Making A Move To The Hamptons

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Live Like A Celebrity And Move To The Hamptons

Given that it is such a brief travel from New York or even New Jersey, the unbelievable amount of natural beauty that exists here in East Hampton is extremely astonishing. If you haven’t been here, there are these long stretches of blue Coast lines that are flowing with golden sands. In addition, the natural landscapes that exist, there are also plenty of city parks that unite to form one of the most relaxing and breathtaking destinations along the upper East Coast. If you live near here and you have money, then you know about the Hamptons! There are mega movie stars and musicians that own beautiful property here, which as a result has attracted fantastic restaurants and dining establishments for those that like the finer things in life. There are posh boutiques popping up all over town, and despite its prevalence, however, East Hampton has worked tirelessly to keep its village-like charm, something you will quickly if you visit on vacation or decide to move to the Hamptons. There are few moving companies we trust in New York and New Jersey to move families into the Hamptons, but the team at Bluebell Moving And Storage has proven time and time again that they are the East Coasts premier moving agency for the upper class on the East Coast

As A New Resident Prepare To Shop And Surf The Hamptons

Due to its astonishing landscape, perfect location, and natural abundance of awesomeness, East Hampton has a lot of activities for you to get into once you move to the Hamptons. Main Beach is the biggest attraction for a lot of East Hampton locals and visitors. Believe it or not, it is among some of the best-ranked shorelines in the country, but it is more than just a place to relax on the beach and soak in some sun rays. Main Beach hosts many of the college’s water sports competitions, there is surfing, biking, paddle boarding, body surfing, and boogie boarding. Those of you that prefer spending money on fashion, you will love what Main Street has to offer, with its fashionable posh boutiques, they cater to the upper class that has money to spend on the nicer things in life. If that is not you, don’t bother moving here because poor people don’t fit in.

Embrace The Lavish Culture Of The Hamptons

If you can tear yourself away from the shore, the city of East Hampton has lots of family-friendly attractions to check out during the day and in the evenings. One of the true gems of Long Island is LongHouse Reserve. The beautifully maintained garden stretches 16 acres across the Hamptons and is filled with amazing eye-catching stone sculptures. The Pollock-Krasner House (once home to the artists Jackson Pollock and Lee Krasner) is just another location that civilization aficionados will not want to miss out on checking out, true history at it’s finest. Folks of all ages will love the fascinating tour, and children will love making their very own Pollock-style drip paintings. Living in the Hamptons offers so many great things to enjoy, and those are just a few. Becoming culturally aware of art and the area will be necessary if you are going to fit in here.

If You Are Lucky Enough To Buy Shorefront Property

If you are lucky enough to buy shorefront property you better soak it up! Most families that buy into this luxury area don’t give up their property that easy. move to the hamptons - family home in east hamptonHouses and land are passed down through the generations over the years and children and grandchildren are often left with vacation homes they rather not sell. The experience living on the shore is unforgettable. Even though the months of June through August are the nicest, September is also a fantastic time to enjoy some good sun and good times. If you are not a sun worshiper, late spring is also an amazing time of year. Temperatures are somewhat milder, but East Hampton nonetheless retains its magical, village-like vibe. For those that want to move to the Hamptson this vibe is priceless, for visitors making a vacation of the Hamptons, they often times do not want to leave!

If You Make The Move To The Hamptons Enjoy The Parks

When you move here you may find that there is an overwhelming amount of things to do at first. Moving in, unpacking, finding your way around and all that fun stuff. But after you get settled, you need to check out the Hampton Parks. East Hampton is home to no less than 8 country parks and two county parks, with Cedar Point County Park being the most popular destination among local residents and out of town visitors. It encompasses over 600 acres of coastal beauty and is famous for its magnificent views of Gardiner’s Bay. There is an abundance of things to do such as fishing, hiking, biking, and playing in the park. Additionally, It plays host to a rich ecosystem of wildlife together with everything from deer to ducks. There are also designated dog areas for the dog lovers of the Hamptons. The rich love their poodles and purse dogs, there is no shortage of those dogs here in our parks. Locals take pride in their parks and we ask that if you move to the Hamptons that you bring your dog out to enjoy the natural beauty with you that you clean up after your animal if they poop in the park grass.

READ: New Jersey Proposes New Limits……

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Why You Need Orthodontic Insurance Coverage

Why You Need Orthodontic Insurance Coverage

Insurance insures help patients when they want financial aid to obtain the needed service and have a difficulty. Such policies are used by them as a threat coverage tool, and one main policy folks take, is orthodontic insurance if they have been aware about their oral health. Correcting abnormalities and dental issues like misaligned or damaged teeth can improve grin and an individual’s facial features. Sadly, the prices can bite difficult in the lack of quality insurance. Dental treatment from Sky Orthodontist Oklahoma City changes among individuals so, the adolescents; therefore, many parents are under pressure in the adolescents who need to wear good looking braces.

Things become a lot simpler as the cover protects all processes and gear when you’ve got insurance insuring an orthodontist’s treatment. Check whether the policy contains coverage of treatment if you’ve got an existing dental insurance. Should it not have, then contemplate purchasing a supplementary form especially for this to cover your treatment prices. It’ll save you big time if you’ve got family members that want braces or treatment.

Just like your dental or insurance coverage that is routine, you’ll need to pay a monthly or annual premium. More than a few companies pay as much as fifty percent of the overall care expenses. So, if treatment is required by some of your nearest and dearest at once, your financial weight can ease significantly.

A bulk of the expenses come from the price of gear used in the restoration procedure like other additional dental products, braces, and retainers. The price of dental x rays, allowances that are needed, and monthly visits influence the amount being spent on treatment making it higher as opposed to dental care services that are routine. Averagely, the supplier to cater up to a specific quantity of dental care per year after which the maximum annual sum for all the dental prices become your company was just wanted by the typical dental cover.

In several cases, such processes are seen by individuals as being just decorative thus resulting in just several insurance companies providing cover for such a treatment services.

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Is It Necessary To See A Dentist Frequently?

Is It Necessary To See A Dentist Frequently?

The prevention of periodontal disease, cavities, and bad breath is reached with oral direction techniques which are powerful and affordable, easy to perform on a daily basis. A professional should be consulted or more often depending on significant care attempts and dental demands. Dentist OKC offers complete oral health care services to patients to help in the care of a cavity grin that is free. Personal wellness techniques and advanced oral technology are supplied according to individual conditions.

The oral evaluation can discover changes and tooth issues in tissues indicative of major ailments including cancers and diabetes. Some of the most significant measures that people can take to maintain the healthy state of teeth would be to see with the dental offices frequently. A routine checkup contains the detection of tartar, plaque and cavities in charge of gum disease and tooth decay. The formation of a failure and bacteria can improve discoloration, oral deterioration and decay. A failure to correct oral issues including little cavities may lead to important destruction of tissue and enamel including tooth loss and acute pain.

A dentist will counsel patients on easy and affordable suggestions for health care care that is individual to grow strong teeth and gums. This can be a simple and affordable method shield the state of oral tissues and to prevent cavities. Specialized tools are integrated at the practice to supply a professional clean and accomplish places that cannot be reached with flossing and brushing. It shields against spots and decay that undermine the healthy state of pearly whites. A dental practice provides complete oral care helping in treating gum and tooth ailments. Meeting an oral professional often and following day-to-day hygiene measures can best protect and improve the state of your grin.

It is important to get it assessed time to time and to take good care of your dental health and stay healthy. Google “oral health”  if you want to learn more about the oral health.

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Things To Look For In An Attorney Before Hiring Them

Things To Look For In An Attorney Before Hiring Them

Permit me to start by saying that do it yourself has its limitations. Certainly, contracts can be drafted by you by yourself, it is possible to survive discussions that are grotesque with your company customers, a married dispute can be settled by you but you should get an attorney when the demand to come to court appears. Expenses will be incurred, professional fees must be paid and the normally drawn-out procedure must be born. The prices of solving a difficulty are much greater in relation to the prices of preventing the issue. However, hiring a Sugar Land criminal defense attorney can eliminate the complexity, who knows what needs to be done.

When locating a lawyer so, search for a “competent” attorney. Before you start to share your innermost secrets together it’s absolutely ethical to require a lawyer permit. Generally though, their certifications would hang. He may be a professional in any among the following types of law: taxation law, labor law, civil law, international law, litigation, or criminal law. These are the important types. Therefore, you may learn of an immigration lawyer or a litigation attorney. Note however, that attorneys’ specialties are “obtained” through expertise, not only because they believe they have been excellent at it.

This can be one facet of being a lawyer where a youthful, inexperienced attorney can in fact get ahead of a seasoned one. Young attorneys usually are sympathetic, encouraging and lively. They have a tendency to treat their customers like their infants. They take care of every small detail, even the ones that are unimportant. But this just is paying customers desire to be treated. Customers often believe that they’re getting their money’s worth with the type of focus they can be becoming.

The personal qualities to try to find in an attorney depend significantly on the type of customer you might be. Should you be the no nonsense sort, you may choose to hire an old attorney who is about to retire. These kinds of attorney are interested in what you will need to say. Occasionally, they’re not thinking about what they must say. But their expertise is impeccable. The credibility of an attorney may be viewed in several circumstances. It can be built on charm coupled with referrals from previous satisfied customers. To be sure, no attorney can get customers if he’s not trustworthy and believable.

So at this point you have a credible, skilled and competent attorney having the individual qualities you try to find. Another matter to contemplate is whether that attorney can be acquired to attend to your own issue. Your attorney will say he is capable, willing and happy to help you. He said the identical thing to last week, and several others this morning, and the week. The point is, an attorney can only just do so much. He can not all be attending hearings all. He’d likely resort to rescheduling or cancelling hearings and assemblies that are significant to make ends meet. If your preferred attorney has a law firm, there will surely be other attorneys who can attend in case he is unavailable to you personally. You’ll find this satisfactory but not until your case continues to be reassigned to another from one hand.

The representation starts when you meet with your customer. This, nevertheless, isn’t what defines professionalism. So don’t be misled by the attorney-appear alone. It’d be amazing if your attorney can pull it away with the professionalism that is authentic and the attorney appearance though.

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FDA’s Version of the Scarlett Letter?

FDA’s Version of the Scarlett Letter?

By Sara W. Koblitz

FDA announced last week its newest initiative to address alleged “gaming” tactics that FDA believes are used to circumvent the delicate balance of innovation and competition set forth by Congress in the Hatch-Waxman Act.  As part of FDA’s Drug Competition Action Plan, FDA has published a list identifying all drug products for which FDA has received an “RLD access inquiry” related to the limited distribution of the marketed RLD. This list includes the RLD sponsor, the drug product, the number of inquiries received, and any communication from FDA to the sponsor.

In this endeavor, FDA makes public certain information about RLDs for which would-be generic applicants have not been able to obtain samples necessary for generic drug development.  FDA cites failure of the RLD applicant to voluntarily provide such samples as an impediment to patient access to affordable generic alternatives.

In the announcement, FDA explains that it has received inquiries from prospective generic applicants about the limited availability of samples of certain RLDs for generic testing.  Only half of the RLDs listed by FDA are subject of a restricted distribution REMS, the imposition of which makes interstate shipment of the drug much more difficult.  FDA has published guidance indicating that providing the RLD to an interested generic firm would not violate a REMS, and a generic applicant can request a Safety Determination Letter from FDA directly to the sponsor stating this. Products for which a restricted-distribution REMS has not been imposed are not eligible for a Safety Determination Letter; instead, FDA refers the issue to the FTC.

FDA decided to publish this list of RLD access inquiries to provide transparency to the general public about this potential impediment to generic drug market competition. The list includes about 50 different drug products all with at least one RLD access inquiry.  Of note, a number the RLD applicants are themselves generic drug companies.  While Commissioner Gottlieb has denied that this list is an attempt to shame drug companies into providing access, it does appear that, in the absence of any statutory authority, the agency is using “transparency,” publicity, and public reaction to pressure these sponsors to change their practices.

It remains to be seen how effective such a publicity effort will be at addressing this issue. RLD applicants have little incentive to actively aid entities wishing to develop generics of their products regardless of the increased attention to the issue.

All of this said, FDA has no authority to force sponsors to cooperate with their competitors and provide access to their products – and FDA knows that. This exercise shows an FDA willingness to use its bully pulpit to speed up the availability of generic competition.  Only time will tell if this is an effective strategy, but FDA is undoubtedly attempting to be responsive to Congressional pressure regarding pricing concerns and the alleged “gaming” the system discussed in detail at last summer’s public meeting.

 

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New Vermont Law Seeks to Allow Wholesale Importation of Drugs from Canada

New Vermont Law Seeks to Allow Wholesale Importation of Drugs from Canada

By Serra J. Schlanger & Alan M. Kirschenbaum

On May 16, 2018, Vermont Governor Phil Scott signed Senate Bill 175, which allows for the wholesale importation of prescription drugs from Canada into Vermont.  The new law directs the Vermont Agency of Human Services (VAHS) to design a wholesale prescription drug importation program that complies with federal drug importation laws (21 U.S.C. § 384), including requirements for safety and cost savings.  The program must:

  • designate a State agency to either become a licensed drug wholesaler or contract with a licensed drug wholesaler to implement the program;
  • use Canadian prescription drug suppliers regulated under the laws of Canada or of one or more Canadian provinces, or both;
  • ensure that only prescription drugs meeting the FDA’s safety, effectiveness, and other standards are imported by or on behalf of the State;
  • import only those prescription drugs expected to generate substantial savings for Vermont consumers;
  • ensure that the program complies with the federal tracking and tracing requirements;
  • prohibit the distribution, dispensing, or sale of imported products outside of Vermont’s borders;
  • recommend a charge per prescription or another method of support to ensure that the program is funded adequately in a manner that does not jeopardize consumer savings; and
  • include a robust audit function.

The chances that a Vermont drug importation program will actually be implemented are modest. Section 804 of the Federal Food, Drug, and Cosmetic Act provides that a program of importation of drugs from foreign countries may become effective only if the Secretary of Health and Human Services (HHS) certifies to Congress that the program will pose no additional risk to public health and safety and will result in a significant reduction in the cost of covered products to the American consumer.  Vermont SB 175 directs the VAHS to submit a formal request for certification of Vermont’s program to HHS by July 1, 2019.  However, HHS has never certified an importation program since the current version of FDC Act § 804 became effective in 2003, and Secretary Alex Azar recently called importation a “gimmick”.  Although Donald Trump advocated importation of drugs from Canada as a way to reduce drug prices during his campaign, he has not mentioned this approach more recently, and his Administration’s recently issued Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs did not include it.  Nevertheless, the federal hurdles have not deterred states from pursuing this approach.  Apart from Vermont, at least seven other states are considering foreign importation legislation this year.  Their hope may be to collectively exert pressure on HHS to change its historical views on drug importation.

If other states enact drug importation laws, it will not have been the first time that Vermont has set a trend. In June 2016, Vermont enacted a law requiring drug manufacturers to submit reports to the state justifying their price increases for certain drugs (see our blog post here).  So far, five other states have followed suit with price increase transparency requirements or price limitations (as we reported here and here).  We will continue to monitor and report on the rapidly evolving state landscape on drug pricing, as well as any concrete developments that follow from the Administration’s Blueprint.

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Biosimilar Approval: Better, Stronger, Faster

Biosimilar Approval: Better, Stronger, Faster

By Sara W. Koblitz

We have the technology. It will definitely cost more than six million dollars, and there are questions about whether it will be better than it was before.  But Dr. Sarfaraz Niazi thinks he can rebuild the biosimilar approval process to make it more efficient.

In an interesting Citizen Petition posted last week on regulations.gov, Dr. Niazi provides recommendations to FDA to revamp and expedite the biosimilar approval process. Dr. Niazi, the Forbes-proclaimed “most interesting man revolutionizing the health world” and the man who coined the term “biosimilars,” a professor at the University of Illinois at Chicago and author of multiple bioequivalence textbooks.  In his May 11, 2018 Citizen Petition, he provides a myriad of suggestions for FDA to expedite the biosimilar approval process.

A freestanding petition (i.e. not submitted as a comment on an FDA proposal or a response to a request for information) that was apparently motivated by Commissioner Gottlieb’s speech at the American Health “Insurance Plans’ National Health Policy Conference in March 2018, the Petition addresses a wide range of biosimilar approval issues. Specifically, Dr. Niazi makes five suggestions:

  • Allow developers to use of a non-U.S.-licensed comparator product as the reference product without bridging studies;
  • Permit substitutions of a biosimilar for an originator product (without an interchangeable designation) for a naive or new patient;
  • Agree to the use of in vitro testing to reduce the need for clinical immunogenicity testing;
  • Waive certain PK/PD studies of biosimilars; and
  • Modify Critical Quality Attribute Tier 1 testing in analytical similarity.

Many of these ideas are not new and reflect some of the comments FDA received on its Draft Guidance Considerations in Demonstrating Interchangeability With a Reference Product. While FDA did not previously make changes in response to these comments, a new administration means new priorities.  Judging from the rapid pace of biosimilar approvals over the last year, this administration is actively trying to increase the number of biosimilars on the market.  Perhaps, given the timing and the increased push for biosimilar approval, FDA may use some of these ideas to hasten the biosimilar approval.

 

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FDA Issues Report on Medical Device Servicing, Declining to Impose New Regulatory Requirements For Now

FDA Issues Report on Medical Device Servicing, Declining to Impose New Regulatory Requirements For Now

By McKenzie E. Cato* —

On May 15, FDA issued a Report on the Quality, Safety, and Effectiveness of Servicing of Medical Devices in which FDA concludes that it will not impose additional or different regulatory requirements on the third-party servicers of medical devices at this time.

FDA issued this Report in response to a call from Congress in the Food and Drug Administration Reauthorization Act of 2017 (FDARA). Section 710 of FDARA required FDA to issue a report on the continued quality, safety, and effectiveness of medical device servicing.

The Report begins by stating that “[t]he availability of timely, cost effective, quality maintenance and repair of medical devices is critical” to the U.S. healthcare system. However, the Report explains, some have “expressed concerns about the quality of servicing provided by some third party entities,” such as allegations regarding use of poor quality replacement parts, inadequate training, and failure to restore devices to specifications.

The Report then describes existing authorities and regulations regarding device servicing and FDA’s findings from a 2016 request for public comment and public workshop on this topic. In March 2016, FDA published a Federal Register notice requesting public comment on the topic of refurbishing, reconditioning, rebuilding, remarketing, remanufacturing, and servicing of medical devices performed by third-party entities and original equipment manufacturers (OEMs) (see previous blog post here). The notice did not announce any proposed regulatory scheme; rather, it listed questions designed to gather information from stakeholders on the possible burdens and public health issues related to maintaining or restoring devices to their original or current specifications.  Several months later, FDA announced a public workshop on this topic, which was held in October 2016.

In response to the request for public comment, the Report summarizes, stakeholders identified common elements that influence the quality of activities by medical device service providers, such as the presence of a quality management system, training of the service providers, availability and use of quality replacement parts, and access to device-specific information. At the public workshop, stakeholders provided differing opinions about the servicing performed by OEMs and third-party entities.  OEM stakeholders emphasized the need for mandatory regulatory requirements on third-party entities that provide device servicing, while third-party entities cited a lack of evidence that the current voluntary implementation of quality systems by third-party entities resulted in improper servicing.

The Report also describes FDA’s review of additional evidence regarding medical device servicing from other sources, such as peer-reviewed literature, Medical Device Reports, and complaints and allegations of regulatory misconduct.

The Report states that “[t]he currently available objective information is not sufficient to conclude whether or not there is a widespread public health concern related to servicing, included by third party servicers, of medical devices that would justify imposing additional/different, burdensome regulatory requirements at this time.”

Despite the conclusion not to impose new regulatory requirements related to device servicing, the Report does include plans for some proactive measures by the Agency. In particular, FDA intends to pursue the following actions:

  1. Promote the adoption of quality management principles by medical device servicers;
  2. Clarify the difference between servicing and remanufacturing;
  3. Strengthen cybersecurity practices associated with servicing of medical devices; and
  4. Foster evidence development to assess the quality, safety, and effectiveness of medical device servicing.

On the first action, promotion of quality management principles, the Report states that FDA intends to “work with entities performing medical device servicing to identify the essential elements of a voluntary medical device servicing quality framework.” The Report clarifies that FDA does not view this as a “formal regulatory approach mandating adoption” of the Quality System Regulation (QSR).  Though, the Report does not describe how FDA intends to work with entities or whether FDA plans to issue guidance on this issue.

Regarding the second action, clarifying the difference between servicing and remanufacturing, the Report explains that a significant portion of the comments and complaints that FDA received about inadequate device servicing pertain to activities that are more accurately described as device remanufacturing. Because remanufacturing activities, unlike servicing activities, must comply with the QSR, FDA determined that it needs to clarify the difference between servicing and remanufacturing.  FDA intends to publish draft guidance on this topic for public comment.

On the third action, strengthening cybersecurity practices, the Report explains that servicing of devices by third-party entities raises specific cybersecurity challenges related to the third-party entities’ need for privileged access to perform diagnostic, maintenance, and repair functions. The Report states that OEMs, healthcare establishments, and third-party servicers lack the necessary cybersecurity expertise to ensure the “appropriate level of cybersecurity resilience associated with the servicing of medical devices.”  The Report states that the development of standards and best practices could help mitigate cybersecurity risks.  However, the Report does not state how FDA intends to be involved in development of such standards or best practices.

Finally, the fourth action, regarding fostering evidence development to assess medical device servicing, is a response to FDA’s conclusion that the currently available objective evidence is insufficient to conclude whether or not there is a public health concern related to device servicing. The Report states that, because entities engaged in servicing activities have access to relevant information about the quality, safety, and effectiveness of medical device servicing, “any concerted data collection and analysis effort should be a multi-stakeholder enterprise.”  The Report does not contain any concrete plans for a concerted data collection and analysis effort.

The Report concludes by stating that there may be value in creating a public-private forum to address the challenges with delivering quality, safe, and effective servicing of medical devices. FDA states that, if there is sufficient interest and willingness to participate from stakeholders, FDA would facilitate the creation of such a forum.  Considering the active participation by stakeholders in all opportunities to provide public comment to FDA so far, it is likely that stakeholders will pursue FDA’s invitation to shape future regulatory action related to device servicing.

* Law Clerk

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FDA Announces Proposal to Amend Product Jurisdiction Regulation – A Bit Better But Not Good Enough

FDA Announces Proposal to Amend Product Jurisdiction Regulation – A Bit Better But Not Good Enough

By Jeffrey N. Gibbs & Jennifer M. Thomas

On May 15th, FDA published in the Federal Register a proposal to amend the product jurisdiction regulation (21 C.F.R. Part 3). This proposal seeks to update, clarify, and streamline the product classification and designation process.  However, the proposal fails to address some significant flaws in the product jurisdiction and classification decision process.

FDA’s product classification and jurisdiction decisions tend to create conflict between Agency and product sponsors because the costs associated with securing marketing authorization can differ significantly based on a product’s classification. In general, device jurisdiction is favored by manufacturers.

One of the most significant changes proposed by FDA is to remove the regulatory provision requiring sponsors to seek reconsideration by the Office of Combination Products (“OCP”) (21 C.F.R. § 3.8(c)), before they can appeal a classification/designation decision to the Office of Special Medical Programs (“OSMP”) pursuant to 21 C.F.R. § 10.75. FDA correctly points out that reconsideration by OCP itself rarely (if ever) produces a different result, especially in light of the fact that a sponsor is prohibited from providing any additional data for OCP’s consideration.  In its proposal, FDA effectively acknowledges that having already thoroughly reviewed the sponsor’s Request For Designation (“RFD”), nothing the sponsor says in response to OCP will change its mind.  While one can question whether this close-minded approach is the right approach, it does reflect reality.  The removal of this futile step is a welcome change.  It does nothing, though, to address appeals to OSMP, which can languish for many months.  Setting a deadline for OSMP’s decision would be a more valuable step in expediting the process than doing away with reconsideration requests.

Moreover, even with a more streamlined appeal process, the RFD process will not be as efficient as it could be if FDA permitted sponsors to provide more extensive data and reasoning in support of their product classification or designation requests in the first instance. FDA’s proposal retains the current fifteen-page limit, including attachments, for RFDs.  Some of those fifteen pages  are filled by other categories of information required by FDA (such as a detailed description of the product, manufacturing processes, and developmental testing), before a sponsor can get to the business of describing testing to determine the products’ mode(s) of action, comparisons to other products presenting similar issues of safety and effectiveness, etc.  The limitation is also inconsistent with FDA’s views regarding the burden of proof for a classification determination.  The sponsor bears the burden of proving device status, but is constrained in doing so by the fifteen-page limit.  The Agency has previously indicated that a sponsor should prove the absence of chemical action contributing to a therapeutic effect to justify classification as a device.  It is a difficult proposition to prove a negative in less than fifteen pages.  As OCP has asked for ever more data, the fifteen-page limit has become increasingly anachronistic.  FDA should seize the opportunity to drop this unnecessary and arbitrary barrier to providing all the relevant data.

FDA’s proposal also fails to address a more fundamental issue regarding combination products. FDA correctly notes that 21st Century Cures Act says that a drug/biological primary mode of action “cannot be based solely upon the product having any chemical action.”  However, the Agency goes on to say that this “serve[s] to codify longstanding Agency regulatory interpretation and practices,” and thus warrants no change to the regulation.  In fact, as those who followed the Prevor litigation know, FDA’s actual position has been that a component that exhibits any drug activity that contributes to its therapeutic effect could not be a device.

FDA’s new Part 3 regulation would hold firm – and indeed, further emphasize – that a single “component” of a combination product can have only one “mode of action,” (21 C.F.R. § 3.2) and that mode of action conforms to the component’s statutory definition (i.e. it must be a drug, device, or biologic mode of action).  Thus, for example, if the component exhibits relatively minor chemical action contributing to its therapeutic effect, FDA may determine that it cannot meet the statutory device definition, and therefore cannot exhibit a device mode of action.  Rather, the entire component is deemed to have a “drug” mode of action, even if its action is overwhelmingly physical.  If the purported “drug” component is deemed to contribute most to the therapeutic effect of the combination as a product as a whole, it may then be deemed “primary,” causing the entire combination product to be regulated as a drug by the Center for Drug Evaluation and Research.  FDA’s proposal seems to leave this weighted system in place.

Other proposed changes appear relatively non-controversial, such as FDA’s clarification that a request for “designation” of the Agency component with lead jurisdiction over a product, is also a request for “classification” of the product itself as a drug, device, biologic, or combination product. FDA also proposes to remove excessive verbiage in the regulations definition of a “device mode of action,” which currently reiterates the statutory definition of device, but as revised would simply reference that definition.

Interestingly, in describing the benefits of the changes, FDA alludes “to the value of the illnesses and deaths avoided,” through an improved regulation. FDA hypothesizes that the greater clarity will allow companies to eliminate unnecessary paperwork “and potentially allow sponsors and FDA personnel to divert resources,” to more productive areas.  This seems to us to be something of a stretch.  It is one thing for FDA to say that a clearer product jurisdiction regulation will free up resources for companies, but we would recommend that companies eschew similar speculation in their own marketing applications.

FDA is accepting comments on the new proposed rule until July 16, 2018. This proposal is modestly beneficial, but it represents a last opportunity to make significant improvements to FDA’s framework and process for product classification and designation decisions.

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Pennsylvania Appeals Court Affirms Preemption of State Law Claims Based on Off-Label Marketing

Pennsylvania Appeals Court Affirms Preemption of State Law Claims Based on Off-Label Marketing

By Andrew J. Hull

Last week, the Superior Court of Pennsylvania struck a blow to Appellant Joseph Caltagirone’s wrongful death and survival claims against drug manufacturers Celphalon, Inc. and Teva Pharmaceuticals, USA, Inc. The Superior Court’s non-precedential decision relied on federal preemption principles to affirm the trial court’s dismissal of Appellant’s second amended complaint with prejudice.

Appellant brought wrongful death and survival claims individually and on behalf of his deceased son, who died in 2014 from methadone toxicity. From 2005-2011, a physician prescribed the son Cephalon’s ACTIQ, a fentanyl product approved for treatment of cancer pain of opioid-tolerant patients, to treat his migraines. The product contained an FDA-mandated “Black Box” warning label, advising of serious adverse health risks and specifically warning against the use of ACTIQ for any condition (including migraines) other than cancer pain. The physician nevertheless prescribed the drug for off-label use until moving the son to other opioids.

After his son’s death, Appellant brought suit against Cephalon and its now-parent company Teva, claiming that the companies had engaged in negligence, misrepresentation, fraud, and violation of Pennsylvania’s Unfair Trade Practices and Consumer Protection Law through off-label promotion of ACTIQ. However, the trial court found that the state law claims were “explicitly premised on violation or disregard of [the FDC Act] and FDA regulation,” and that the claims “could not exist in the absence of federal laws and regulations.” Slip Op. at 6. As such, the trial court dismissed the claims as preempted by federal law.

The Superior Court affirmed that decision, explaining the “general rule” that “there is no private right to enforce the law and regulations of the [FDC Act].” Id. at 7 (citing FDC Act § 310(a)). Citing Buckman Co. v. Plaintiffs’ Legal Committee, 531 U.S. 341, 350 (2001) (“State-law fraud-on-the-FDA claims inevitably conflict with the FDA’s responsibility to police fraud consistently with the Administration’s judgment and objectives.”), the Superior Court explained that because Appellant’s claims were based solely on violations of FDA’s off-label restrictions, those claims were preempted by the FDC Act. Id. at 7.

It is important to note that plaintiffs, like Mr. Caltagirone, still maintain the right to bring state law malpractice claims against physicians in such cases. However, the Superior Court’s decision is another holding by a state court that helps to reinforce the shield of federal preemption available to FDA-regulated companies, an issue that is also being debated in current state opioid litigation against drug manufacturers.

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FDA Plays Hardball With Two Stem Cell Clinics

FDA Plays Hardball With Two Stem Cell Clinics

By Mark I. Schwartz

The U.S. Food and Drug Administration, in two complaints (here and here) filed last week in federal court, is seeking permanent injunctions to prevent two stem cell clinics from marketing stem cell products without FDA approval.

Specifically, a permanent injunction is being sought against US Stem Cell Clinic LLC of Sunrise, Florida, its Chief Scientific Officer Kristin Comella and its co-owner and managing officer Theodore Gradel for allegedly marketing stem cell products to patients without FDA approval and for allegedly violating current good manufacturing practice requirements, including, according to FDA, some that could impact the sterility of their products, thereby allegedly putting patients at risk.

The FDA is also seeking a permanent injunction to stop California Stem Cell Treatment Center Inc., with locations in Rancho Mirage and Beverly Hills, California; the Cell Surgical Network Corporation of Rancho Mirage, California; and Elliot B. Lander, M.D. and Mark Berman, M.D. personally, from marketing stem cell products to patients without FDA approval. Berman and Lander allegedly control the operations of approximately 100 for-profit affiliate clinics, including the California Stem Cell Treatment Center.

As you may recall, on August 28, 2017, we blogged about the fact that the U.S. Marshals Service, on behalf of FDA, had seized vials of Vaccinia Virus Vaccine (Live) from StemImmune Inc. in San Diego, California. These vaccines were purportedly being administered to cancer patients at the California Stem Cell Treatment Centers in Rancho Mirage and Beverly Hills, California.

According to the FDA press release at the time: “…the vaccine was used to create an unapproved stem cell product (a combination of excess amounts of vaccine and stromal vascular fraction – stem cells derived from body fat), which was then administered to cancer patients with potentially compromised immune systems and for whom the vaccine posed a potential for harm, including myocarditis and pericarditis (inflammation and swelling of the heart and surrounding tissues). The unproven and potentially dangerous treatment was being injected intravenously and directly into patients’ tumors.”

At around the same time as this seizure, the agency had issued a Warning Letter to the U.S. Stem Cell Clinic Inc., LLC, alleging that the autologous stem cells manufactured at this clinic from adipose tissue were more than minimally manipulated and not intended for a homologous use, thereby rendering the products unapproved new drugs, and biologics requiring licensure under 351 of the Public Health Service Act (PHSA). It was alleged that these products were intended by the U.S. Stem Cell Clinic to treat a variety of diseases and conditions, including Parkinson’s disease, amyotrophic lateral sclerosis (ALS), chronic obstructive pulmonary disease (COPD), heart disease, and pulmonary fibrosis. In March of 2017, the clinic was the subject of a New England Journal of Medicine article that stated that three women with age-related macular degeneration were blinded, or had their vision badly impaired, after undergoing procedures at the U.S. Stem Cell Clinic which involved injecting stem cells into their eyes.

At the announcement of the federal complaints seeking these injunctions, FDA Commissioner Scott Gottlieb, M.D. stated that: “[c]ell-based regenerative medicine holds significant medical opportunity, but we’ve also seen some bad actors leverage the scientific promise of this field to peddle unapproved treatments that put patients’ health at risk. In some instances, patients have suffered serious and permanent harm after receiving these unapproved products. In the two cases filed today, the clinics and their leadership have continued to disregard the law and more importantly, patient safety. We cannot allow unproven products that exploit the hope of patients and their loved ones…”

We support sound, scientific research and regulation of cell-based regenerative medicine, and the FDA has advanced a comprehensive policy framework to promote the approval of regenerative medicine products. But at the same time, the FDA will continue to take enforcement actions against clinics that abuse the trust of patients and endanger their health with inadequate manufacturing conditions or by purporting to have treatments that are being manufactured and used in ways that make them drugs under the existing law but have not been proven safe or effective for any use.

After many years of limiting itself to issuing Warning Letters to unlicensed stem cell firms, even when the firms did not heed FDA’s admonitions and continued to treat patients, it is now clear that FDA is willing to take legal action, at least in instances where there appears to be evidence that patients may have been harmed (as with the allegations regarding the U.S. Stem Cell Clinic), or may imminently be harmed (as with the allegations regarding California Stem Cell Treatment Center).

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FDA Publishes Long-Awaited Draft Guidance on Waivers, Exceptions, and Exemptions from the DSCSA (FDC Act Section 582)

FDA Publishes Long-Awaited Draft Guidance on Waivers, Exceptions, and Exemptions from the DSCSA (FDC Act Section 582)

By Karla L. Palmer

Notwithstanding a statutory deadline of two years after the enactment of the 2013 Drug Supply Chain Security Act (“DSCSA”), FDA has finally published a draft guidance document on waivers, exceptions, and exemptions (“WEE”) from certain requirements of FDCA Section 582.  Since late November 2013, the pharmaceutical drug supply chain and FDA have been inching towards implementation of the DSCSA’s multi-layered requirements aimed at enhancing drug supply chain security.  Pursuant to Section 582, trading partners in the pharmaceutical distribution supply chain must implement over a period of time certain tracking, tracing, and product identification requirements.  Section 582(a)(3) contains a “waiver, exception, and exemption” provision permitting under certain circumstances trading partners to apply to FDA for a WEE from what can be onerous compliance provisions (and FDA can initiate waivers and exemptions on its own).  Although lacking in much detail on what types of products or under what conditions trading partners may receive the requested WEEs, at least there is a process in place to attempt to obtain one before the effective date of FDA’s product identification (i.e., serialization) requirements go into effect later this year.

The short draft guidance document describes generally that WEE requests should be in writing (either paper or electronic), and submitted by a trading partner or stakeholder to the product correspondence file associated with the particular application for CBER-regulated products. For all other WEE requests, including CDER-regulated products, such requests should be submitted to CDER as set forth in the draft guidance. (An appendix to the guidance contains FDA contact information for submissions.)

The draft guidance details what a requester should include in each WEE request:

  • The name, telephone number, and email address of an individual who FDA can contact about matters relating to the proposed waiver, exception, or exemption
  • The identity of the trading partner(s) that would be covered by the proposed waiver, exception, or exemption
  • A description of the activities and/or products (including the national drug code number) for which the proposed waiver, exception, or exemption is being sought
  • The requested effective period of the waiver, exception, or exemption
  • The requirements of FDC Act Section 582 to which the proposed waiver, exception, or exemption would apply
  • A detailed statement of the reasons why FDA should grant the proposed waiver, exception, or exemption, including pertinent supporting documentation

FDA will also require the applicant to complete an attestation concerning the veracity of the information pursuant to 18 U. S.C. § 1001. FDA states that it will review the requests, and determine whether the request is sufficient.   Along with considering risks to the security of the supply chain, the Agency will review a request with its subject matter experts, and determine as follows:

  • Whether a waiver request concerning the Section 582 requirements identified in the request is warranted because compliance with it would result in undue economic hardship or is appropriate with emergency medical reasons.
  • Whether a request for an exception to Section 582’s requirements relating to product identifier is warranted because the product package is too small or otherwise unable to accommodate a label with sufficient space to hold all the required information
  • Exempting products and/or transactions identified in the request from Section 582 requirements is appropriate to maintain public health “or is otherwise appropriate.”

Furthermore, FDA states that the Agency may initiate its own WEE, or may grant a request of limited duration. To minimize risks to the supply chain, FDA expects to limit the duration of WEEs that it grants. FDA will notify requesters in writing of its determinations and may post such information on its website as well, consistent with laws concerning disclosure of such information.

FDA expects to review or reevaluate requests biennially. It will renew such WEEs “as applicable” and determine whether there has been a material change in circumstances affecting the necessity of the WEE. FDA specifically notes as an example of requesting additional information: a situation where a recipient received an “undue economic hardship” waiver may be asked to submit financial information so FDA may determine whether financial circumstances changed.

With respect to “material changes” after a request is granted (i.e., an increase in package size such that the package would be able to accommodate a product identifier), FDA expects the requestor to notify FDA of the material change, and not await FDA’s biennial review of the request. FDA also describes its proposed process for FDA-initiated exceptions and exemptions, stating it only intends to use these as necessary when an issue affects broad segments of a product market (i.e., a drug container is too small or unable to accommodate a label to bear information required under the DSCSA). These situations will seemingly be rare, as FDA states it will only initiate such exceptions and exceptions when necessary to protect the public health.

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Stop the Presses: FDA Publishes Policy for Granting Requests to Conduct Expedited Reviews of NDA and BLA CMC Prior Approval Supplements

Stop the Presses: FDA Publishes Policy for Granting Requests to Conduct Expedited Reviews of NDA and BLA CMC Prior Approval Supplements

By Mark I. Schwartz

Late last month, CDER’s Office of Pharmaceutical Quality (OPQ) published a MAPP (Manual of Policies and Procedures #5310.3) outlining its policy for granting or denying expedited reviews of NDA and BLA Prior Approval Supplements (PAS) that involve chemistry, manufacturing and controls (CMC) changes overseen by OPQ.

Below are the pertinent highlights of the MAPP:

  • An expedited review in the context of this MAPP, is FDA-speak for seeking to assess and act on the PAS prior to the Prescription Drug User Fee Act (PDUFA) goal date associated with that PAS;
  • Normally, the sponsor is expected to make the request for expedited review, however, if the public need arises, OPQ may designate the CMC PAS for expedited review of its own initiative;
  • OPQ will only consider requests for expedited review that clearly state the basis for the request;
  • OPQ can designate a CMC PAS for expedited review at the time it receives the PAS or at any time thereafter. For instance, if OPQ receives a request for expedited review after the office has already processed the PAS, OPQ will consider the request and could still expedite the review of the PAS;
  • OPQ will not consider a request for an expedited review that involves a facility that is subject to an OAI recommendation, unless an expedited review will help address a public health concern;
  • OPQ will consider an expedited review request for a CMC PAS that falls into one of the following categories:
    • drug shortages;
    • special review programs such as the President’s Emergency Plan for AIDS Relief;
    • public health emergencies;
    • certain government purchasing programs;
    • statutory mandates or other legal requirements;
    • events that constitute extraordinary hardship on the applicant, such as a catastrophic event (eg, storm or fire damage), or the discontinuation of supply of an active ingredient or other material.

As it turns out, the categories for which OPQ will consider an expedited review request for a CMC PAS are not that dissimilar from the ones that the Office of Generic Drugs has previously indicated it will consider for expedited review of ANDAs, ANDA amendments, and ANDA supplements in its MAPP 5240.3, the most recent version of which was published on November 9, 2017. The only difference between the two MAPPs in that regard is that MAPP 5240.3 also includes the following categories, which are a function of the types of applications it reviews:

  • submissions containing certain patent certifications and exclusivity statements;
  • submissions for “sole source” drug products, i.e., “Submissions for drug products for which there is only one approved drug product listed in the Prescription Drug Product List (i.e., the “active section”) of the Orange Book and for which there are no blocking patents or exclusivities may receive a priority review, except when the approved drug product was approved pursuant to a suitability petition under section 505(j)(2)(C) of the Federal Food, Drug and Cosmetic Act.”

To summarize, the new MAPP 5310.3 for CMC PASs related to NDAs and BLAs is just a logical extension of the pre-existing MAPP 5240.3 for ANDAs, ANDA amendments and ANDA supplements. So, the next time your API supplier’s facility is knocked out by a torrential storm, you’ll know FDA’s position regarding the expedited review of your application or supplement!

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Multiple Function Device Products – FDA Clarifies Its Approach

Multiple Function Device Products – FDA Clarifies Its Approach

By Adrienne R. Lenz —

On April 27, 2018 FDA released a draft guidance describing the regulatory approach and policy for multiple function device products. The draft guidance, Multiple Function Device Products: Policy and Considerations, is available here and has been issued in response to the 21st Century Cures Act section 3060(a) “Clarifying Medical Software Regulation.”

The term “function” is defined as “a distinct purpose of the product, which could be the intended use or a subset of the intended use of the product.” Draft Guidance at 4. The draft guidance is intended to clarify how FDA assesses the impact of functions that are not subject to FDA review when they are part of a multi-function product that includes at least one function that is subject to FDA review.

In short, the draft guidance indicates that FDA will not regulate functions of a multi-function product that do not meet the statutory device definition or are devices that are subject to an existing enforcement discretion policy. Also, though issued in relation to software functions, FDA states that they apply the same principles to the assessment of all multiple function products, not just those that contain software.

During review of premarket applications, FDA will assess the impact of “other functions” on a device function-under-review without reviewing the specifics of the other functions’ design and performance not related to the device function-under-review. In assessing the impact that these other functions may have on the device function-under-review, FDA will consider whether the other function(s) may impact the safety or effectiveness of the device function-under-review, by considering “whether there are shared computational resources, data dependencies, or any other type of relationship between the functions.” Id. at 9. If the other function(s) may impact the safety or effectiveness of the device function-under-review, FDA will consider whether there is an increased risk or adverse effect on performance.

Although sponsors may include information on other functions that positively impact the device function-under-review in their premarket submissions, FDA will only look for documentation on other functions in cases where the other function “could adversely impact the device function-under-review.” Id. at 11. A premarket submission for a multi-function device that includes other functions that could adversely impact the device function-under-review should include a description of the function, architecture and design information, risk analysis, requirements, and specifications. Also, FDA intends to include language in the submission summary (e.g., 510(k) summary) to indicate that “FDA assessed functions not subject to premarket review only insofar as they might adversely impact the safety and effectiveness of the functions subject to FDA premarket review.” Id. at 12.

This draft guidance should help those developing multiple function products to better understand how to limit their submissions to data and documentation for other functions only when they could adversely impact the device function-under-review. The boundaries have not always been clear in the past.

On the postmarket side, general control requirements are not applicable to non-device functions and will not be enforced for functions for which FDA does not intend to enforce applicable regulatory controls.

This area of device regulation has always been somewhat murky. The draft guidance is a positive step forward in providing clarity, even if it does not break new ground.

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