Bruce A. Feinberg, DO: Let me get back to that question, though, about how much variance you see in prescribing behaviors and doctors favoring, if we use that example, one taxane over another taxane in the treatment of a breast cancer patient.
Brandon Shank, PharmD, MPH, BCOP: I think Marcus was alluding to it. It depends on what the insurance coverage is. For our physicians, they would usually use the reference product. But sometimes if there’s insurance approval…
Bruce A. Feinberg, DO: And how is that communicated to the physician? Is that your job? You’re supposed to be able to tell them, “You can’t give that to this patient.”
Brandon Shank, PharmD, MPH, BCOP: The state board of pharmacies are also implementing changes and legislation to help support that. And the communication to the physicians varies depending on what that is. But it would be if there was a substitute. We haven’t encountered that situation yet, except in outpatient coverage where the physician was notified of the substitution the biosimilar. If the physician wanted the necessary brand, they could also indicate that on an outpatient prescription order. At an institutional level, I don’t think they have the same control. It goes to the therapeutics committee, which would be chaired by a physician that would approve that. I’m not aware of any automatic substitutions, and I don’t see that right now in the landscape because of the interchangeability and variant data. And the physicians would want to interpret that and be able to use that before automatic substitutions were made. That may change in the future with the Purple Book or through more formal guidance.
Hope S. Rugo, MD: Are you talking specifically about therapeutics, there? And chemotherapy and more biosimilars? I just wanted to be clear about where you wouldn’t see the automatic substitution, because we do have relatively automatic substitution for the filgrastim product. But we don’t have anything. Of course, there aren’t any therapeutic biosimilars, so we don’t really have to address the question right now.
Brandon Shank, PharmD, MPH, BCOP: Now, it would just be supportive care with the growth factor. And I think that would be made at an institutional level. Currently, we give, at my institution, the branded Neupogen product. But a biosimilar, at other institutions, may get approved through a therapeutic committee.
Hope S. Rugo, MD: Right, which we have. Yes.
Brandon Shank, PharmD, MPH, BCOP: For chemotherapy—actually, we should say “biotherapy”—it would be a whole different game. We’ll see how pharmacy and therapeutics committees dictate that at their institutions.