Download Biosimilar Drugs - Community Oncology Alliance

The Community Oncology Alliance Conference
Moving Forward on Payment Reform
April 23, 2015
Biosimilar Drugs:
Opportunities and Issues
Phil Johnson MS RPh
Safe School Meds, Principle Partner
Moffitt Cancer Center, Director of Pharmacy (Retired)
Disclosures
• I have no financial relationships
relevant to this program.
Learning Objectives
• Describe the molecular and manufacturing differences
between biological versus traditional small-molecule
drugs.
• Explain the regulatory landscape of biosimilars in the
USA and Europe.
• Assess the factors to consider relevant to the
interchangeability of biosimilars and indications for use.
• Discuss safety issues and key components of a
successful pharmacovigilance program.
• Discuss financial implications with the advent of
biosimilar drugs.
AGENDA
•
•
•
•
•
•
What are biosimilar drugs?
Regulatory issues
Safety concerns and Pharmacovigilence
Indications for use
Financial implications
Summary / Key Points
First Biotechnology Process
Yeast Fermentation 4,000 BC
• Budweiser
• Amstel
• Heineken
• St. Pauli Girl
• Molson
Are these equivalent or interchangeable?
Biologics vs. Small Molecule Drugs
Mellstedt H. EJC Supplements 2013;11:1-11.
Small Molecule Synthesis: Aspirin
Manufacturing of Small Molecules
1. Chemical process based on a series of
controlled and predictable chemical
reactions
2. Process is standardized between
manufacturers
3. Final structure easily verified
4. Contaminants are quantifiable
Biologic Categories
•
•
•
•
•
Monoclonal antibodies
Complex sugars
Blood derivatives
Vaccines
Recombinant or purified proteins
– Cytokines
– Thrombolytic agents
– Enzymes
Biosimilar Manufacturing
• Several major steps included in development
– Modifying the selected gene of interest
– Inserting the desired gene into a specific host cell
– Replicating cell line and increased protein
expression
– Harvesting protein products from the cell
– Purifying the selected protein
• More patents on the process than on the drug
Biosimilar Manufacturing
http://www.pharmqd.com Accessed 2014 Oct 16.
Similarities and Differences
“Similar” vs. Reference Product
BIOSIMILAR Specification
Comparison with REFERENCE
Formulation
May be different
Delivery device/container
May be different
Routes of administration
Licensure depends on application
Conditions of use
Licensure includes all indications for
reference product (recent precedent)
Strength
Must be the same
Specific potential molecular
differences
Amino acid substitution
N- and C-terminal modifications
Mismatched disulfide bonds
Post-translation modifications folding
Carboxylation
Formylation
Glycosylation
Methylation
Phosphorylation
PEGylation
http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/ucm259809.htm
Are biosimilar drug issues new ?
Which, if any, are relevant to current discussion?
• Human Growth Hormone
– First to be substituted
• Human Insulin
– Many choices, little hesitation to interchange
• Interferon Alpha 2a, 2b, Beta, Gamma
– Payer directed formulary equivalence / interchange
• Influenza Vaccine
– Multiple manufacturers; you provide what you can get
• Heparin
– Harvested, purified, equivalence by batch
• Low molecular weight heparin (LMWH)
– Significant dosing issues when interchanged
• Anti-infectives
– Therapeutic Class representative for sensitivity tests
• CMS considered erythropoietin and darbepoetin “Functional
Equivalents”
AGENDA
•
•
•
•
•
•
What are biosimilar drugs?
Regulatory issues
Safety concerns and Pharmacovigilence
Indications for use
Financial implications
Summary / Key Points
Hatch-Waxman Amendments
to Federal Food Drug and Cosmetic Act (FDCA)- 1984
• Allowed generic firm to use safety and efficacy
data of innovator drug after expiration of patents
and exclusivities
• A generic must have the same indications,
strength, purity and quality as the original product.
• It must be prepared in the same formulation and
be bioequivalent
• Increased availability of generics
• 1984 12% prescriptions were generic
• 2012 80% prescriptions were generic
Drug Price Competition and Patent Term Restoration Act of 1984, Pub. L. No. 98-417, 1984 Stat. 1538 (codified as
amended in scattered sections of 21 & 35 U.S.C.).
Evolution of Biosimilar Approval Pathway in U.S.
• Two federal laws for the approval of pharmaceuticals
– Food, Drug, and Cosmetic Act (FDCA)
• New drug application (NDA)
• Abbreviated NDA (ANDA)
– Public Health Service Act (PHSA)
• Biologics license application (BLA)
• Most biologics approved under PHSA
– “Hatch Waxman Act” of 1984 does not apply
– Biologics Price Competition and Innovation Act (BPCI) of
2009 created an abbreviated FDA approval pathway for
biosimilars
• Full interpretation and implementation still pending
• According to the FDA, “drugs” are different from
“biologics”
Zelenetz AD et al. J Natl Compr Canc Netw. 2011; 9(Suppl 4):S1–S22.
FDA Approval Pathways
Drugs
•
•
Small-molecules
Approved via FDCA
New Drug
Application
(NDA)
505(b)(1)
Safety and
Efficacy must be
demonstrated
Abbreviated
New Drug
Application
(ANDA)
505(b)(2)
Bioequivalence
must be
demonstrated
Biologics
•
Approved via PHSA¥
Biologics License
Application
(BLA)
351(a)
Safety and
Efficacy must be
demonstrated
Biosimilar
Biologics License
Application
351(k)
Must demonstrate
that it is highly
similar to 351(a)
reference
Interchangeable
biosimilars
require more data
†FDCA
= Federal Food Drug and Cosmetic Act
¥PHSA = Public Health Service Act
Many types of biologic products
Reference or
Originator
Biosimilar
Interchangeable
Biosimilar
New biologic
approved via
BLA
Depth of data
submitted to the
FDA
“Standard” data
package
Abbreviated data
package
Abbreviated data
package, more
information on
efficacy and
safety
“Standard” data
package; efficacy
and safety on its
own merit
Compared to
reference?
N/A
Yes
Yes
Not Required
Current
example in USA
Filgrastim
Neupogen ®
Filgrastim-sndz
Zarxio ®
Not Yet
Tbo-filgrastim
Granix ®
EMA Model: Biosimilars Regulations
www.ema.europa.eu
Overarching Guideline on Similar Biological Medicinal Products (Oct 05)
Quality
Guideline on Similar Biological Medicinal Products
Containing Biotechnology-Derived Proteins as Active
Substance: Quality Issues (June 06)
Nonclinical
& Clinical
Guideline on Similar Biological Medicinal Products
Containing Biotechnology-Derived Proteins as Active
Substance: Nonclinical & Clinical Issues (June 06)
Annexes
Epoetin
July 2006
G-CSF
June 2006
Insulin
June 2006
HGH
June 2006
Heparin LMWH &
Others Draft
13 biosimilar marketing authorizations have been granted
EMA=European Medicines Agency
General
Applicable
to all
Biosimilars
Specific:
Product data
requirements
The Naming Game
History of Naming
Selected Terms Used to Describe “Generic” Biologics
•
•
•
•
•
•
•
•
Post patent biologicals
Biogenerics
Subsequent entry protein pharmaceuticals
Second-generation biologicals
Follow-on biologicals
Follow-on protein products
Bio-betters
Biosimilars
Source of Names and Numbers
• Originator Manufacturer (Reference Product)
– Trade Name
• Unites States Adopted Names (USAN)
– Provide by AMA
– Generally adopted by FDA
– The generic name (Reference Name)
Reference
Slide
• United States Pharmacopeia (USP)
– Monographs and consistency concerns
• Institute for Safe Medication Practices (ISMP)
– Naming clarity / Safety concerns
– Labeling standards
• Food and Drug Administration (FDA)
– Ultimately approves name
– Assigns National Drug Code (NDC)
• Centers for Medicare & Medicaid Services (CMS)
– Assigns HCPCS codes which could be the same between
biosimilars
HCPCS=Healthcare Common Procedure Coding System
Recent Naming Events (Precedents ?)
• Prefix vs Suffix
– Granix (tbo-Filgrastim), Full NDA approval
– Zaltrap (ziv-aflibercept)
– Zarxio (Filgrastim-sndz) (FDA “placekeeper name”???)
• Tyrosine Kinase Inhibitors naming convention
– PONATinib and PAZOPanib
• WHO (Oct 2013)
– Leaning toward “Generic + Suffix”
• EU naming
– Allows the biosimilar to use same non-proprietary name as reference
• HER-2 targeted Kadcyla (ado-trastuzumab emtansine)
•
•
•
•
•
Trastuzumab: 8mg/kg loading; 6mg/kg q 3 weeks maintenance
Ado-trastuzumab: no loading; 3.6mg/kg q 3 weeks
FDA rejected “trastuzumab emtansine” and added prefix “ado”
ISMP Alert 4-17-13: Use both brand and full generic name to avoid confusion
International Medication Safety Network (IMSN) Alert 5-8-14: USAN and WHO did
not approve FDA name, leading to international confusion
• Confusion documented as leading to overdoses of ado-trastuzumab
• FDA working on naming resolution
“IMSN Alert – Risk of confusion between the names trastuzumab-emtansine and trastuzumab”, May 8, 2014, IMSN Alert
“Confusion regarding the generic name of the HER2-targetd drug KADCYLA (ado-trastuzumab emtansine)”, April 17, 2013 NANALERT
Importance of a Naming Strategy
• Goal:
– Identify relationship between the “biosimilar”
and “reference” / “originator”
• Therapeutic category
• Dosing
– Differentiate products
•
•
•
•
Support pharmacovigilance (PV)
Intended product administered to patient
Outcomes and ADEs attributed to correct product
Avoid “sound alike” and “look alike” errors
– Facilitate effective product “track and trace”
(anti-counterfeiting)
Naming Options
• Options
– Totally different names from originator
• Preferred by originator pharmaceutical companies
– Same USAN name as originator
• EU policy
– Unique suffix attached to originator’s USAN
• Error prone because some computer fields truncate long
names
• Facilitates listing adjacent to reference in formulary data
bases
– Unique prefix attached to originator’s USAN
• Precedent with some new drugs
• Supported by ISMP and Hematology/Oncology Pharmacy
Association (HOPA)
– Current FDA position with Sandoz Filgrastim
• Assigned “PLACEHOLDER” name
State initiatives:
warranted or not?
State Legislation Status
as of October 2014
http://www.ncsl.org/research/health/state-laws-and-legislation-related-to-biologic-medications-and-substitution-of-biosimilars.aspx
State Proposals Are Driven By BPCI Act…
• Biologics Price Competition and Innovation Act of 2009
– Allows approval by FDA of a biosimilar product as
“interchangeable”
• Must demonstrate NO clinically meaningful differences in safety,
purity, and potency
• FDA continues work on implementing BPCI Act
• States have considered proposals to restrict substitution of
biologic medications that are deemed similar/
interchangeable, but have not been cleared by FDA for
interchange
• Supporters of state proposals believe the ultimate decision
on substitution should be left to the patient’s prescribing
physician
– Perhaps concern for patient safety
– Perhaps desire to protect use of “originator” drug
• Opponents believe state proposals are restrictive and
inconsistent with forthcoming national standards
U.S. Senate. Biologics Price Competition and Innovation Act. URL in reference list
U.S. Congress. Sections 7001-7003 (Biologics Price Competition and Innovation Act of 2009) of the Patient Protection and
Affordable Care Act (Public Law 111-148). URL in reference list
Frequent Features of State Legislation
•
Any biological product under consideration for substitution must be
certified and listed as approved for substitution by the FDA
•
•
•
•
•
•
No products have gained such approval as biosimilars in the United States
Prescriber would be able to prevent substitution by stating
“dispense as written” or “brand medically necessary”
Prescriber must be notified of any allowable substitution made
at a pharmacy
Individual patient must be notified that a substitute or switch
has been made; in some cases, state law requires patient consent
before any such switch is made
Pharmacist and the physician must retain records of substituted
biologic medications
State must maintain a public list of permissible interchangeable
products
http://www.ncsl.org/research/health/state-laws-and-legislation-related-to-biologic-medications-and-substitution-of-biosimilars.aspx
Enacted State Legislation
October 2014
• Florida, HB 365 (2013), Chapter 2013-102
http://www.flsenate.gov/Session/Bill/2013/0365/BillText/er/PDF
• North Dakota, SB 2190 (2013)
http://www.legis.nd.gov/assembly/63-2013/documents/13-051104000.pdf?20131023091537
• Oregon, SB 460 (2013), Chapter 342, 2013 Laws,
https://olis.leg.state.or.us/LIZ/2013R1/Measures/Text/SB0460/Enr
olled (contains sunset clause)
• Utah, SB 78 (2013),
http://le.utah.gov/~2013/bills/sbillenr/sb0078.pdf (contains sunset
clause)
• Virginia, SB 1285, (2013), Chapter 544 (contains sunset clause),
http://lis.virginia.gov/cgi-bin/legp604.exe?131+ful+CHAP0544
Amendment Enacted by State of Florida
(Key Points)
•
•
•
•
•
Section 1. Subsection (6) of section 465.019, Florida 18 Statutes, is
AMENDED to read:
(6) In a Class II institutional pharmacy, an institutional formulary system
may be adopted with approval of the medical staff for the purpose of
identifying those medicinal drugs, and proprietary preparations, biologics,
biosimilars, and biosimilar interchangeables that may be dispensed by the
pharmacists employed in such institution. …shall establish policies and
procedures for the development of the system in accordance with the joint
standards of the American Hospital Association and American Society of
Hospital Pharmacists for the utilization of a hospital formulary system…..
Section 2. Section 465.0252, Florida Statutes, is created to read:
465.0252 Substitution of interchangeable biosimilar products.
(3) A pharmacist who practices in a class II or modified 54 class II institutional
pharmacy shall comply with the notification provisions of paragraph (2)(c)
by entering the substitution in the institution's written medical record
system or electronic medical record system.
http://www.flsenate.gov/Session/Bill/2013/0365/BillText/er/PDF
Where is this going?
...Considerations For Pharmacy
• Familiarize yourself with state and federal laws
– Much may hinge on future FDA determinations of
biosimilarity and interchangeability
– Some laws are being adopted with sunset clauses and
may expire before applications/determinations occur
– Seek amendments that reward existing good practice
• Closely follow your state Board of Pharmacy’s
guidance
– Is there a need to reconcile biosimilar substitution with
existing state laws on substitution of generic drugs?
AGENDA
•
•
•
•
•
•
What are biosimilar drugs?
Regulatory issues
Safety concerns and Pharmacovigilence
Indications for use
Financial implications
Summary / Key Points
Antibody Formation: “Immunogenicity”
• Potential increases with amino acid sequence changes
• Immune responses have different consequences
–
–
–
–
Neutralize the molecule, making it therapeutically ineffective
Hypersensitivity reactions
No clinical effect
Rare but serious autoimmune responses can be lifethreatening
• Pure red cell aplasia (PRCA) with anti-epoetin antibody
• Immunogenicity of biologic drugs is unpredictable,
unforeseeable
– Scientific tools for detecting immunogenicity exist, but in some
cases they are undeveloped
Kessler M et al. Nephrol Dial Transplant. 2006; 21:v9-v12.
Chirmule N, et al. AAPS J. 2012;14(2):296-302
Factors Affecting the
Immunogenicity of Proteins
• Disease Factors
– Immune dysregulation
– Inflammatory responses
• Patient Factors
– Major histocompatibility complex background
• Product Factors
–
–
–
–
–
AA sequence, structure, etc.
Impurities
Formulation
Route of administration
Dose
Chirmule N, et al. AAPS J. 2012;14(2):296-302
Is dosing an issue?
• Molecular size differs among biosimilar drugs
– Will “gram” based dosing be equivalent?
• Should “international unit” dosing be required?
– “Vial contains 123 mcg (equivalent to 250 units) per mL”
– Should “units” only be required when molecular size
difference is greater than __?__ %
– Erythropoietin is 34,000 daltons, typical dose = 10,000
units
– Filgrastim is 18,800 daltons, typical dose = 300 mcg
• Should all prescribing and dosing be based on units?
• Should dose equivalent be based on originator
dosing?
– What if the originator stops production?
• Should pharmacy advocate for standards or just
monitor the emerging market?
Are Companion Diagnostics Interchangeable ?
• FDA Guidance for Industry and FDA Staff, August 6, 2014
• For regulators (and payers ?)
– Determine which patients will benefit
– Decrease the chance of a drug being used off-label …
• For drug makers
– Easier to obtain approval …
• Key points in guidance:
– "in most circumstances, an IVD companion diagnostic device and
its corresponding therapeutic product should be approved or
cleared contemporaneously by FDA for the use indicated in the
therapeutic product labeling."
– In cases where the drug cannot be used safely or effectively
without the companion diagnostic (CDx), FDA will not approve it.
– FDA will, however, approve some drugs without a CDx in certain
circumstances.
• Therapy is intended to treat a serious or life-threatening disease
http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM262327.pdf
13 Drugs with FDA Required Companion Diagnostics
Approximately 80 companion tests are in use
•
•
•
•
•
•
•
Erbitux (cetuximab)
Vectibix (panitumumab)
Exjade (deferasirox)
Gilotrif (afatinib)
Gleevec/Glivec (imatinib
mesylate)
Herceptin (trastuzumab)
Perjeta (pertuzumab)
•
•
•
•
•
Kadcyla (ado-trastuzumab
emtansine)
Mekinist (trametenib)
Tafinlar (dabrafenib)
Tarceva (erlotinib)
Xalkori (crizotinib)
•
Zelboraf (vemurafenib)
Will CDx apply to a single drug or a therapeutic class ?
Will this effect interchangeability ?
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/InVitroDiagnostics/ucm301431.htm
Biosimilar Pharmacovigilance:
Role of the Pharmacist
• Monitor and report
– Adverse events: FDA MedWatch
– Medication errors
• Correct assessment of safety event
– What was ordered vs. what patient received ?
• Maintenance of EMR
• Bar code administration
• Medication reconciliation for all providers
• Consider transitions of care
Does coding help differentiate ?
• NDC and HCPCS codes can support differentiation
• Billing claims data can be a useful in pharmacovigilance
– Outcomes
– Adverse Events
• Problems with using billing data
– NDA: Leuprolide Acetate (depot formulations)
• Lupron Depot: intramuscular injection
• Eligard: subcutaneous injection
• 2013 HCPCS code:
• J1950: Injection, leuprolide acetate (for depot suspension), per
3.75 mg
– BLA: Epoetin alfa
• Procrit® and Epogen®
• 2013 HCPCS codes:
• J0885: Injection, epoetin alfa, (for non-ESRD use), 1000 units
• J0886: Injection, epoetin alfa, 1000 units (for ESRD on dialysis)
Biosimilar Pharmacovigilance
Constant Monitoring to Identify and Characterize
Safety Risk
Pharmacovigilance
• Define monitoring parameters
• Easy reporting methods
• Real-time data
• Ensure traceability
Risk minimization
• Healthcare provider feedback
and communication
• Recalls and alerts
• REMS?
• Naming standards
• Integration into electronic medical
record (EMR)
• Drug codes: HCPCS, NDC, etc.
• Prospective registries
Zuñiga L, Calvo B. Pharmacoepidemiol Drug Saf. 2010 Jul;19:661-9.
Felix T, et al. Nat Biotechnol. 2014 ;32:128-30.
Casadevall N, et al. Expert Opin Biol Ther. 2013;13:1039-47.
AGENDA
•
•
•
•
•
•
What are biosimilar drugs?
Regulatory issues
Safety concerns and Pharmacovigilence
Indications for use
Financial implications
Summary / Key Points
Interchangeability Definition
• Interchangeability definition
– “Biosimilar to the U.S.-licensed reference biological
product … expected to produce the same clinical
result as the reference product in any given patient.”
– “For a biological product that is administered more than
once to an individual, the risk in terms of safety or
diminished efficacy of alternating or switching between
use of the biological product and the reference product
will not be greater than the risk of using the reference
product without such alternation or switch”
PHS Act, section 351(k)(4). http://www.fda.gov/downloads/drugs/
guidancecomplianceregulatoryinformation/ucm216146.pdf. Accessed 2014 Nov 13.
FDA “Purple Book”
• Biological products approved by FDA and
dates of approval
• Approval pathway: e.g., 351(a), 351(k)
• Lists if a biosimilar is interchangeable
• Defines exclusivity period
http://www.fda.gov/Drugs/DevelopmentApprovalProcess/HowDrugsareDevelopedandApproved/Appro
valApplications/TherapeuticBiologicApplications/Biosimilars/ucm411418.htm. Accessed 2014 Oct 16.
Decision Domains Supporting Use
“Documented” Practice Standards
Restricted Formularies
and Clinical Pathways
Evidence
Rated
Compendia
Reference
biologic
labeled
indication
Biosimilar
labeled
indications
Are Indications Interchangeable ?
• Provider Formulary and P&T committee
–
–
–
–
Is the “risk” of unknown worth the “benefit”
Ability to monitor and report (pharmacovigilance)
Multiple providers (especially oral chemo)
What evidence will they require to support
interchange
• Payers
– How will payers make their coverage
determinations?
– Compendia therapeutic class representatives
AGENDA
•
•
•
•
•
•
What are biosimilar drugs?
Regulatory issues
Safety concerns and Pharmacovigilence
Indications for use
Financial implications
Summary / Key Points
Generics vs Biosimilars
CMS Billing Guidance, April 2015
• CMS Payment
– Initial: 106% AWP
– Then: Biosimilar ASP + 6% Reference ASP
• CMS release:
– “…unique opportunity to achieve measurable cost savings
and greater beneficiary access to expensive therapeutic
treatments for chronic conditions.”
– “CMS is considering policy options for coding of additional
biosimilars and will release further guidance in the future”
– Expects price to be 15 – 30% lower than reference product
http://mobile.biopharma-reporter.com/Markets-Regulations/US-CMS-releases-new-info-around-biosimilar-pricinguptake?utm_source=copyright&utm_medium=OnSite&utm_campaign=copyright#.VSPTi_nF-Gl
Bottom Line
• CMS OPPS Reimbursement for 2015
– Filgrastim 5mcg = $4.99
• ASP = $4.7075
• 6% = $0.2824
– tbo-filgrastim 5mcg = $3.920 (106% WAC)
– If new biosimilar is priced 20% less:
• ASP = 3.7660 + 0.2824 = $4.0484 payment
• Margin = 7.5%
– For 300 mcg dose
•
•
•
•
$282.450 payment for reference drug (Neupogen®)
$242.904 payment for biosimilar
6% reference same for both = $16.944
Cost difference: 282.45 - 225.96= $56.49
– Assumptions:
• Your cost = ASP
• Your regional OPPS reimbursement is the same as National
Patient / Co-Pay Assistance ?
• Most originator drugs have PAP
• Most “biosimilar drugs” are produced by
companies that have PAP programs
– Granix (TevaCore.com)
– Zarxio (Will announce at product launch)
• To be competitive, providers should insist
on at least the same level of support as
with the originator drug.
Patent Cliff
Drug
(selected items)
Patent Expires
Lovenox
2012
Neupogen
2013
Epogen
2013
Lantus
2014
Interferon beta 1-a
2015
Neulasta
2015
Synagis
2015
Humira
2016
Rituximab
2016
Erbitux
2016
Remicade
2018
Avastin
2019
Herceptin
2019
Aranesp
2024
Embrel
2028
European EPO Commercial Experience
 Prior to biosimilar entry,
originators had already
Impact on
introduced price discounts
Price
 Biosimilar EPOs are priced at ~
20% less than the originator
brands
 Originators responded to limit
biosimilar uptake
Response
From
Originators
 Questions on the quality, safety,
and efficacy of biosimilars
 Advising clinicians against
switching EPO products
 Questioning the adequacy of EU
pharmacovigilance systems to
effectively monitor biosimilars in
clinical practice
 Clinicians comfortable with the
introduction of biosimilars
 No unexpected safety concerns
identified in 24 months
Result
 Extensive “Post Authorization
Safety Studies” have been
undertaken by the biosimilar
manufacturers to monitor safety
of their products in the market
 Branded EPOs are switched to
biosmiliars on tenders today
(interchangeability)
 75% cost reduction announced
during FIP 2010 World
Conference
 EU payors are driving biosimilar
uptake if funding mechanisms
give them influence
AGENDA
•
•
•
•
•
•
What are biosimilar drugs?
Regulatory issues
Safety concerns and Pharmacovigilence
Indications for use
Financial implications
Summary / Key Points
Summary
• Biosimilar use and regulation exists in Europe and is
being defined in the U.S.
– Naming to be determined
– Interchangeability to be determined
• Pharmacists must lead Pharmacovigilence efforts
–
–
–
–
Monitoring and Reporting Adverse Events
Dosing Issues
Coding Issues
Companion Diagnostic Issues
• What / Who will determine use ?
– Cost alone
– Payer Formulary
– Provider Formulary
Questions ?