Biosimilar Laws | Sonia Oskouei, PharmD, VP Biosimilars at Cardinal Health

(Speech to Text)

Biosimilar Laws | Sonia Oskouei, PharmD, VP Biosimilars at Cardinal Health

Mike Koelzer, Host: [00:00:00] Sonya for those who haven't come across you online, introduce yourself and tell our listeners what we're talking about today. 

Sonia Oskouei, PharmD: Sure. So I'm Sonya OS. I'm vice president of biosimilars at Cardinal health, and I'm in a role to lead our national biosimilar strategy on behalf of the providers and life science companies we work with.

So what we're gonna focus our discussion on today is really around the role biosimilars play in our healthcare and, and even some significant milestones we achieved recently with the first insulin biosimilar approved in the us. 

Mike Koelzer, Host: Basically we can't call anything generic because it's a huge molecule that you can't duplicate.

Is that close? 

Sonia Oskouei, PharmD: No, that's very close. Um, so really the reason why we can't call the generic to your point is that these aren't chemically identical, which is what. Brand to generic comparison is, and the reason why they're not chemically identical is because these are biologic products. Biologic medicines in general by nature are made from living cells.

And so you're always going to have inherent variability in biologics, even the same biologic drug or product. You could have batch to batch variation in the manufacturing process. That's just the, the, uh, inherent nature of working with living cells. So when you're making a biosimilar, the best you could essentially create is a highly similar version of an existing FDA approved biologic.

And so that's where you're even the term biosimilar comes from. 

Mike Koelzer, Host: Okay. Now the insulin that's made from the same company and has a different name, can be called a generic when it comes out of the same exact machine and you know, they've labeled it. Whatever instead of the brand name, is that even generic or even there when it's the same product with a different picture on the box?

Is that still only a biosimilar? 

Sonia Oskouei, PharmD: So this is where we get, um, it gets gray. a little messy cuz we start talking technicalities here. So it 

Mike Koelzer, Host: still is messy so I have a right to feel confused still. Yes, 

Sonia Oskouei, PharmD: no, this is a very confusing space. So what we have on the market today, we do have a few insulin products that have what they call authorized generics, which is the same manufacturer making their insulin product.

But I'm using air quotes, which you can't see in a generic version, why this feels so messy and appropriately. So it wasn't until March, 2020. So just last year, the FDA moved a certain category of biologic products, including insulin. To be managed and regulated as biologics from the traditional pathway that they were typically, uh, managed literally FDA made a cutoff point that if you are 40 amino acids in the chain, now you're gonna be regulated as biologics.

So this led to the conversion of insulin and other products like human growth hormone to be regulated as biologics by the FDA. So it's confusing because now that they're regulated as biologics, you're gonna have the originator biologic, you have this pathway to get a biosimilar. Now, now that it's regulated as biologics, but it's almost like that term authorized generic no longer makes sense because you can't, as we just talked about, have a true generic biologic, 

Mike Koelzer, Host: maybe even two brand names of the same exact product.

Maybe they're not even similar because it's like two bottles of wine with the same exact label. Maybe those aren't even exactly the same. Right. 

Sonia Oskouei, PharmD: Right. Yeah, no, I mean, that's why we talk about, um, so you have the biologic, you have, the biosimilar, insulins is extra confusing cuz you have this authorized generic that caught up essentially in this transition of how these products are being regulated.

But to your point, even if we look at an originator biologic in itself, batch to batch, like we mentioned, can have that inherent variability. It's almost like a biography. And I'm gonna say this, conceptually is almost a biosimilar of itself. 

Mike Koelzer, Host: Is there still room to keep the phrase generic equivalent or would that have been gone if they wouldn't have used it a few years ago?

Sonia Oskouei, PharmD: Yeah. Most likely what we would see is that. Entrance that continued the term of authorized generic, probably like we see it with no vlog. There's insulin as part. Right. So, I mean, we would probably continue to see that type of authorized generic terminology. Basically. You could think of the shift, like before the shift to being regulated as biologics, you have the orange book as your reference between brain and generic.

Now you have the purple book for biologics. So that's where you see biologic, biosimilars and interchangeable biosimilars designated. 

Mike Koelzer, Host: All right. So just to make sure I'm clear. So in my head, these authorized generics, what's another term for them then. So for example, you got the brand name a and you got the generic B, it comes off the same machine, let's say the same hour and they slap different labels on it.

What's another [00:05:00] term besides authorized generic. Is it an authorized biosimilar or what's the term? 

Sonia Oskouei, PharmD: You would think there, there actually isn't another term today. It's still being considered an authorized generic, but that's why it's almost like it's becoming gray. It doesn't make as much sense because now that these products are regulated as biologics, it's almost like, what is this?

Cuz these aren't really true generics. Um, especially now they're being managed as biologics, but today that terminology is still used for those few products that have authorized generics of insulin. 

Mike Koelzer, Host: I think the key term is authorized instead of just calling it a generic. You, you can't authorized 

Sonia Oskouei, PharmD: generic, the ag version.

Yeah. That's confusing. Very confusing. I mean, now we're talking especially about retail pharmacies. So the significance of our first insulin biosimilar being approved in the US is really a big milestone for a few reasons. One it's the, like I just mentioned the first biosimilar we have approved for diabetes care and what better product insulin.

It's the first biosimilar that's going to now be available at retail pharmacy sites of care. And it's the first interchangeable biosimilar to be approved in the us. But this is a huge moment for us. I would say biologics history by having this approval that just came, uh, weeks ago. And so the impact of this is gonna be pretty, I think, significant to monitor and 

Mike Koelzer, Host: follow.

You gotta bear with me. So I'm a little slow here, but let me see if I got this. No, this is confusing. a year or so ago. We had them saying that we had authorized generics. Yeah. That was a year or so ago. So you'd have the same company just slapping a different label on something. Yeah. But now we are saying that that's been expanded even further where the FDA's saying different companies are biosimilar and cutting to the chase.

If a pharmacist has something written for the brand name, they can use one of these biosimilars, even though it's not made from the same company, just with a different label. Is that the end point of this basically, 

Sonia Oskouei, PharmD: or the regulatory designation of interchangeability? That is the end point, but let me distinguish between the few things you said.

So first and foremost, yes, you're right. What authorized generics are, is the same manufacturer, essentially creating a, you know, authorized generic version of that product. A biosimilar is a different manufacturer, creating a product that is highly similar to that originator biologic. So that's the biosimilar approval pathway.

What interchangeability is, is a regulatory designation by the FDA that allows pharmacist level substitution per state. So not all biosimilars are interchangeable. In fact, until this insulin approval, we have not had an interchangeable biosimilar on the market. We could talk, talk around those dynamics more too, but interchangeability what's important to know it's a, it's an, a separate designation from the us FDA from a regulatory standpoint, and the way you achieve it typically is through, you know, as a manufacturer, via biosimilar candidate, you submit additional data, typically in the form of switching studies between the reference product, which we would, you know, say the brand biologic means the same thing between that agent and the biosimilar FDA has GA guidance available that says, you know, a switching study where you switch back and forth three times show no differences in outcomes would be what was recommended to achieve interchangeability designation.

And then at the end of the day, if they, the biosimilar candidate is approved as an interchangeable biosimilar, that's where it allows pharmacist level substitution per state law. So, this is like, when you, you know, go to the doctor, you get a prescription for a brand drug, you go to the pharmacy, the pharmacy dispenses generic drugs.

I mean, this is the same concept, right? It sounds familiar, but now you're able to do it with these biologics and biosimilars that are interchangeable 

Mike Koelzer, Host: up until, let's say a half a year ago, there was brand name products on the shelf and then the authorized generic same company and so on mm-hmm and the PBMs didn't like that because they still wanted us to sell the name brand, which had another half, a thousand dollars tucked in there for rebates and all that crap.

Right. I imagine now they don't want the interchangeable biosimilar there because now they've lost the control because now other manufacturers are coming in there. I wanna find the losers in this. Did I capture that right? That, you know, the PBMs don't want less money in this system? Who else are the losers in this?

When a biosimilar comes in? 

Sonia Oskouei, PharmD: Well, the whole goal of biosimilars, the reason why, you know, even at our organization, we have a strategy, many healthcare organizations have strategies around this is really because these are significant tools to bring in competition to the most costly treatment options and critical treatment options, increasing [00:10:00] competition, ultimately, hoping to lower price and enhance access accessibility to these critical treatment options.

So it's easy to get behind because this is a very patient-centric right. This is good to your point, the success and the extent of adoption of biosimilars in the US, specifically in the retail setting, as we're talking here, It's going to be very much influenced by how the managed care landscape reacts.

And to your point specifically, the PBMs, the whole goal of creating interchangeability that allows automatic pharmacist substitution is to create a more generic-like market. So you have that competition where ultimately clinically these are just as safe and effective products. So in the end, their goal would be okay, we're gonna reimburse the same amount.

These are the same products. And then you have that price competition ultimately hoping to lower cost. Now, this is why I'm saying this insulin approval as an interchange biosimilar. So significant because it's the first time we have that interchangeable biosimilar approved in the us. And now all eyes I think are going to be on how PBMs of the managed care landscape react to this because I have a feeling that.

We don't get the, um, I'll say managed care coverage or support, or at least at parody coverage for these interchangeable biosimilars, it's gonna get a lot of attention because you now have this ability for automatic pharmacy level substitution, first state laws, but the PBM still prefers the brand or the originator on their formularies.

It's basically like, what's the point? You know, how, how is this designation helpful? So this is why it's, it's very significant. And I'll say, this is what we're talking about is not biosimilar specific. As you know, this is the healthcare dynamic that is going on. And, and you're seeing from Biden's executive order from Congress policy discussions, this is becoming more and more at the forefront of the conversation with, with pricing reform.

So my personal opinion, I tend to be optimistic here is that there is going to be a tipping point. As we have more of these products come to market, we have increased competition. Um, I do think we're gonna reach a place. You're essentially gonna be forced from a managed care landscape to cover these lower cost alternatives.

It's just critical. It's when you think about us healthcare, pharmaceutical pricing, and the way to address the challenges we have, you really have two main paths. You could either have increased competition and lower costs and access or price controls, which everybody is fearful of and, and fears could stop innovation from occurring, all that.

So the competition is really what's needed, and that's why earlier I said, what better product to bring a biosimilar to than insulin discovered literally over a hundred years ago. And yet we're still talking about price scrutiny around insulins 

Mike Koelzer, Host: in our pharmacy. We don't carry any brand name, drugs, and it's not really common, but at least in Michigan, the competition was getting worse.

So heavy that we were losing our pharmacy was losing like a thousand dollars a day by carrying brand name medicines because the reimbursement from the insurance was about 90% of our purchase price. So then

We also don't carry any insulin. Why? Because even though there are authorized generics, the PBMs and even our state Medicaid is only covering brand name insulin. I'm just gonna say $500 versus a hundred dollars. They're only covering the brand name insulin, because if we took a generic insulin and tried to fill it under even our Medicaid program, they would say no, not covered.

And if you do get it covered through maybe a prior authorization, you're still. Getting reimbursed at this ridiculous cost because they're still treating it as a, I guess, a single source drug because it's from the company. So it's ridiculous, but we can't even carry insulin because of the reimbursement.

So to your point, this authorized generic is interesting because it seems that I don't know if they'll be forced to do it, but the attention, a story like mine and maybe multiplied by 20,000 other ones, if it happens that the insurances say, no, we're not gonna cover these authorized generics, it would seem that would hit the airways.

Right. And cause some problems. 

Sonia Oskouei, PharmD: This is where the whole promise of biosimilars is coming in. Through increased competition for insulins. This is what we're trying to address is this market dynamic. You need more players in the game to essentially bring that competition to a level where you could have these discussions with a managed care [00:15:00] landscape.

You have now lower cost alternatives. Here's a significant opportunity for cost savings. There have been three manufacturers supplying over 95% of the global insulin supply, essentially from the beginning of time. . So this is a huge part of the promise of biosimilars of bringing more competition to your point.

This is exactly the dynamic. Why we're, we're so interested in this product and the first interchangeable biosimilar, because if the payers don't start opening up access to these products, um, which we know today, by the way, in the insulin space, really you see coverage for the lower cost alternative in managed Medicaid plans and very limited.

This whole issue of price, prescription prices in the us. I mean, it's not gonna be addressed. That's why I said this. It's gonna shed a lot of light to your point. I think, um, we could eventually start to see patient Ava, advocacy organizations, and other organizations. That's, that's where I am, why I feel we're gonna reach a tipping point.

Mike Koelzer, Host: It's finally, maybe when you get different manufacturers involved, get them a little bit pissed off to say, how come mine's not on the formulary and so 

Sonia Oskouei, PharmD: on. Right? Exactly. And there are more players in this space that we should see more insulin biosimilars come to market. Um, we're expecting the first short-acting insulin biosimilar for no blog biosimilar to be approved this fall.

Um, that one would, is likely going to be also interchangeable. Um, just like the one currently announced. So we're gonna have more and more of these players coming into the market. And to your point, I think that's gonna be a. That's gonna be key to enabling access to these products. Cause all these dynamics you're explaining are really at the detriment of the patients who have to pay cash high, high deductibles.

And then of course the pharmacies that can't support these patients or the scripts that they have and their families have. So we want more and more of these agents and biosimilars coming to market. 

Mike Koelzer, Host: There's a large chain pharmacy that has brought insulin into their store. That's ridiculously low priced, helping the patient, but maybe pissing off some of the pharmacies, independent pharmacies and maybe other chains that can't get that medicine.

I know you're aware of it. Comment on that. Yeah, 

Sonia Oskouei, PharmD: no, we've, we've heard that pain point from our network of retail independence as well. It's losing patients because they can't compete on that price. And then you lose that patient scripts, the family, their scripts. Um, so it really is a big deal. , but that is where you also can see the potential benefit of having more competition in the market with lower cost alternatives like biosimilars.

These large chains are the ones you're referring to. Often the product can be a human insulin product as well, which we also have biosimilars in the pipeline for. So again, this is where having more competition in the market, the lower costs, these potentially get over as opportunities for our retail.

Independence can keep that, you know, the patients, their families, those scripts as well, and have more of a fighting chance to, to keep those scripts compared to some of these larger chains that get the deals by working directly with that manufacturer. 

Mike Koelzer, Host: What this does now, I think is at least it pisses off some people to say, come on, what's going on here, having this conversation and kind of opening up the door to get this going, get all the.

Wholesalers on board fighting in the same direction, the patients, all that kind of stuff. No, it's 

Sonia Oskouei, PharmD: true. I mean, we see, we saw this almost in the oncology market, so taking a step back in the US, we now have 20 biosimilars officially on the market. 17 of them have oncology indications. So the vast majority of activity thus far has been in oncology and starting off with those therapeutic oncology biosimilars for, um, the most common treatment options we, we see with biologics, there were a lot of healthcare providers in clinics and practices that were just to your point, eager for another option because you essentially had the brand manufacturer have control of the market for so long and control of the economic dynamics and the pricing, the contracting.

Then now that they had some more competition, you had an eagerness to try. To the biosimilars or these competitive products, just to have some more sense of control in the product choice that they have. Are those all interchangeable 

Mike Koelzer, Host: now? 

Sonia Oskouei, PharmD: No. So ly, which is Beatrice's long acting insulin for Lantis, just got that interchangeable biosimilar, official designation and approval a couple weeks ago by the FDA.

That is the first interchangeable biosimilar. What about the cancer ones? None of 'em are, but no other biosimilar is, but here's the thing that's important to explain. They, they most likely won't ever be. And I'll explain why this is where we have quite a bit [00:20:00] of, I'll say, continued educational needs.

When it comes to biosimilars on what this designation actually means, why would a manufacturer go after a biosim candidate? So as we mentioned earlier, interchangeability it's first of all, unique to us. We're the only country that has it as a regulatory designation. And what's most important about this designation is the implications that pharmacist level substitution is.

Designation is gonna be most relevant or most meaningful for the pharmacy benefit type biosimilars. Those that are dispensed from a retail pharmacy or meaning specialty pharmacy, part D all the biosimilars we've had thus far are primarily medical benefit products. These are outpatient infused healthcare provider administered products.

So as a biosimilar manufacturer, you have to make sure you would get a strong ROI to see that designation. And that interchangeably designation is they have the most influence or weight or impact on pharmacy benefits type products. So it makes sense that these manufacturers, for all those oncology products or the three rheumatology infl, you know, biosimilars that we have available, it makes sense that they haven't even tried to go after interchangeability, cuz it doesn't make as much, uh, impact for those product types.

Mike Koelzer, Host: Were you saying that a generic company, let's say there's a startup who's making a biosimilar of, let's say a cancer drug. It would seem they want to make it interchangeable so they can get their drug to play in the game. Are you saying there's not a desire for that? 

Sonia Oskouei, PharmD: Well, the reason why a biosimilar manufacturer who's playing in oncology in the medical benefit space, for example, would not be as encouraged to seek interchangeability is because that product is not being dispensed by a pharmacist where the pharmacist is going to drive the conversion to a product healthcare provider, prescribes it.

And then you go to the infusion center. For example, they administer it at that point of substitution, automatic substitution is not their medical benefit space in those classes of trade. 

Mike Koelzer, Host: So I understand what you're saying, where pharmacists are used to it, and they're familiar with it. And they typically want to go with a generic, even though it's not in the pharmacy, why wouldn't it happen in the infusion setting?

So 

Sonia Oskouei, PharmD: the switch can and does happen in bio, in the infusion setting. I mean, we look at the oncology biosimilars, uh, all of them have exceeded 50% market share today, and that's not, that's not all just new diagnosis. That's converting patients to the biosimilars. So that occurs, but that is at the prescriber level or the physician level, or it's in a, it depends if you're talking about like the health system or provider clinic, some health systems, they have policies, for example, where it's, the authority is given to pharmacists to make the substitution to a biosimilar.

So there's, I'll say institution specific policies and strategies to converting the biosimilars, but in terms of a autumn authority for a pharmacist to automatically switch from a brand to a biosimilar, that's where the role of interchangeability designation comes in in a 

Mike Koelzer, Host: pharmacy, a pharmacist is used to it and they're like, okay, Mrs.

Smith, we can switch this. You're saying that is not in. Infusion setting, because those are more institutional choices and there's nobody really in that chain, that's gonna make that decision. It's not gonna be the infusion tech or something, making that decision. Is that what you're saying? That it's somewhere mixed up more in the operation than in pharmacy where it's a switch.

Sonia Oskouei, PharmD: Yeah. It's almost like who has the authority to make the switch, um, automatically per state 

Mike Koelzer, Host: law. I see. And so since most state laws already have that for pharmacists, they'll say, Hey, let's do that because pharmacists can already do this. Where on the other side, they can say, why go for interchangeability?

Because there's not a law that allows it. So let's not mess with that right now, unless we wanna change that. 

Sonia Oskouei, PharmD: Or you don't even need a law on the medical benefit side, because think about in a provider practice, for example an oncologist will write, okay, I wanna administer this product. Um, they could choose which product they wanna use, and there's a different incentive of reasons why they may wanna use a biosimilar over the brand.

So they prescribe it. And then that goes to the infusion center and the patient goes there, products infuse and get reimbursed, you know, that whole cycle. So that's like a practice setting where you don't always have a pharmacist doing an intervention there versus you could have a health system where you do have a pharmacist involved and approving the product.

And that's where I say you don't need the law made that could be formulary policies written for a health system to say, pharmacists can automatically substitute this, for example, for an out, for an infused product. 

Mike Koelzer, Host: And it sounds like then the reason why the interchangeability is beneficial on the pharmacy side is because, unless they're writing it as a DAW or something, right, the pharmacist.

Have that authority. So let's do it exactly, let's do it where we can, [00:25:00] even at a last chance, let's try to get the pharmacy to make this interchangeable. So let's put all of our, most of our eggs into that 

Sonia Oskouei, PharmD: basket and to those products that are going to be dispensed in a retail pharmacy. Exactly. Um, that's exactly right.

So this is like that brand generic dynamic that you see that we were talking about. You come to the pharmacy with a brand pharmacist automatically consulted or dispenses a generic. It gives you that same type of model, except with these agents 

Mike Koelzer, Host: bringing this full circle, that's gonna typically be more insulin, which you already see in that setting versus these other yeah.

Cancer 

Sonia Oskouei, PharmD: ones. Exactly. You don't see these products dispense in or the oncology biosimilars that you have that are on the market. Those aren't dispensed in a retail pharmacy. , 

Mike Koelzer, Host: there's not many positions where they bring somebody in, in a wholesaler just to explain what the hell's going on with this stuff.

Right. I mean, because most of these things, it's like the back of your hand, there's a generic and whether you're able to do it or not, but your whole job is really trying to discuss this with people and make 'em feel comfortable, I would guess. 

Sonia Oskouei, PharmD: Yeah. It's definitely part of it. I mean, education is a huge part of our strategy.

I mean, that's, we talk about, you know, I keep saying this is biosimilars, but this is also overall us healthcare. And, and this is significant. I mean, this is, as we mentioned, key tools to address. Accessibility and affordability of critical treatments. I mean, you look at the top jug expenditures in the US year after year.

Majority of them are biologics that either now have biosimilars approved for or in the pipeline to be approved for. So this continues to become more and more of a priority. And for an organization like Cardinal health, that I'm part of, we have a strategic focus on this area because it continues to become more of a strategic priority for the healthcare providers that we're supporting, especially over this past year with COVID.

I mean, we had more and more outreaches from healthcare institutions, looking at ways of creating or strengthening a biosimilar strategy to really maximize the value of these products. And so to everything we were talking about thus far, All the products due to the biosim we've had on the market, the discussions have been for, um, specialty offices, clinics, health systems, but now with this insulin first approval, it's opened up the door for a whole new site of care and retail pharmacies.

And that's why we're taking a lot of steps now in helping educate retail, pharmacists, and provide resources to help understand these products like we're talking about today. Be able to navigate them. We even created an interactive map that shows state by state interchangeability laws that you could go and understand.

Okay, what's my state specific law for biosimilar interchangeability. So we are doing as much as we begin to help prime and, and set the stage for retail pharmacists. Because again, these products weren't going to be managed. These insulin biosimilars weren't going to be managed as biosimilars until just recently last year when they transitioned to be regulated as biologics.

So until then, there really wasn't a reason for retail pharmacists to be as close to the topic of biosim. but now it's going to serve as a big opportunity. 

Mike Koelzer, Host: So I mentioned the name brand insulin companies. Can't be too happy about this, right? Because these are gonna be different companies, maybe startups, maybe some other generic companies making this now, is that right?

Sonia Oskouei, PharmD: Yeah. Yeah, it's more competition. I mean, it's what we see in the market. So it's not going to be to the extent of, we see like brands when they U lose their exclusivity periods and their patents, you have all these generics come in and then you see that pretty rapid price erosion. Yeah. This is the same type of concept of having more competition, lowering, lowering prices, except this is with biologics where you're not gonna have a ton of, you know, a multiple of biosimilars coming in at the same time, and there's not gonna be as rapid of a price erosion.

And the reason why, why that is, is when you think about starting back to where we start our conversation, the complexity of biologic products compared to chemically made generics. For example, the investments in manufacturing, even a biosimilar is still significant. It's much closer to the investment of creating a branded biologic.

So there. There's talks about like, well, is there eventually gonna be like a race to the bottom? Like we see generics. I don't, I don't think that's the case, at least in the foreseeable future, because all these manufacturers I invest in these still complex biologic products, they all need to kind of recuperate their costs as well in coming and investing in that market.

So there this, the competition will help lower costs, but it's not as extreme as you see in generics, but to your point, yep. Origin manufacturers, of course, this is bringing competition to those products where they haven't had it thus far, but I will say the we've started to see already benefits of biosimilars of the market and whether it be from having direct options of lower cost treatment options, like we've seen in oncology and immunology, not only from that, but you also see it fostering innovation from these [00:30:00] brand or originator manufacturers, which is a good thing too.

You're starting to see more. Novel dosage forms, combination products, um, just totally different treatments that are even improving outcomes. Furthermore, so the competition is good from a pricing standpoint, but also from an 

Mike Koelzer, Host: innovation standpoint, it seems like the brand name companies are just gonna come up with some baloney difference of their product that maybe isn't chemical difference, but maybe a different type of injector or something like that.

I mean, it doesn't change the drug, but I imagine it doesn't change the interchangeability of it, but I suppose it could. 

Sonia Oskouei, PharmD: Yeah. So, well, that's actually a good point. I mean, brand manufacturers that we've seen thus far based on the biosimilars, we have taken different strategies. We've seen, for example, in rheumatology, we have three infliximab biosimilars, which are biosimilars for Remicade.

And in that scenario, you could see the originator brand for Remicade, which is Janssen competing on price with the biosimilars. So if you look at ASP, the average sales price quarter over quarter, you see all, all those products kind of mimicking each other, going down in ASP. So that competition is doing what it's intended to do, right?

Lowering price. And that manufacturers are competing with the biosimilars. When you look at oncology, you look at some of the therapeutic oncology biosimilars, the originator manufacturer decided not to compete on price thus far. And so you see the average sales price brain consistent in the biosimilar average sales price continue to decrease.

So I would say also you see manufacture by manufacturer strategies. It depends on the company as well, but to your point, another strategy is trying to make the biosimilars obsolete. So trying to move on to newer products, newer administrations forms like I was talking about so that you won't even wanna use the biosimilars or the originator biologic.

And this could be a whole nother topic, but. The reason why insulin activity today is so important is that this interchangeability designation announcement came. And we're gonna see how this plays out because in my mind, this is just a snapshot of what's to come and what we might see for the number one selling drug in the world, Humira, which is anticipated to have biosimilar competition by 2023.

And there are a few Humira biosimilar candidates that are seeking interchangeability too. So having this first interchangeability designation with insulin will give us the experience that'll shed to light, maybe some of the challenges, ways that it could be improved, all really in preparation for some of these huge, huge products like the 

Mike Koelzer, Host: adalimumab.

I agree. I think insulin is a nice entry into this idea because like my example of the $500 brand name versus the hundred dollars generic made by the same damn company on the same day, just a different label. And to think that. People don't have access to that hundred dollars one versus 500. And just getting that information out is like, well, then you can say, well, we've done it with insulin.

This is, you know, this is the year 2027, and we've done it for five or six years with this and seems to be going well, you know, it's a nice pattern then. 

Sonia Oskouei, PharmD: That's, I mean, that's why I say, I think with more competition and hopefully by the time 20, 23 more experience some of these practices, I just can't see that they're sustainable.

Mike Koelzer, Host: Once you bring 'em out into the light, it's like their whole strategy is darkness. 

Sonia Oskouei, PharmD: Yeah. It's, we're having a lot more, um, like I mentioned, from, from a congressional right government relations standpoint, government affairs, there's a lot more activity happening, you know, from both administrations over the past several years, it's a bipartisan issue.

I mean, there's more and more coming to light. There's even, um, Congress passed two laws, not too long ago. One is on, uh, literally called advancing biosimilar education act where there's a focus on creating more biosimilar education. And the other was around the ensuring innovation act and that was intended.

And that's been created in the past for the very reason where any exclusivity period granted to a brand manufacturer is on the foundation of true innovation and not to delay competition from lower cost alternatives makes sense. So there's more and more attention on these activities coming, which is why I say, I do think there's gonna be a tipping point where you're going to have to cover these lower cost alternatives.

You're gonna have more and more competitors. It's gonna be hard, harder and harder to justify not doing. 

Mike Koelzer, Host: Any listeners. I have usually decided to take a little break when I start talking about medical stuff. but not that I'm good at business, but I'm worse at medicine. It looks like 50 years down the road. It seems like almost every drug is considered a biologic because it's interacting somehow with your body and your genetics.

And maybe it's not crazy individualized for a person, but because your DNA is such that either you [00:35:00] are a certain category of person or whatever you could argue in 50 years, like almost everything's gonna be a biological drug. 

Sonia Oskouei, PharmD: Yeah. It's one of the fastest growing categories of treatment in the world and in the US, it's also the most expensive category Which is why this competition is so important. I mean, you think about what biologic products are what's going on right now. I mean, vaccines, insulin treatments for cancer treatments for rheumatologic conditions like rheumatoid arthritis and Crohn's disease. These are all biologics that are being used to treat.

So these are critical and important. We want continued innovation and newer products coming to market, but that's where you also want more competition coming into the market. So these are accessible and affordable. You know, an average effectively treated rheumatoid arthritis. Patient could cost up to a hundred thousand dollars.

Ophthalmology. We have biologics that are most commonly used to treat the leading cause of blindness that could cause up to $24,000 in eye a year. So these things are expensive. These are critical life changing and really have revolutionized treatment options for critical conditions, but they're extremely costly.

So we want to have more competition to, again, increase accessibility for these of these 

products. 

Mike Koelzer, Host: I 

have two daughters with rheumatoid arthritis 

and they say, it's not hereditary, but I've had a couple daughters with it. And 

they say, they're treating my daughters when they're young so that, 

you know, 

they don't have hands that don't work 50 years from now.

And that's where you're saving some of those costs by doing some of that stuff now. But yeah, it'd be nice if it was cheaper. 

Sonia Oskouei, PharmD: Yeah. Well, that's what I mean. You look at currently as part of that, List of approved biosimilars. So we technically now have 30 FDA approved biosimilars, but only 20 of them officially on the market assembly.

That Atlantis biosimilar that recently got interchangeability that technically has to make it even more confusing. Assembly is currently on the market, but not as that interchangeable biosimilar designation because they got caught in the transition period where the FDA regulated it. So now that they made the official approval and the announcement that it's an interchangeable biosimilar, the manufacturer's basically gotta relaunch it as an interchangeable biosimilar.

So not to go down that rabbit hole, but technically I'm just saying that because we technically have 20 biosimilar on the market, despite having 30 approved the difference there is really due to patent litigation settlements between the biosimilar companies and the brand companies that have essentially delayed the availability of those products.

And based on those patent litigations umbrella, for example, is a biologic commonly used in rheumatologic conditions. May not see biosimilar competition, despite having got the approval already, may not have a competition come to market by 2020 until 2029. Humira's like I said, we're most likely gonna see by 2023, but to put that in perspective, that means Humira's gonna be on the comp on the market for over 20 years without competition.

Bra will be on the market for over 30 years without competition. So this type of patent issue too, and the challenge delaying products coming to market is a real issue too, which is why you see some of these bills being passed and Congress talking about 'em. But, to that point that we made earlier, Especially for a product like ENBR, by the time that biosim can come to market, I would argue it's probably not gonna even be a relevant treatment choice.

Mike Koelzer, Host: It's kinda like don't start taking a trip to a star right now in a certain space vehicle, because you're gonna pass that a hundred years that we spent now in a day with a new 

Sonia Oskouei, PharmD: vehicle. That's a good analogy or that Star's gonna burn out. It's not gonna even be there. 

Mike Koelzer, Host: You said ENBR okay. So for our listeners, I think a new drug invention may be like 17 years or something.

And let's say seven of those are spent in research and all that. So maybe there's 10 years on the market. Why does ENBR get 

Sonia Oskouei, PharmD: so long that was through patent litigation settlements that they had with a biosimilar manufacturer in what the originator had. So what you see is originator manufacturers, um, based on their product that we bring to market will have many patents.

Um, and these patents on that product can be things from dosing intervals. They could be down to the buffer that's in the solution. Um, Humira is notorious for this patent. Uh, Humira has over a hundred patents on that 

Mike Koelzer, Host: product. Let's say a drug gets 10 years in the market. You're saying it's not a traditional drug patent.

It's some other patent that for some reason has longer 

Sonia Oskouei, PharmD: can extend the exclusivity period. Yeah. So what's interesting is biologics in the us. When they're granted approval, they're granted 12 years of market exclusivity. That's for being a new biologic product on the market. That's actually the highest that I know of in the world.

I think the second highest that I've heard of is Australia , which has 10 years of exclusivity. So us grants, 12 years of biologic exclusivity, once you're approved, some of these products can have ex extended [00:40:00] exclusivities based on the patents they have on these products for all those different things that I talked about that could be patent 

Mike Koelzer, Host: patented other than the chemical.

Yeah. What are some of those things that are not just chemical related? Yeah, 

Sonia Oskouei, PharmD: it could be the device that the drug is administered and some of these could be established after. You approve the product. Oh, yes. Um, but that's where some of these bills are coming in, to avoid or prevent what they say, evergreening of these products.

So you're seeing more and more actions against doing that type of extending your exclusivity period. Orphan indications, for example, is another reason why, you know, a product could have an extended exclusivity period. Um, but that's, that's been brought to light. And I will say probably with Humira has been, um, brought to light quite a bit with that patent litigation.

And what they say is many, many patents that they have on some of these critical treatments. And that's why these bills are coming out to say making sure any exclusivity period is based on true innovation, not to just prevent competition more and more coming out on that topic. 

Mike Koelzer, Host: I imagine that let's say your average drug tablet, they maybe have kind of a blueprint and anybody can make this and you probably need authorization still.

I'm sure you need authorization, but it's probably. A higher percentage of time where they'll authorize something, cuz they'll say, yep, that's a chemical. But with the biosimilars, I imagine that there's probably fewer cuz a company can make this and it's probably not as much of a rubber stamp as you would have with just a 

Sonia Oskouei, PharmD: chemical.

Right. That's what I'm saying. From an investment standpoint, a biosimilar is closer to the time and dollar investment of an originator biologic. So it still takes significant investment and you essentially, um, reverse engineering the biologic to create the path to this biosimilar and create this product.

Right? Yeah. So a lot more investments go into this, the manufacturing of a biosimilar, which feeds into the market dynamics that we see today in terms of pricing, um, with these, with these products as. 

Mike Koelzer, Host: Sonia, what do you do all week? 

Sonia Oskouei, PharmD: I just hang out at the beach. I wasn't 

Mike Koelzer, Host: implying that breaks your week down.

Let's say there's a handful or five or six main things you do. What do you do? You're talking to people like me. Yeah. What's involved with your week. 

Sonia Oskouei, PharmD: What I do with my time in the, you know, during the weeks is all around bringing and supporting a healthy competition in the US market to enhance accessibility of these products.

So education is a big, I would say a lot of work that we do engagement with our providers to understand the operational challenges, the economic assessments, what's going behind the considerations of utilizing biosimilars. And how can we support the evaluation of the adoption process? Where, where it makes sense.

It's working with life science companies and the biosimilar companies to help them understand what is the current market environment? How should you prepare for coming, bringing a biosimilar to the us? Um, it's working with our government relations team as well, and having a voice at the table for some of these policy considerations or educational efforts by the FDA or the CMS, um, initiatives that could be more, I would say, supportive or encouraging the, the development of further education on biosimilars and creating a supportive healthcare environment that could enhance the accessibility of these products from our outcomes division centered on retail, pharmacy networks.

It's looking at ways that we could work with even payers on being able to help bring lower cost treatment options and bring savings opportunities for patients. Now that we're going to have more and more biosimilars hit the retail setting. So my position is really looking across the organization and leveraging the capabilities we have to maximize 

Mike Koelzer, Host: biosimilars.

How many people do you have at your disposal? Is it just you or do you have a little army of people? So 

Sonia Oskouei, PharmD: I, I always joke that they say, you know, um, the biosimilars team I'm like, well, the whole organization is the EMRs team 

Mike Koelzer, Host: because that's where a big future of pharmacy is. 

Sonia Oskouei, PharmD: Right? Yeah. These are, they're still, I mean, there's close to a hundred biosimilar, uh, candidates in the pipeline as the ones that are on the market start to as say, maximize their market share.

You're gonna have the entrance of new products, biosimilars coming in the market. So I have a team that I work more closely with. That's dedicated. I have a director and my team that's leading the retail biosimilar strategy focusing on now that we have insulin preparing for the Humiras and these other pharmacy benefit type products.

We have, but to all those different divisions I just spoke about it's really having these strategic work streams that we're able to work across the organization on, on different opportunities. How many people 

Mike Koelzer, Host: call you boss, besides your husband? that's gonna make a joke. Yeah. how many people are you boss 

Sonia Oskouei, PharmD: over?

I mean, from a direct line, it's just one and part of it's based on our organizational structure, like our, our marketing communication support kind of sit in their own division, but they support the business units. I 

Mike Koelzer, Host: gotcha. But they support you. What do you [00:45:00] do though? I'm not gonna report to your boss and tell 'em I found something out, but what do you do?

Do you sit at your computer and send emails all day or do you post COVID? Are you gonna travel to companies and sit in and talk to them? Are you, what do you do? During the week. Is it a lot of email? Is it a lot of phone calls? Is it a lot of traveling? What do you do? 

Sonia Oskouei, PharmD: So, yeah, so these days I'm not traveling.

And then I don't think many people are doing too much of that, but if it wasn't COVID, I probably would be traveling more and more to different sites and really meeting with our different provider types. Like the pharmacists, we work with the providers, we work with to understand what their pain points are, where they need support, what 

Mike Koelzer, Host: providers, give me an example of that.

Sonia Oskouei, PharmD: Sure. So it could be pharmacies or it could be health system, pharmacy leaders. Um, it could be clinics where we think of specialty clinics that service oncology clinics, rheumatology clinics, even retina specialists, um, all the different therapeutic areas that biosim may touch. 

Mike Koelzer, Host: You're not sitting in the back room over some stale donuts and cold coffee at pharmacies.

Right. You're hitting certain organizations. I imagine. I think 

Sonia Oskouei, PharmD: both are important from my view. Yes. It's not individual. Um, although I often like to join those discussions because we have account teams that are more dedicated to sites specifically or pharmacy specifically that are there to support. So I often join those discussions because it's important for me.

You 

Mike Koelzer, Host: already have a rep that represents a pharmacy or goes to the pharmacy and so on, but you might come in on piggyback on 

Sonia Oskouei, PharmD: that. Well from a strategic standpoint, yes it's meeting with senior leaders from different either healthcare organizations or the pharmaceutical companies or, but I will say it's, it could be different levels.

I also like to join in those discussions that are more with an individual independent pharmacy and an individual clinic because you also wanna have that perspective of. Down to the operations of adopting a biosimilar. What does that look like? What are some pain points? So we have, I mean, from an organization like ours, we have many advisory councils too, for example, that we have with different entity types or organization types.

So having continuous insights on what's going on, ultimately informs our strategy on what we need to be focusing on and working 

Mike Koelzer, Host: on, asking it negatively, what would get you fired and positively? How do you know when you're doing your job? Because you're not really sales, you're more like information, but how do you know when you've done your job?

Well, or do you just find out when you're in the unemployment line? 

Sonia Oskouei, PharmD: Yeah. That, well, you never know. 

Mike Koelzer, Host: I doubt that. I'm just wondering though, how do you know when you've done? What are you supposed to do? Here's why I ask: it sounds like a pretty cool job, because you can kind of get creative because there's no pioneers in front of you because it's a new thing.

So how do you know when you've done enough. 

Sonia Oskouei, PharmD: Where I find a key metric for defining success in my role is bringing cost savings to the providers we support. So if I see from our health systems, our practices, that's helping their bottom line, which means they could get that one extra administrator to help do prior authorizations, all the, I mean, these are the downstream effects that define success in a role like mine.

Mike Koelzer, Host: So you can look at what their spend was on something last year and see where it's cut down and so on. And that's certainly a solid metric to go on. 

Sonia Oskouei, PharmD: That's a critical standpoint. Of course, everything we're doing comes from education. And we do market research. We do surveys. I mean the educational component of this, um, and seeing greater adoption and clinical confidence.

I mean, that's a sign of effective education as well. So the more we could do to develop these resources, you know, FDA creates a lot of this material, but increasing the material. But I always say you can't just have every. How often do you go to the FDA's website? Right. And like, look at education.

So we need multi stakeholder educational efforts when it comes to this, to our point earlier, I feel like this is something that is like years down the road, we're all gonna be laughing. Like, remember when biosim much first came to market, just how we hear stories of remembering when generics first came to market.

So the more we could do to just help the overall acceptance of these products that are based on sound scientific evidence, um, is, is steps in the right direction as well. 

Mike Koelzer, Host: If you, for some reason, lost this job through no fault of your own, of course. Cause I know you're doing a great job. Yeah. But if you, for some reason were not able to continue with this job, let's say Cardinal stopped doing biosimilars or something like that.

Let's just say something crazy. Yeah. What would you do on your own in this market as a business? What would you do? like in the biosimilar market, like if you were a pharmacist, but without Cardinal. Yeah. What would you be doing? I mean, you wouldn't probably just be selling them. You mean still 

Sonia Oskouei, PharmD: focused on biosimilars?

Mike Koelzer, Host: [00:50:00] Yeah. What would you do in biosimilars if you had to make money in biosimilars, but on your own, what would it be? That's a big question. Maybe something like this consulting. 

Sonia Oskouei, PharmD: I was gonna say something around, it could be consultative like supporting developers or even providers and being able to evaluate and manage these products.

I could see some presence in government relations and government affairs, because this is a much bigger challenge. Bio Somers to me is just a vehicle and a great use case to bring visibility to a lot of the challenges in healthcare. , 

Mike Koelzer, Host: it's a hot topic that gets you involved with the current problems in healthcare.

Sonia Oskouei, PharmD: Yeah. And it's, I mean, these are all important for multiple reasons. Ensuring we have lower cost treatments available to patients and the managed care landscape evolves in a model that encourages it is important because what do we have developed to your point in the future? I mean, we have many biologics.

We have cell gene therapy, precision therapy is becoming more and more prevalent where you have companion diagnostics and biomarkers that are informing which treatments are gonna work or not work in cancers. I mean, these are all critical to that downstream effect of enhanced healthcare in the us.

So that's where I would say, I mean, a lot of my poly focus would be into ensuring this innovation and in improvement in patient outcomes can continue. Um, and you need accessibility to these lower cost treatment options to enable room and growth for these newer agents 

Mike Koelzer, Host: talking about innovation.

Whenever I look back in history, I always think that those people were. Not as intelligent as we are now, but that's not a true statement. But whenever I think of the past, I think they just didn't know very much, but look, a hundred years from now, I was watching a Ted talk the other day and they were showing 3d animation inside cells.

And they were showing how we think of cells as just a blob. But if you're really narrow in, if you could look inside of a cell, things are happening, you know, there's this little circle thing. And there's these little things with little feet, they're kind of walking down this tub, ULE inside a cell. I mean, there's really physical things happening inside the cells.

It's just really, really small, but you think of all the nano stuff now and you can't picture it now, just like we think we're so advanced from a hundred years ago, but you think of like biologicals being like, oh yeah, that's a biological, but someday, I mean, we could make nano stuff that could fit inside of a cell and actually tell this thing, what.

Tube to walk down or something like that. I mean, it's, it's huge. It's just, it's 

Sonia Oskouei, PharmD: incredible. I know this is not to that extreme, but there's an oral insulin candidate being studied in development. I mean, there's advancements in all areas where I think someday one day we're gonna be like, can't believe we were injecting ourselves.

Yeah. Like we could just take this tablet now or we can monitor it this easily. I mean, these advancements, I think, are gonna continue to work. 

Mike Koelzer, Host: What would you do if you were not in pharmacy? What path would you take? If they said no more medical? Where would you be going? 

Sonia Oskouei, PharmD: Oh, you took me outta healthcare too then.

Is that right? Oh, you're gone. 

Mike Koelzer, Host: No, you're no, I'm sorry on, you're doing a fine job, but no you're done. I mean, you're done anymore. No, we're skipping from biologicals. We're not going the pharmacy route. We're outta there. We're outta healthcare. We're outta healthcare. 

Sonia Oskouei, PharmD: Oh, wow. Well, if I still had my knees, I'd probably be a soccer player, but I played most of my life.

And so now I, um, I can't handle it. So that's probably out the window. Were you a good soccer player? I played in college and I played my whole life. Nice. Yeah. So it's kind of a, a sport that 

Mike Koelzer, Host: I love it. But you lost your knees cuz people kicked you on the knee. No. Is that right? 

Sonia Oskouei, PharmD: I didn't, I didn't lose my knees, but I, I can't handle soccer anymore 

Mike Koelzer, Host: because people kicked you or because there's too much use just too much use 

Sonia Oskouei, PharmD: running and stuff, running, playing soccer.

Yeah. My knees kind of hurt too much. I try to play soccer. 

Mike Koelzer, Host: All of you, young kids. I'm gradually hitting my stride again in life. Cuz I'm mid fifties and I'm getting in better shape now, but I did all the running and all that stuff. But everybody you talk to now who really did a lot of running and stuff, all their knees are shot and their hips are shot and things like that.

So I just kinda laid low. That's true. And now I'm really gonna power up here though, but there's a lot of people that just things have gone to crap. Yeah. Because they overused them. 

Sonia Oskouei, PharmD: You're right. I look back all the time. Like, you know, I have those friends that would play like inner meals or here are there for fun.

And now they're doing much better today. Like being able to play whatever. So I think it's like we're in there, but let's. You know when you, yeah. Yeah. I know when you love a sport. Hey, but I am trying to learn, um, tennis now. So I'm trying to shift gears. I'm very competitive. So I'm like, I think I can get really good at tennis I don't know, but we'll 

Mike Koelzer, Host: see, you know, what we old farts do.

I don't do it myself, but pickleball. Have you seen pickle 

Sonia Oskouei, PharmD: ball? [00:55:00] You know, I've seen signs and I've heard of it. Honestly, I'm not quite sure what it is though. 

Mike Koelzer, Host: Pickleball is like half tennis. you're playing with it like a wiffle ball. It'd be like taking a real baseball player and say, all right, start playing wiffle ball.

Yeah. Tennis is like saying start playing pickleball. It's a wiffle ball. Basically. You're on a half core. You're playing with a wiffle ball. It's got paddles and things like that, but it's, it's a little bit less stressful. So when we talk again in 10 years, you can say, well, Mike, I had to go in a pickle ball now.

Yeah. All right. So, so, so you're still on the stand here. What are you gonna do? Non-medical if you had to. Okay. 

Sonia Oskouei, PharmD: If I'm, well, there's two, two paths I could take. This one is just for fun, just something enjoyable. But if I really wanted to do a career that's outside of healthcare, probably something in, um, technology and, and see, I was about to say digital health.

And then I was like, Nope, I'm going back into healthcare. If we know AI, natural language processing, machine learning, these are all hot topics here, but I'll tell you that I've always been drawn to the new and latest breaking and, you know, innovation in in fact, I coincidentally, and this is this wasn't on purpose, but it actually played out this way.

And I enjoy it. Now, every role that I've had thus far has been a newly created position. Mm, interesting. Even from my second year residency, I was a first, second year health system, pharmacy administration resident at our, at our health system. So yeah, it's from that point, every position I've been in, there's nobody in it before me.

And I've, it's funny that that's the case, but I, I actually love that. You mentioned that earlier, just. It's almost like a cool role. Cause you get to create and innovate and go for new opportunities. Yeah. So anything that's at the forefront is new, um, I would love to be, I love being part of those types of initiatives.

Mike Koelzer, Host: I think that's a gift too, because there are people, especially pharmacists. We're talking about this in a show recently that yes, pharmacists get set in front of something and they say, do this and don't stop doing that for yeah. Eight hours. Maybe some people get bored from it. So let's say you need something even more exciting.

You take another job, let's say it's innovation or sales or, you know, whatever. There's still a solid metric there, you know, when you've done your job. Well, yeah. You know, because there's some metric there, but I think that this is very broad lumping, but I think that sometimes a pharmacy owner, along with the stuff you are talking about there, sometimes there's a little bit.

Angst there because you don't really know what the finish line looks like. You don't really know how to find it's undefined and it takes a certain skill to go about your weak kind of being undefined. You don't really know when you hit it. So that was the question. It's like, how do you know?

Well, you, yeah, that's a nice gift you have. And a nice observation you have of saying that's where you fit kind of in that undefined 

Sonia Oskouei, PharmD: role. Yeah, no, it's a good point. It's and I think both mentalities and all, anything in between is important. It's all important. It's all important. All very important. I agree.

I mean, but that's why I am in this role. When you try new things, you're finding new opportunities. When you get that first opportunity to increase patient adherence and you see the adherence rates go down. I mean, it's such a rewarding feeling. And then you create these models and the foundation to take it even further and expand and apply it to new initiatives.

That to me is always fun when you get to see that small success and then quickly translate it to expand, um, and grow it. But it's true. It's, it's a, it's very different, I don't have like a, I don't walk into the position to say, you need to hit this, this and this. And that's for this fiscal year, um, is really defining what that looks like and how we can bring the most value for all the providers.

We work and support with life science companies and all the other stakeholder 

Mike Koelzer, Host: types who knows where the field's gonna go. So I think you're in the right spot and I think Cardinal has the right person in the right spot so way to 

Sonia Oskouei, PharmD: go. Thank you. , that's very kind of me to say thank you and thank you for everything you're doing and taking care of the communities.

I mean, I hope more and more of them. Biosimilars and competition can bring more accessibility to these products where pharmacies like yours and others can really comprehensively support the patients than your communities with the right 

Mike Koelzer, Host: products. The thing that's cool about healthcare for me is that it's exponential of what's gonna happen in healthcare.

You know, it's not linear, you know, it's not linear back from the 1950s of penicillin until now. I mean, it's just exponential. It's just so amazing. Yeah. 

Sonia Oskouei, PharmD: I don't know if you saw it recently. I mean, there's like RNA based on the vaccines with COVID now looking at vaccines for HIV. I mean, these things are just ha the.

The velocity of scientific advancement is at a whole new level now. And it's exciting. 

Mike Koelzer, Host: Yeah. It's exciting. All right. Sonya pleasure meeting you. Thanks for talking. You too. 

Sonia Oskouei, PharmD: Thank you. I really enjoyed our discussion. 

Mike Koelzer, Host: We'll come back for an update if we need one or when we need one. 

Sonia Oskouei, PharmD: Absolutely. Hopefully I won't come back and say, I have tennis elbow after picking up tennis.

So 

Mike Koelzer, Host: tennis is really not an easy sport. That's [01:00:00] a lot of jarring and stuff like 

Sonia Oskouei, PharmD: that, but I see a lot of people play it like well into senior ages. So that's why I thought, you know, maybe this is something I could do for a very long time. I could 

Mike Koelzer, Host: be wrong though. I suppose they do. I never look good though, with little cotton balls on the back of my socks.

not a good look for me. All right, Sonya. Nice talking to you. Take care. You too. Take care. All right. Bye-bye bye.