renewal requests until after an upcoming follow-up. As a secondary outcome, the cost avoidance was reported by each outcome of follow-up: medication not changed, medication discontinued, medication changed, dose changed, or medication held. If the follow-up resulted in the medication being held, pharmacists reviewed the outcome of the medication being held (medication restarted unchanged, medication discontinued, medication changed, or dose changed). Outcomes of the cost avoidance analysis by medication included the median cost per prescription fill avoided, total cost avoidance, and median cost per prescription fill avoided by volume of fills. Additional secondary outcomes included the reasons for refill renewal postponements, outcome of the follow-up, and reasons for therapy changes.

The IHSSP refill renewal request process, the outcome of follow-up, associated waste avoidance, and the definitions of the different types of waste are depicted in Figure 1. Data were managed using Research Electronic Data Capture hosted at Vanderbilt University.^21,22 Patient clinical data were collected from the EHR and Specialty Pharmacy management software. Medication fill data were collected from the pharmacy dispensing system.

FIGURE 1.

Overview of Study Design

COST AND WASTE AVOIDANCE CALCULATIONS

All refill renewal requests with a follow-up outcome other than medication not changed were designated as medication waste avoidance. If a patient had multiple prescriptions postponed for different strengths of the same medication (ie, a multistrength regimen), the regimen was counted as a single instance of medication waste avoidance. Postponed refill renewal requests that were held after follow-up were included in the cost avoidance analysis based on the final outcome (medication restarted unchanged, medication discontinued, medication changed, or dose changed). Postponed refill renewal requests that resulted in the medication being changed or discontinued after follow-up were designated as an instance of cost avoidance. Dose changes were designated as an instance of cost avoidance only if the dose change would have resulted in excess medication. If part of the current medication could have been used to accommodate the new dose, only the amount that could not be used or would have been in excess was assigned a quantity for the cost avoidance analysis. The amount that could have been used for the new dose was excluded from the analysis. For example, if a renewal request was postponed for a treatment regimen of temozolomide 100 mg, quantity 15, plus temozolomide 5 mg, quantity 10, and the outcome of the follow-up was a dose change to temozolomide 100 mg, quantity 10, then this would be considered as one instance of medication waste avoidance because it was a multistrength regimen. The cost avoidance analysis would include 2 instances of cost avoidance, temozolomide 100 mg, quantity 5, and temozolomide 5 mg, quantity 10, because those would be the quantities wasted or in excess of what was needed after the change. A range of costs avoided were calculated in US dollars by multiplying AWP minus 20% (AWP-20%), and WAC per unit (ie, tablets or capsules) times the number of excess units that would have been dispensed. These pricing models were chosen to estimate cost avoided by the pharmacy (WAC) and the payer (AWP-20%).

STATISTICAL ANALYSIS

Descriptive statistics were used to summarize the data. Continuous variables were reported as median and interquartile ranges, whereas categorical variables were reported as frequencies and percentages.

Results

Specialty pharmacists reviewed 2,304 refill renewal requests; 204 were postponed (Figure 2). After applying the exclusion criteria, 12 failed to complete the follow-up, 5 transferred care between postponement and follow-up, and 3 died before follow-up, leaving 184 postponed refill renewal requests. The cost avoidance analysis included 166 postponed refill renewal requests; 18 were excluded because the medication was continued with no change or could have been used to accommodate a dose change. Fewer postponed refill renewal requests (n = 159) were included in the medication waste avoidance analysis because 25 were part of a multistrength regimen and not counted toward medication waste. There were 135 unique patients represented. Patients were 58% female and 85% White with a median age of 65 years (Table 1).

FIGURE 2.

Attrition Table

TABLE 1.

Patient Characteristics

Characteristics	Data
Patient characteristics (N = 135)
Age, median (IQR), years	65 (51-73)
Sex, n (%)
Female	78 (58)
Male	57 (42)
Ethnic group, n (%)
Not Hispanic, Latino/a, or Spanish origin	122 (90)
Other Hispanic, Latino/a, or Spanish origin	2 (1)
Unknown	11 (8)
Race, n (%)
White	115 (85)
Black or African American	6 (4)
Other	7 (5)
Unknown	7 (5)
Instances of medication wastea (N = 159), n (%)
Reason for medication postponement
Clinic visit	152 (96)
Laboratory tests needed	6 (4)
Imaging needed	1 (1)
Outcome of follow-up
No change to postponed medication	3 (2)
Medication change	8 (5)
Dosing change	51 (32)
Medication discontinued	89 (56)
Medication held	8 (5)

^a Patients can have more than 1 instance of medication waste.

The total cost avoidance associated with postponing refill renewal requests until after a scheduled follow-up ranged from $549,187.03 using WAC pricing to $751,994.99 using AWP-20% with the median cost per prescription fill avoided ranging from $366.04 (WAC) to $1,931.18 (AWP-20%). Medication discontinuations contributed between $257,482.69 (WAC) and $369,839.71 (AWP-20%) to the total cost avoidance, whereas medication changes and dose changes resulted in less cost avoidance, $85,342.28 (WAC) to $87,533.54 (AWP-20%) and $145,659.62 (WAC) to $237,925.22 (AWP-20%), respectively. Costs avoided from medications held differed from the other categories because AWP-20% was the lower range instead of WAC ($56,696.52 [AWP-20%] and $60,702.45 [WAC]). The median cost per prescription fill avoided for each outcome (Figure 3) were as follows: medication discontinued was $335.86 (WAC) to $1,454.11 (AWP-20%) (n = 98); medication changed was $9,295.58 (WAC) to $9,233.28 (AWP-20%) (n = 10); and dose changed was $468.73 (WAC) to $2,256.07 (AWP-20%) (n = 58). The median cost per prescription fill avoided for held medications were included in the category of ultimate outcome.

FIGURE 3.

Cost per Prescription Fill Avoided by Outcome of Follow-Up Using AWP-20% and WAC

Further analysis using AWP-20% was performed to determine the cost avoidance by medication, evaluating total cost avoidance, median cost per prescription fill avoided, and median cost per prescription fill avoided by fill volume (Table 2). Temozolomide contributed the most toward total cost avoidance ($187,426.86) and cost per prescription fill avoided by volume ($2,302.08 per fill [n = 62]). Tucatinib ($20,712.96), regorafenib ($18,879.17), ribociclib ($18,864.31), alpelisib ($17,973.31), and ruxolitinib ($14,953.92) provided the highest median cost per prescription fill avoided. Temozolomide, palbociclib, everolimus, and trifluridine- tipiracil were all among the top 5 medications that contributed most toward total cost avoidance and median cost per prescription fill avoided by volume. A complete list of medications and cost avoidance can be found in the Supplementary Materials ^{(215.4KB, pdf)} (available in online article).

TABLE 2.

Medications Contributing Most to Cost Avoidance Using Average Wholesale Price Minus 20%

	Fills avoided, n	Cost
Median cost per prescription fill avoided ranked by cost avoided
Tucatinib	1	$20,712.96
Regorafenib	2	$18,879.17
Ribociclib	1	$18,864.31
Alpelisib	1	$17,973.31
Ruxolitinib	1	$14,953.92
Total cost avoidance ranked by cost avoided
Temozolomide	62	$187,426.86
Palbociclib	10	$125,204.80
Everolimus	5	$62,940.53
Trifluridine-tipiracil	5	$55,349.12
Olaparib	4	$50,003.52
Median cost per prescription fill avoided by volume ranked by volume of prescription fills avoided
Temozolomide	62	$2,302.08
Capecitabine	35	$788.93
Lomustine	17	$964.34
Palbociclib	10	$13,414.80
Everolimus	5	$13,564.54
Trifluridine-tipiracil	5	$9,625.92

Of the 159 refill renewal requests included in the medication waste analysis, most were postponed because of an upcoming clinic appointment (96%, n = 152). Patient follow-ups were scheduled a median of 8 (interquartile range = 0-18) days after the pharmacist postponed the refill renewal request. After clinical follow-up, medication was continued with no change in 2% (n = 3) of postponed renewals. Medication was discontinued in 56% (n = 89), the dose was changed in 32% (n = 51), the medication was changed in 5% (n = 8), and the medication was held in 5% (n = 8). Of the medications held, 2 (25%) restarted medications with no change, 2 (25%) had a dose change, and 4 (50%) discontinued medication after the hold. The reasons for the outcome of follow-up are illustrated in the Supplementary Materials ^{(215.4KB, pdf)} . Suboptimal response (eg, disease progression) was the primary reason for medication discontinuations (49%, n = 44) and medication changes (88%, n = 7). The leading causes of dose changes were side effects (53%, n = 27) and standard dose titration (43%, n = 22), with 53% (n = 27) being dose or frequency reduction. Medications were held because of side effects (50%, n = 4), abnormal laboratory values (25%, n = 2), or both (25%, n = 2).

Discussion

Innovative efforts to avoid medication and financial waste are needed in oncology, where the financial burden to the health care system is estimated to reach $246 billion by 2030.²³ The current study demonstrates a novel method to avoid oral anticancer medication waste and unnecessary costs by IHSSP specialty pharmacists’ review of EHR and prescription claim data to identify potential changes in therapy before requesting refills from prescribers. Although sending refill renewal requests was not automatic before the implementation of this formal review process, automatic refill renewal requests are not an uncommon practice for pharmacies, especially when visibility into the patient treatment course is absent. When renewal requests are sent, the clinic staff must determine if the request is appropriate. Integrated specialty pharmacists followed patients closely before implementation and would defer sending refill renewal requests when they knew a patient was not going to continue treatment; however, implementation of this standardized review took monitoring a step further to ensure potential changes to therapy were being considered, not just known changes. It also shifted the responsibility of assessing the patient’s quantity of medication on hand and the presence of an upcoming medical follow-up to the integrated specialty pharmacist. Pharmacist clinical review and postponement of refill renewal requests until after a scheduled follow-up resulted in an estimated cost avoidance of up to $750,000 (AWP-20%) in 12 months with only 2% of postponed refill renewals resulting in no change to current therapy after the follow-up. This demonstrates that the pharmacists were effective at applying their clinical knowledge to identify the potential for a change in therapy and situations when postponing a refill renewal request was appropriate. IHSSP pharmacists can use their unique access to the EHR and pharmacy dispensing data to optimize the oral anticancer medication refill renewal process and avoid potential waste.

Previous work addressing oral anticancer medication waste in oncology has focused on programs such as split-fill and using a medication repository.^11,12,24 Clinical pharmacist review of refill renewal requests offers an additional and more comprehensive approach to waste avoidance that differs from split-fill or repository programs. Split-fill programs are applied across a specific population (eg, all patients initiating anticancer medications) and may be limited by the increased cost to the patient in the form of additional copays.⁹ Although payers may charge copays to equilibrate the patient’s 30-day copay requirements or adjust the initial copay to match the days supply for the split fill. Repository programs are limited to eligible patients and governed by state and board of pharmacy laws and regulations.¹³ Specialty pharmacist review of refill renewal requests for medication on hand and upcoming follow-up is patient-specific, based on clinical data, and can be implemented on a wide scale within IHSSPs without increased financial burden to the patient. The benefit of split-fill programs in oncology is primarily due to avoiding medication waste at the beginning of treatment by limiting the amount of medication initially dispensed and ensuring tolerability before larger quantities are provided.¹² Repository programs target waste after a dispensed medication is unused.¹³ Pharmacist review of refill renewal requests further contributes to waste avoidance that may occur at any point in treatment because of disease progression, side effects, dose titration, abnormal laboratory test results, or therapy completion.

Oncology treatment plans are dependent on multiple factors, including response to therapy and medication tolerability. In the current study, medication discontinuation after follow-up resulted in the highest cost avoidance of up to $369,839.71 (AWP-20%). Similar to results found by Monga et al of patients taking oral anticancer medications, discontinuation in the current study was most commonly caused by disease progression (49% of discontinuations).⁹ This finding is not surprising given that most of these medications are intended to slow progression or extend a patient’s lifespan rather than cure the underlying disease. Dose changes accounted for the second highest cost avoidance, up to $237,925.22 (AWP-20%). Notably, in this study a cost avoidance value was only assigned if the previously prescribed medication could not be used to continue treatment after the change; thus, many dose changes resulted in the potential for unused medication. These findings support previous literature noting substantial drug waste and economic burden associated with dose modifications that do not allow for the use of the medication supply on hand and instead require a new prescription be filled.²⁵ Dose changes were often caused by side effects (53%) or standard dose titration (43%). Medication changes that resulted in cost avoidance were less common, accounting for up to $87,533.56 (AWP-20%). Similar to medication discontinuations, medication changes were commonly because of disease progression (88% of medication changes). With the growing number of oral anticancer medications, pharmacists play an important role in treatment monitoring²⁶ and have demonstrated improved adherence^27-29 and patient satisfaction.²⁰ The current study demonstrates that pharmacists can also effectively prevent waste by monitoring refill renewal requests.

Clinical pharmacists reviewed more than 2,500 refill renewal requests and postponed sending refill requests to the prescriber in fewer than 10% of cases. Although labor intensive, the potential cost avoidance associated with reviewing the EHR and pharmacy dispensing software before requesting refill renewals was significant. However, if resources are limited, specialty pharmacies could consider focusing this intervention on medications that have a high potential for cost avoidance per fill (eg, one tucatinib prescription avoided $20,712.96 [AWP-20%] in waste) or those medications that have a high volume and high total cost avoidance potential because of frequent laboratory monitoring and multiple strengths required to make the total dose (eg, temozolomide had 66 cost avoidance interventions resulting in $187,426.86 [AWP-20%] avoided). As medication volume can vary by practice location, patient population, and geographical prevalence of cancer type, the pharmacist could tailor the review to the most frequently dispensed at their site. IHSSPs have an ideal model to provide cost avoidance interventions because of their direct access to the provider, the EHR, and the dispensing pharmacy.³⁰ As demonstrated by the current study, IHSSPs should take advantage of this access to provide waste reduction programs. By not automatically refilling medications without proper evaluation, IHSSP pharmacists avoided more than half a million dollars in unnecessary costs to the patient (copays), third-party insurance (reimbursement to the pharmacy), and health care system (medication, materials, and staffing expenditures). As primary beneficiaries of these avoided costs, payers should consider partnering with and incentivizing IHSSPs to implement similar models of waste avoidance.

LIMITATIONS

This study is not without limitations. It was conducted in a single-center oncology outpatient clinic with a largely homogeneous study population in which most patients seen were being treated for solid tumor indications. We would anticipate similar potential for cost and medication waste avoidance when expanding this program to include a higher volume of hematology oral anticancer medications and when performed by other IHSSPs. This study was conducted during the height of the coronavirus disease 2019 pandemic; however, the number of refill renewal requests generated by the specialty pharmacy in 2020 were similar to those generated in the prior year. The high refill renewal approval rate in the specialty oncology clinic before implementation may reflect higher approvals than could be anticipated from nonintegrated specialty pharmacies. Even though specialty pharmacist review of refill renewals was implemented as standard practice as of January 1, 2020, the oncology specialty pharmacists were closely monitoring patients before that date and sending refill renewal requests was not automatic. Therefore, the specialty pharmacists may have declined sending a refill renewal request if they knew a patient would not be continuing the current therapy. There is a chance that, if deferred requests had been sent, the physician’s office would have declined sending a new prescription, although we feel this study shows that integrated specialty pharmacists are qualified to determine when a deferral of refill renewal requests is appropriate and eases the burden of clinic staff. The cost avoidance analysis uses readily available drug WAC and AWP-20%, which is not a true depiction of actual drug cost. However, AWP-20% was used to approximate average discounts in the market for dispensing costs of oral anticancer medications. WAC is the base for pharmacy purchasing agreements and is used to estimate the potential medication cost avoided by the pharmacy. Unfortunately, the lack of transparency and contract disclosure restrictions around medication pricing in the United States makes it difficult to report an exact number. A range of potential cost savings was provided to give a closer picture of potential cost avoidance to multiple stakeholders. We were also conservative when assigning postponed prescriptions to the cost analysis. We reviewed each medication based on the last refill quantity before postponement and did not include any portion of a postponed prescription that, if filled, could have been used by the patient to accommodate a dose change. This study did not include an analysis of additional labor costs for the pharmacists. We recognize that although this program did not necessitate extra pharmacist hours at the IHSSP, other IHSSPs may not be able to adopt this program without additional workforce requirements. Medications contributing to cost avoidance can vary based on individual practice characteristics and regional trends; therefore, the data related to medications contributing to cost avoidance are not generalizable. Lastly, in excluding patients who did not complete the scheduled follow-up or transferred care, we may be underestimating the number of patients with a change to therapy after clinical pharmacist review and postponement of the refill renewal request.

Conclusions

IHSSP clinical pharmacists are well positioned to leverage access to critical medical and pharmacy data to determine the appropriateness of requesting or postponing prescription refill renewal requests. Specialty pharmacist postponement of refill renewal requests after EHR and identification of follow-up that may impact therapy contributed substantially to medication waste and cost avoidance.