I work for an EYLEA patient support program in Ontario. I have recently been tasked with understanding an issue relating prescriptions that our pharmacy has received for patients that they are unable to fill - i.e. the doses/Rx become 'unfilled'. At a basic level, ‘unfilled(s)’ are simply doses that our pharmacy (PCY) were unable to commercialize, and that the PSP was not/is not able to replace with no charge drug (NCD – bridging doses).
The unfilled issue is closely related to the two types of ordering/inventory models used by our clinics: 
1.) 'Order in Advance' (OIA) model: The clinic will organize a list of patients who will be scheduled to receive treatment at the next injection clinics. The clinic will then send orders to PCY in advance of the injection clinic for the doses required to treat those patients who were scheduled in. 
2.) ‘Consignment’ model clinics: These clinics are set up with two types of drug (EYLEA) stock - 'In-clinic stock' and commercial 'consignment' stock. ‘In-clinic stock’ is composed of NCD doses provided by the PSP and are intended to be used for a patient's first treatment (NOW dose - type of NCD). Once the clinic has administered the patient’s first dose, the clinics then submits an enrollment form for the patient to the PSP. The enrollment form (EF) also acts as a valid Rx (includes full SIG and all other required info) and indicates if a NOW dose (pulled from in-clinic stock) was used for the patient. Once the PSP receives the EF, a PSP case manager (CM) will attach the EF (valid Rx) to a dispense request and send it to PCY so that a NOW replacement dose is sent to the clinic to replace the NOW dose pulled from their 'in-clinic' stock. 
The clinic's commercial 'consignment' stock is intended to be used for patients for whom the PSP/PCY confirmed have active coverage. The final type of doses sent to / received by clinics are the other type of NCD dose provided the PSP called ‘holdover’ (HO) doses, that are sent o support patients ongoing treatment (Tx) while the PSP continues to work to establish coverage with the patient’s insurer (prior authorization, trillium drug program (TDP) application pending etc.).
The unfilled issue is primarily produced/the result of our ‘consignment’ model clinics. Because the clinics order after they have already injected the patients at their last injection clinic, there is no time for the PSP to identify issues that would prevent a dose from being billed commercially or from being replaced NCD program doses. Many of these clinics will also proceed to inject patients even after they have been notified by the PSP that there is an issue/the patient is non-compliant etc. because there is little accountability/repercussions for the clinics to date (for reasons to be discussed later) and their stock is always reconciled – how these doses are being reconciled is currently unclear.
There are many types, or reasons, why doses end up being unfilled and the types/reasons can be split into two categories generally – 1.) PCY: issues that prevent PCY from being able to bill (‘fill’) an unfilled commercially and 2.) PSP: factors that prevent the PSP from replacing the dose with a NOW or Holdover dose due to Program NCD eligibility criteria. The following is a breakdown of the most common unfilled ‘types’ / reasons, and brief insights as to how they individually could be addressed/resolved (format as table) :  

PCY Unfilled Types:
1.	‘Refill too soon’
•	Description:
o	New order submitted less than 28 days from last successful billing
•	Comments and suggestions:
o	Suggestion: Potential LMS PRO enhancement - if PCY/PRO integration is feasible
2.	Adjudication issues 
•	Description:
o	‘client ID’, ‘Spouse not enrolled’, 'coverage expired before service' errors etc.
•	Comments and suggestions:
o	Comment: PCY utilizes adjudicator/PCY info line to resolve issue when possible
3.	Coordination of benefit (CoB) issues (typically TDP/private)
•	Description:
o	Situations wherein in a patient’s primary plan is no longer paying and documentation is required to switch their secondary plan to first payer – typically public/private patients with low max plans.

E.g. Patient maxes out private plan’s coverage for the year; TDP requires a maxed out letter as confirmation from the insurer before they will switch to first payer and accept direct billing.

TDP only allows a 7 day back billing period and the time it takes reach the patient and request the maxed-out letter from their insurer, send the maxed out letter to TDP and allow 7-10 days for them to process the document, and finally call Trillium to have them switch to first payer and ‘open the billing window’ for direct billing, results in PCY being unable to bill direct. 

•	Comments and suggestions:
o	Updated TDP consent form – includes CMs + PCY 
	Recently implemented - now being used by Eye-Q CMs in ON
	Will allow PCY to open billing windows for patients but 
	Will not resolve TDP processing time / back billing period issues.
o	SPOC
	Recently implemented. Will assist CMs in building more collaborative relationships with their clinics and to better track and manage patient issues generally.
o	Eye-Q process enhancements
	Program could revise current process or introduce a new process to better manage the coordination of benefit for low-max public/private patients – i.e. better track/anticipate/act on ‘max-out’.
	However, If PCY is unable to back-bill more than 7-days once TDP billing window is open, changes would only benefit a very small subset of patients.
4.	Outstanding AR
•	Description: 
o	Typically resulting from outstanding TDP deductible payments and TDP manual submissions, and occasionally with cash paying patients.
	TDP manual submissions:

Many patients are unable to manage the upfront cost of paying for the EYLEA unfilled out-of-pocket, manually submitting the receipt to TDP, and waiting the 4-6 weeks processing time to be reimbursed by TDP – leading to PCY sometimes submitting on their behalf and patient accruing substantial outstanding AR as a result. Typically capped at $3k(?).
•	Comments and suggestions:
o	More concrete processes at PCY for managing patients with outstanding AR + field alignment.
	Many patients with significant outstanding AR continue to receive injections 
	Many patients with significant outstanding AR continue to receive injections 
	There should be a clear process in place at PCY for following-up with patients with outstanding AR – e.g. something similar to Program’s 3 follow-up attempt rule.
	If a patient demonstrates non-compliance, there should be a process in place between PCY, the field team, and Eye-Q to ensure all parties are aligned and that the issue/situation is clearly communicated to the clinic.
Eye-Q Unfilled Types
1.	Patient not enrolled
•	Description: 
o	Clinic has not submitted enrollment form to Eye-Q (via LMS PRO or to PSP inbox)
o	NCD eligibility: Program cannot replace doses if patient received treatment more than two weeks prior to enrollment
•	Comments and suggestions:
o	Suggestions:
	LMS PRO enhancements could have a significant impact on these types of unfilled – e.g. a block that prevents a clinic from submitting an order for a patient who is not enrolled
	Review unfilled reports for last several months and identify which clinics/MDs these types of unfilled are most frequently related to
	PCY/Field/PSO should align to work with the clinics producing these unfilled – identify where the gap is in their process and assist them in establishing a better one.
o	Comment:
	There was a new process implemented in March that allowed Christine at PCY to enroll patients on a particular clinic’s behalf (TRI). Christine was given access to LMS PRO, and provided training by a field team member, and was directed to identify patient who had not been enrolled during her review of the unfilled report and submit their enrollment forms to the Program through PRO.
	Christine/PCY are no longer using this process as of this month (?) – reasons unclear.
2.	Unable to Contact / Non-compliant 
•	Description: 
o	The Program has been unable to reach the patient and/or the patient is not complying with reimbursement navigation processes.
o	Process:
	Program attempts to reach the patient (by phone and/or email) to complete their welcome call or follow-up on their coverage → after three attempts, an ‘Unable to contact’ letter is sent to the clinic and pharmacy, and the patient is discharged.
	If the program was unable to reach the patient to complete their welcome call → the ‘unable to contact’ letter is sent but the patient is not immediately discharged. The program will attempt to reach the patient twice more, one week later, and one month later, before discharging the patient. 
o	NCD Eligibility: 
	Program is unable to replace doses dispensed after an unable to contact letter is sent, and before a patient has been re-enrolled.
•	Comments and suggestions:
o	Comment:
	SPOC was implemented for all clinics this month – should help to better align program and clinics regarding patient statuses.
o	Suggestions:
	LMS PRO enhancements – an update/flag could be pushed through to PRO every time a ‘unable to contact’ email is sent out from LMS 360; acknowledgment checks or a block could be thrown when a clinic attempts to submit an order for a flagged patient or add them to an injection clinic (if using PRO to organize their injection clinics)
	SPOC CMs to start calling clinics, in addition to the ‘unable to contact letter that is sent, to advise when a patient is unreachable/non-compliant.
o	Alignment between Eye-Q/PCY/Field could be improved to better communicate the issue, the patient’s coverage and enrollment status, and non-eligibility for NCD to clinics. 
3.	Insurance Issue 
•	Description:
o	E.g. - Prior authorization approval pending, insurance plan terminated/lapse in coverage, prior auth. denial appeal in progress etc.
o	Program is usually able to replace these types of unfills with NCD
•	Comments and suggestions
o	Comment:
	These types of unfilled are reconciled during monthly unfilled review – suggestions/improvements in this context would take aim at optimizing PCY/Eye-Q’s processes such that the time from ‘Unfilled’ to reconciled via NCD program dose is reduced
o	Suggestions:
	PCY and Eye-Q core team could improve processes related to how we communicate and action unfills for patients with common insurance issues.
	PCY, when following-up with Eye-Q regarding unfills, does not always explicitly communicate that a patient has an unfilled – may just say that the billing is not going through etc. 
Some training/re-training may be required for Eye-Q CMs – CMs should recognize that if they are receiving a call from PCY it is likely because they have received an order but are unable to successfully bill, regardless of whether explicitly stated. CMs should know what information to communicate to PCY in this context (e.g. program will or will not be able to replace dose etc.) and how they should properly action the file to track/address the unfilled.

I met with our companies COO, Ali, last week to discuss the issue and how it could potentially be addressed. Ali left me with a number of action items at the end of that meeting – he asked that I send him a comprehensive report with:

1.	Overview of the issue
2.	a List types/reasons for unfilled + how they could possibly be addressed (Eye-Q perspective)
3.	A list unanswered questions we have regarding the unfilled issue – to help inform potential solutions
4.	Outline proposed LMS PRO enhancement/integration solutions in detail and any other potential solutions
5.	Forward him a copy of PCY’s April unfilled summary report 
6.	Propose list of relevant parties who should be looped-in on subsequent meetings

The following are my notes from my meeting with Ali (COO, previously a consultant with Mckinsey), as well as  my general rough unfilled notes. review all notes and information provided and produce a well formatted, comprehensive report that includes:

- an Overview of the issue
- a List types/reasons for unfilled + how they could possibly be addressed (Eye-Q perspective) + other factors/issues that contribute to the unfilled issue
- A list unanswered questions we have regarding the unfilled issue – to help inform potential solutions
- Outline the proposed LMS PRO enhancement/integration solutions in details + any other potential solutions

at the bottom of the report, include your insights and any possible solutions that you've identified - for example: a comprehensive plan and implementation guide for a standardized inventory management system that our PSO/Field team could help clinics to establish/implement.


Meeting notes:

•	From outset of meeting, evident that Ali had only received a very cursory explanation/overview of unfilled issue, and Program NCD processes more generally.
•	Provided basic overview of Program NCD terminology and process
o	NOW vs. HO – where they fit in in Program flow
o	Consignment vs in-clinic (NOW) stock; ‘Program doses’ (NCD)

•	Provided basic overview of what an unfilled Rx is
o	Unfilled: dose that PCY cannot commercialize and for which the Program has not/cannot provide a NCD replacement 
o	Outlined example scenario that commonly leads to an Rx being left unfilled – steps from clinic order → to PCY → to Program → back to PCY.
o	Unfilled Rx not an issue unique to Sentrex and issue is largely related to volume + public reim. landscape/patient demographic in ON
	number of unfilled doses that are not able to be reconciled month to month, despite preventive processes Program/PCY have in place, being the obvious pain point.   

•	Emphasized the difference between ‘Order in Advance’ (OiA) vs. ‘Consignment’ models
o	Clinic’s using ‘Order in Advance’ model have significantly fewer unfilled 
o	Used ATL clinic’s (predominantly OiA) as a parallel to illustrate impact 

•	Outlined Unfilled Project – PCY vs. Program review process 
o	PCY process 
	Christine – new hire dedicated to working on unfills and my counterpart at PCY
	Unfilled sheet: report pulled from Power BI; updated by Christine to include the recent PA notes from Kroll and and her own (limited) evaluation and actions
o	 Eye-Q process
	Provided example of review process 
	Discussed Program’s NCD eligibility criteria determination – i.e. “Can Eye-Q resolve – Y/N”
o	Outlined in greater details some the different types of common unfilled that do not meet Program NCD eligibility criteria 
o	Advised of unfilled timeline – the eligibility determination/unfilled resolution is not immediate – e.g. program can replace a dose but require a valid Rx.

•	A central focus for Ali seemed to be consignment clinics and what happens with those doses that PCY is unable to commercialize, and that are not eligible for replacement with a program dose – “who is left holding the bag?” 
o	A patient’s unresolved unfilled from previous months’ reviews are often not included in their unfilled entries on subsequent monthly unfilled sheets – what happened to those doses? 
	From our experience + feedback from PSO – impression is that very few of these are reconciled via client samples
o	This has been a point of confusion for me for some time and I was not able to provide a satisfactory answer

•	Ali then asked me very directly what I felt were the main factors that continue to produce unresolvable unfilled Rx, and, with greater emphasis, how the issue could potentially be addressed
•	Advised that there are several outstanding questions that, if answered, would provide clarity and possibly help inform potential solutions –
o	e.g. “who is left holding the bag” currently; do all/how many clinics currently use LMS PRO to organize their injection clinics, etc.   

•	Reiterated that unfilled Rx are primarily produced by ‘Consignment’ model clinics and that my impression is that stock and patient files (specifically in regard to communications received from Program – e.g. ‘Unable to contact’ letters) are very disorganized in some of our clinics.
o	Seems that clinics do not always differentiate between consignment vs ‘in-clinic stock’, and that the doses they pull from the fridge are not clearly documented as being pulled for particular patients. 
o	Touched on how the number of legacy/white glove clinics we have in ON and how competitive the Ophthalmology space is in the province pose obstacles to potential solutions in this this context.

•	Did not discuss in any detail the need for greater alignment between program/PCY/field/PSO, or the responsibility/accountability of the different parties


Single Proposed Solution: Enhanced Luminav Pro Integrations  
•	Proposed that a significant portion of the unresolvable ‘types’ of unfilled could potentially be addressed through greater integration of LMS 360 / PCY / LMS PRO, and through the introduction of new checks and balances for clinic’s when setting up injection clinic’s and submitting orders.
•	These integrations would identify certain conditions/patient statuses, based on data pulled from LMS 360/PCY, that should always be (but are not currently) informing a clinic’s decision to inject a patient.
•	Through these new integrations, new checks and balances could be introduced to allow for either: 
A)	Increased clinic accountability: patients who fail to meet certain status/condition checks (e.g. all eligible program doses used) would be very clearly flagged; the clinic could be required to acknowledge the flagged issue before proceeding to add the patient to an injection clinic or to submit an order to PCY. 
B)	Preventative action: Clinics could be blocked from submitting order for patient who fail to meet certain status/condition checks (e.g. patient not enrolled)
o	Whether the check be is either A) or B) would depend on the clinic (hypercare etc.) or could decided similarly to how problem clinics in ATL (NB) were handled – i.e. consignment stock removed.

•	Greater integration and the introduction of new checks/blocks could serve to bridge the gap between ‘Order in Advance’ and ‘Consignment’ clinics
o	Order in advance clinics have fewer unfilled doses because the time between their placing of the order, receiving the delivery, and the injection clinic/patient’s injection allows the clinic to register there is an issue (delivery unfilled notice; review communications received from program - UtC/non-compliance letters etc); patient not enrolled) before they inject a patient. Consignment clinics will just inject the patient, submit the order to PCY, and discover too late that there is an issue.
o	
o	Regardless of whether a clinic is ‘Order in Advance’ or ‘Consignment’, all clinics must organize and add patient to their upcoming injection clinics ahead of actually injecting said patients 
o	Assuming most/all clinic do use (or could be persuaded to use) LMS PRO to organize their injection clinics, the proposed integrations could provide the time required for patient issues to be flagged by the clinic and/or pharmacy before a patient actually receives an injection. 
o	This flagging could be automated (as outlined in more detail below) or partially manual – considering we someone at PCY who’s sole job is working on these unfilled 
	a notice/update could be pushed through to PCY once a clinic finalizes the set-up of an injection clinic. This notice/update would include a list of all patients scheduled to receive an injection; Christine could review the upcoming injection clinic patient lists for our ‘problem clinics’

•	Proposed integrations/checks – LMS 360 vs. PCY    
o	Some of the required LMS 360 integrations may already exist in LMS PRO (e.g. ‘Patient enrolled?’); There is currently no PCY system/data integration with LMS PRO as far as I am aware.

o	Proposed LMS 360 integrations / checks
	Patient enrolled in program (profile exists)? – Y/N 
	Patient has used X number of eligible program doses? – Y/N
	Patient discharged as UtC? – Y/N (submission of a UtC letter should register in PRO)
	Patient discharged as X (Other) – Y/N

o	Proposed PCY integrations / checks
	Patient has an unfilled on file? – Y/N
	Patient has $X in outstanding AR? – Y/N

o	Proposed combined integration / check 
	Patient has a recent unfilled that was ‘inactivated’ via receipt of a program dose (PCY data) - AND – Patient’s coverage is still pending (360 data)  
•	Ali ended the meeting by outlining the following action items:
o	Forward PCY’s April unfilled summary report 
o	Draw up list of questions to be answered
o	List types/reasons for unfilled + how they could possibly be addressed (Eye-Q perspective)
o	Outline proposed LMS PRO enhanced integrations (as done to some extent above)
o	Draw up list of relevant parties who should be looped-in
•	I unfortunately did not clarify if Ali wanted this sent to him by next Friday, May 26, or in advance so that a meeting organized for Friday – so Ideally it would be sent by Tues/Wed next week.

General rough unfilled notes:

•	The Process: When the pharmacy fills the commercial doses at the clinic, there are patients identified where coverage does not go through. This could be for a variety of reasons:
o	A patient has not paid their insurance deductibles (common)
o	They are requesting a refill too soon
o	A patient does not yet have coverage approved AND
	Is unreachable by the pharmacy or PSP
	The prior authorization is not yet approved
	They have not completed the public application
	Is not enrolled in the PSP who can assist with the above
	NIHB forms are not signed by the clinic
	Patients private insurance plan has maxed out
•	When a patient maxes out, pharmacy notifies the program so that they can acquire a max out letter from the private insurer and send it to the public plan
	Program requires a valid Rx 
	Not all unfilled are valid
o	Largely an issue relating to Volume in ON → Unfilled are not unique to Sentrex PCY/our clinic – however the number of unfilled we are dealing with is
o	Sometimes helpful to consider Unfilled in terms of two type categories:
	First unfilled: point at which issue is identified; more easily explained and resolved – patient not enrolled; lapse in coverage; 
	Subsequent/multiple unfilled: Somethings gone wrong – clinic/PCY/program should all already be aware that there is an issue – depending on issue program will send a dose, otherwise dose more likely to remain unfilled.

•	Potential insights could be found in taking a closer look at the processes and level of colaberation in the ATL region between PCY/PSP/clinics 
•	Atlantic region (ATL) vs ontario (ON) – fewer unfilled in Atlantic – possibly because:
o	Much lower volume overall
o	All order in advance in NL 
o	Highest volume clinics in NS are Wholesale \\ other clinics will order in advance for glace bay clinic → represents half or more off all prov volume
o	Clinic/PSP Case mangers (CMs)/ pharmacy (PCY) communicate on every file 
o	Fewer hands in pot – I person/
o	PSP sending very clear comm re: outstanding SA/UtC etc – all parties looped in 
o	In serious problem clinics (e.g. continue to inject patient/multiple patients after a patient(s) been discharged from the program as Unable to Contact (UtC) – take away the clinics consignment stock
o	Field case managers (FCM) are looped in on all UtC/compliance issues 
o	Clinics are possibly more organized and manage their stock better
o	Generally a closer relationship between all stakeholders 
o	PCY generally does more?
o	Example – Dr. Wang/Jackman – Hybrid: Christa 
•	Quebec 
o	Two PCY sending us lists
o	Private patients only
o	Same issues – UtC, not enrolled etc.
o	QC problem clinic (think Ventresca) → difference: goes straight to Bayer 
o	Patient’s not part of equation 

•	Stock management
o	The two types of stock are supposed to be managed separately in clinic – ‘in-clinic stock’ vs commercial consignment
o	PCY responsible for managing consignment? Commercial consignment 
o	Float/commercial consignment – provided by Sentrex – should be managed PCY? On paper being managed by PSO?
o	Consignment (Program) 
o	On clinic’s side – simply puts in a sheet of x doses for x patients, do no specify type 
o	PCY received order – if do not know where PT is in coverage – e.g lapse (know program will cover it)
	Vs. reassignments 
o	After model 
	I need this many Eylea, I reassigned this many, I don’t need 
	E.g. 5 PTs did not show up – reassign to PT’s coming this week – we need to make sure documentation of that very clear  
	E.g. 
	HOW IS THEIR STOCK GETTING TOPPED UP? IS PCY EATING COST
•	Legacy clinics + competitive commercial region 
o	The program inherited many/most of our clinics and patients from another PSP administrator
o	Clinics very established in their in their ways/processes and very reluctant to change as a result
o	Ophthalmology is a very competitive commercial space in Ontario which makes it very difficult to be heavy handed with the clinics as they can, or will threaten to, switch to another PSP or drug
o	This reluctance to change and white glove treatment is a central issue for provider solutions Ontario (PSO) and our Field (FCM) teams – prevents us from trying to/being able to implement potential solutions or processes that may help address the unfilled issue easily 
	E.g. switch problem clinics from consignment to order in advance model; implement a standardized inventory/fridge management system and have a FCM go in on a regular basis for reconciliation; standardized patient file/appointment management; non-compliance / patient issues tracker etc.
o	They don't have the man power either and a lot of clinics are "picky" when it comes to who can touch their inventory
•	Out-of-network clinics 
o	Sunnybrook & St. Josephs (Dr. Iqbal, prescription shop)
o	No visibility, typically only made aware of issue when stock gets low (Iqbal)
o	Karen currently triaging SB – acting as a delegate in many ways 
•	Switching consignment to order in advance
o	For example Dr Orr clinic if we don't send a dose for a patient they will call and cancel that patient's appointment because they order in advance but then a clinic like TRI can't do that because they've already injected the patient
o	Look at ATL
o	Could create its own issues given the volume in ON 
o	PCY would struggle to keep up with reassignments, which would in turn make the reconciliation process for clinics more difficult.

•	Luminav PRO 
o	Overview:
	LMS PRO (Luminav PRO, or ‘PRO’) is proprietary software system that our company developed and provided to our clinic. Clinics can use PRO to create patient profiles, enroll patients into the EYLEA PSP (Eye-Q), set-up / add patient’s to an upcoming injection clinic, and to send EYLEA prescription orders to our pharmacy. 
	PRO has been integrated to some extent with both our PSP’s (Eye-Q) CRM (LMS 360) and our pharmacies system. As a result, certain information found in both systems relating to patients is available to the clinics in LMS PRO – such as if a patient is enrolled/discharged, how many bridging doses (NOW – initial dose, and holdovers (HO) – 3 total eligible) the patient has received, the status of the patient’s coverage and if a prior auth is pending.
	Our company (Sentrex) works very closely with the developers of LMS PRO/LMS 360/PCY system, and most enhancements / requests for greater integration are feasible as long as they are reasonable (scope, difficulty to implement) do not present a privacy breach risk (our clinics also treat patients with drugs other than Eylea)
o	IMPORTANT POTENTIAL SOLUTIONS can be found in greater integrations/enhancements between LMS 360/pharmacy and LMS PRO
	PRO should very loudly/obviously flag patient’s who: have been discharged/are not enrolled; pharmacy was previously not able to fill a dose for (unfilled)
	Depending on how receptive the clinic is / their preference: PRO could prevent clinics from placing EYLEA orders to our PCY for patients flagged for either of these issues 
	Greater integration could help to bridge the gap on this issue in terms of consignment vs order in advance clinics 
•	Order in advance clinics have few unfilled doses at PCY because the time between placing the order, receiving the delivery, and the injection clinic/patient appt. allows the clinic to register there is an issue (order slip that comes with delivery indicates PCY was unable to fill the dose for a patient; review communications received from program(UtC/non-compliance letters etc); patient not enrolled) before they inject a patient. Consignment clinic will just inject the patient and send the order in after the fact – discover too late that there is an issue.
	 However – all clinics need to set up their injection clinics prior to actually injecting patients. With greater integrations between PRO/360/PCY potential unfilled issues could be flagged before the patients come in for their appointment during the clinic and are injected with a consignment dose 
•	On PCY’s end – a notice/update could be pushed through to PCY once a clinic finalizes the set-up of an injection clinic. This notice/update would include a list of all patients scheduled to receive an injection; those for whom PCY has an unfilled/coverage is inactive could be flagged for TBD follow-up with clinic/PSP
•	On clinic end – patient’s who’s coverage is pending/not enrolled/UtC (info coming from LMS 360) would be flagged; patient’s who have an unfilled (info coming from PCY) would be flagged.
o	 Potential issues with PRO solutions and additional questions to answer
	Is seems some/many clinic use their previous/other MR systems to track patient files and patient appointments/injection clinics, and only use LMS PRO to submit orders for EYLEA (and often to enroll patients into Eye-Q) – How many of our clinics operate in this way? What is holding them back from fully adopting PRO?
	Unfilled doses due to patient not enrolled: Why are clinics able to create profiles for new patients and submit the NOW (initial) dose order to pharmacy if they fail to ‘Push’ through the enrollment form to eye-Q PSP? 
	Even if clinic does set up injection clinics in PRO:
•	Yes, but their scheduling software and their software that they used to document patients injections is different than the portal they order through pharmacy for. 
•	So unless somebody's physically going into our portal pulling that data and then adding it to the patient's file on whatever MR system they're using, it won't be effective
•	E.g. Nixon they use a system for ordering but then they use a paper system for when the patient's actually getting injected so into document anything and also put what drug and what eye

o	Broadly why? What should be happening? Ideal world – what?
	Everyone aware, stock managed properly, PCY needs to do more –
•	PCY is where all the info comes to together 
o	Having unfilled is normal – having 
	Accountability, inv/stock management
	Accountability – who has ownership 

o	Field employed by Bayer || PSO employed by Sentrex
	PSO wants to leverage knowledge of field to advance Sentrex interests 
	Field is employer by client (Bayer) and is concerned with breaching silo 
o	One team – all ophthalmology minus Eye-Q
	Before not engaging Eye-Q b.c Bayer did not want to be involved.
o	Show live example to Ali 

•	Unfilled project: Eye-Q PSP + PCY
o	PCY unfilled review process 
	Christine is my counterpart at PCY who’s sole job is working on/attempting to clean up unfilled
	Christine is newer and less experienced than previous PA who was working with me on unfilled project
	Christine does not do any actual adjudication (only test bills) and mostly just: updates the unfilled tracker with the most recent adjudication results and PA notes in Kroll; follows up with clinics re: unfilled for certain types of unfilled patients – e.g. UtC patients, not enrolled patients, patient’s who are eligible for a no charge drug (NCD – holdover/NOW) dose, but the program requires a new enrollment form (EF) in order to send a replacement (the EF acts as a valid Rx – if required info is missing on EF, it can’t be used by program to send free drug – e.g. eye being treated or the # of doses requested) etc.
	Christine’s lack of experience and her not being permitted to adjudicate means:
•	Less accurate assessment/identifying reason as to why a dose cannot be filled/billed 
•	Due to lesser accuracy of assessment: poorer communications to clinic/psp regarding unfilled patients
•	Inability to troubleshoot/find creative adjudication solutions that a more experienced PA may be able to use to resolve certain unfilled
	Potential gaps in PCY process – invalid unfilled records 
•	PCY failing to register that some unfilled entries on tracker (report pulled from Kroll) are not valid unfilled. PCY fails to register some invalid unfills due to the interplay of three primary factors: NCD doses sent by program (HO + NOW doses), Eye-Q program enrollment date, and standard treatment scheduling (per monograph – patient receive injections no less than 28 days apart, and 1 dose every month typically for the first 3 months)  
•	A dose/Rx can be unfilled at one point in time can be filled (replaced) at a later date for a number of reasons (commercialized via back-billing, reassignment, replaced via a NCD dose sent by program)
•	When a unfilled dose is filled/replaced by one such method, PCY is supposed to ‘inactivate’ the relevant unfilled – this does not always happen/does not happen right away
•	PCY does not currently have a consistent process to confirm if an unfilled is valid/should have been inactivated 
•	Instead, the Eye-Q CM’s working on this project do their best to validate unfills – the process to confirm that an unfilled entry is valid (or if an unfilled entry should possibly have been inactivated) goes as follows: 
o	Confirm: 1) Dates of unfilled (does time between order dates make sense?) 2) how many NCD doses were sent by program and dispensed 3) when was the patient enrolled in Eye-Q  4) do all of these factors align with a typical patients treatment schedule? Should an unfilled have been inactivated?  
o	
	Train Christine on Luminav and review process 
•	Not enrolled
o	Are all clinic in ON using PRO? 
o	How able to send an order if patient is not enrolled?
•	PCY should be doing the the actual reconciliation 
o	They can use help line, see error 
•	Unfilled sheet – what happens to old unfilled? Sheet does not reflect total unfilled
•	Bi-weekly field reconciliation for problem clinic – sign offs 
•	Potential Solutions/things that could help to improve situation/number of unfilled
Bridge between 

-	Section 1 Here are my questions 
-	Who’s left holding bag 
-	how do consignment clinics have stock – what happens to previous unfilled doses keep continuing to consignment – previous consign
-	Tech solutions – section 2 
-	Send list of April issues – pick one issue and go after it 
-	Separate – list of all things that cause unfilled and how they can we addressed
o	Not enrolled etc.
-	Pull together a team – who needs to be there 
Notes: 
-	accountability 
-	draw out normal processes for consignment vs. order in advance – indicated the areas where process breaks down and leads to unfilled.
-	Limitations 
-	To what estent do clinics use PRO
-	Identify potential breach issues with integrations 
-	Outline which parties would/should be responsible for what
-	Greater breakdown of identifying unfilled reasons 
-	Identify potential issues 
o	Breach
o	→ order in advance: reassignments 
-	UtC letters should generate a record in PRO
-	Defined UtC as a status, contrasted with not enrolled → in practice/in terms of solution very similar 

Meeting summary
-	Overview of issue 
o	What is consignment vs in clinic stock – provided by who
o	What is a NOW dose vs a HO – terminology 
o	Consignment vs order in advance clinics
o	Reasons doses are unfilled  
o	Focused on consignment clinics 
-	Outlined PCY’s process 
-	Outlined program dose eligibility and PSP review process 
-	Significant focus on what happens to those unresolved unfilled → who is eating cost
-	Focused on consignment clinics