Appeal of Physician-Dispensed Abiraterone and Enzalutamide for mCRPC Grows Stronger

With novel treatments such as abiraterone acetate (Zytiga) and enzalutamide (Xtandi) emerging and financial challenges of diminished reimbursement faced by urology practices mounting, urology groups are beginning to offer in-office dispensing to their metastatic castration-resistant prostate cancer (mCRPC) patients.

Bryan A. Mehlhaff, MD

With novel treatments such as abiraterone acetate (Zytiga) and enzalutamide (Xtandi) emerging and financial challenges of diminished reimbursement faced by urology practices mounting, urology groups are beginning to offer in-office dispensing to their metastatic castration-resistant prostate cancer (mCRPC) patients.

In-office dispensing can meet patient needs by enhancing patient care and outcomes, as well as provides practices with another service line and revenue stream, said Karen K. Kellogg, PharmD, director business solutions, VitalSource GPO, Specialty Solutions, during a breakout session at the 2015 LUGPA Annual Meeting.

Kellogg, along with David J. Coury, CEO of UroGPO, and Bryan A. Mehlhaff, MD, of Oregon Urology, served as panelists during the session titled, “In-office Dispensing With Urologists.”

Oncology practices have been utilizing in-office dispensing for quite some time and had success with the buy-and-bill model. But as more urologists prescribe abiraterone and enzalutamide, as well as provide the safety and financial counseling, the follow-up, and patient support that the medication requires, it has become readily apparent that the only thing urologists were not doing was dispensing the drugs.

“There’s a lot of interest in urology groups to get involved in in-office dispensing. It’s only been in the last year that we’ve incorporated it in our practice,” said Mehlhaff. “It has now become an integral part of how we take care of our patients.”

The benefits of physicians dispensing are both clinical and financial. From a clinical perspective, it enables practices to have greater continuity of care and improves patient adherence to therapy. It also reduces barriers and abandonment rates by providing an easier path to treatment.

From a financial perspective, in-office dispensing distinguishes a practice from its competitors and can minimize the time-consuming task of correcting misunderstood prescriptions.

“How many times does a prescription go unfilled because the patient did not know about the high out-of-pocket cost or because the prescription was not available at the local retail pharmacy?” asked Kellogg.

Start-up Questions for In-Office Dispensing

There are a number of start-up questions and considerations to make if a practice is interested in going the in-office dispensing route. Questions about the practice’s current and potential dispensing volume, the use of e-prescription services, the current payer mix, and if the physician leaders and managers in the practice are engaged should all be considered before making the business decision.

Specific requirements to set up an in-office dispensary include researching physician dispensing state regulations, equipment (computer, dispensing software, and printer), acquisition of an NCPDP/NABP number, third-party payer direct contracts, staff training on dispensing software and workflow, and inventory procurement (selection of a drug wholesaler).

“If your group has many offices, I would recommend creating one dispensing site,” said Coury. “Then have all of your offices e-prescribe into that one site.”

One of the largest hurdles once the dispensary is established is dealing with insurers and prior authorization, said Coury. All Medicare Part D plans will require a prior authorization in 2015 on oral oncolytics. Although it sounds difficult because staff training is required, training is usually straightforward.

“The advantage is your office will be dealing with prescription benefit managers, not insurers,” said Coury. “You’re not billing medical plans, you’re billing prescription plans, and so it’s a whole new set of payers. Luckily, PBMs are used to dealing with prior authorization and they turn around orders within a day.”

Insurers also use specialty pharmacy to deliver expensive medications. But there are disadvantages with using that service, said Mehlhaff.

“I’ve had problems with specialty pharmacy in the past, especially when it comes to shipping the drug,” said Mehlhaff. “The specialty pharmacy ships the drug automatically, no matter what—whether it’s snowing, whether the office is closed, on the weekend, even when the patient is no longer living. That’s just a waste of money and resources.”

With the complicated sequence of treatment regimens that prostate cancer patients may encounter, “it’s important to have control, have the ability to monitor, and have the ability to check laboratory work and drug levels,” added Coury. The specialty pharmacy has that information, but it’s not readily available to the physician. When the physician dispenses, he has that information at his fingertips. “It gives you a stronger clinical touchpoint with your patients,” said Coury.


Physician dispensing is one more way to provide the comprehensive quality care that benefits patients. In Mehlhaff’s practice, patients have said that they feel more connected to the office staff with the increased interaction that accompanies dispensing.

“My nurse is talking with them, asking them how they’re doing or are they due for a refill. There’s always a discussion if something is going on. It serves as another touchpoint with the patient,” said Mehlhaff. “It’s what the specialty pharmacy is supposed to be doing with the patient, but it’s not the same follow through when my office interacts with the patient directly.”

Mehlhaff says patients also feel reassured when they see the same people over the course of their regimen. They appreciate that it’s part of a comprehensive treatment pathway. “My patients have uniformly responded to dispensing in a positive way.”

In Mehlhaff’s practice, the actual dispensing set up is not like a retail pharmacy, in which quantities of drugs are stored. Drug inventory and overhead are not a factor because the orders are sent out on an as-needed, case-by-case basis.

“The order is sent out from the dispensary to the PBM. The PBM adjudicates the claim, almost immediately, and the drug is usually sent back within 24 to 48 hours. Our staff then informs the patient that the drug is available, we administer the drug, and monitor for any adverse events."

If there is an adverse event, the practice knows immediately that the patient will not be ordering the drug for the next cycle. In a specialty pharmacy arrangement, that information is not always conveyed to the specialty pharmacy in time for the next delivery to be halted.

“Once the decision to move forward about establishing in-office dispensing is made, I’m hoping most urologists will run with it,” said Mehlhaff. “There has been a lot of urology groups standing on the sidelines in the face of all the advanced therapeutics in prostate cancer. Some physicians may not want to administer Provenge because that’s an IV infusion and they’re uncomfortable with that. Xtandi and Zytiga are new and the physician has to check labs, and it’s difficult to manage the complicated patient. I hope to encourage all these physicians to treat these advanced patients.”