Bending the Trend: Strategies to Manage Your Pharmacy Benefit

Transcription

1 Bending the Trend: Strategies to Manage Your Pharmacy Benefit

2 Speakers Gail Levenson Principal, National Pharmacy Practice Xerox HR Services Alaina Sandhu Senior Consultant, National Pharmacy Practice Xerox HR Services 2 March 28, 2016

3 Pharmacy Benefit Marketplace Dynamics & Trends Today s Area of Focus Pharmacy Benefit Pricing Specialty Medications Formulary Strategies Retiree Benefit Strategies 3 March 28, 2016

4 Pharmacy Benefit Marketplace Dynamics & Trends 4 March 28, 2016

5 Pharmacy Benefits Overview Dynamics and Trends Prescription drug benefits are a cornerstone to a comprehensive health benefits program Appropriate and adherent drug therapy stabilizes various medical conditions and reduces long term medical costs Conversely, inappropriate prescription drug use, abuse and waste can lead to unnecessary costs and potentially higher medical costs Understanding and controlling prescription drug benefit costs is a top priority for plan sponsors Prescription drug costs continue to rise; prescription drug spend is increasing as a percent of plan sponsors total medical spend Specialty drug trend is in the double digits, with some industry experts forecasting it will represent almost 50% of total drug costs by the year March 28, 2016

6 PBM Landscape PBM Consolidation, expanded relationships with Retail Pharmacies CVS Health Combined with Caremark in 2007 Created a link between managed pharmacy (PBM) and retail Signed 10-year agreement with Aetna in 2010 Express Scripts Purchased Medco in 2012, creating largest PBM Signed 12-year agreement with Wellpoint in 2010 Optum/Catamaran Rite Aid SXC acquired CatalystRx in 2012 to form Catamaran Signed 10-year agreement with CIGNA March 2015, UnitedHealth Group acquires Catamaran March 2016, announced partnership with Walgreens to provide a similar mail order at retail partnership to compete with CVS Maintenance Choice Announced $2 billion dollar acquisition of EnvisionRx, a private PBM who covered approximately 4M lives Likely competition for CVS with expanded retail services Purchased by Walgreens 6 March 28, 2016

7 Pharmacy Benefit Marketplace Marketshare Three PBMs (CVS Caremark, Express Scripts and OptumRx) control 75% of prescriptions and 80% of the market by life count (Bloomberg Intelligence, July 23, 2015). PBM Marketshare by Total Prescription Equivalents Others 7% Medimpact Humana Prime 5% 6% 6% United Health + Catamaran 13% 9% CVS Health 24% Express Scripts 29% 0% 5% 10% 15% 20% 25% 30% *United Health Group owns the PBM, OptumRx; it acquired the PBM Catamaran during July Catamaran was the company formed from the combination of two PBMs, CatalystRx and SXC (completed during July 2012) and purchased the PBM RESTAT during August PBM = Pharmacy Benefit Manager 7 March 28, 2016

8 Pharmacy Benefit Marketplace Trends & Dynamics Fewer non-specialty brand drug patent expirations slowdown in savings from generics Increases in generic drug prices Rapidly rising specialty/biotech drug costs primary Rx cost driver There is no industry standard for what constitutes a specialty drug Generally includes biologic derived agents that target specific immune processes and proteins that are required to manage/treat complex, chronic conditions (cancers, hepatitis, multiple sclerosis, rheumatoid arthritis) Previously limited to self-administered and/or office-administered injectables and infused medications but many are now available as oral medications Represent 20% 40% of plan costs, which is only about half of total spend (as half is typically covered within the medical benefit), and expected to increase Trending 10%+ 8 March 28, 2016

9 Pharmacy Benefit Marketplace Trends & Dynamics Companies finding clever ways to increase revenue (e.g., compound prescriptions, manufacturer couponing) Compounds - What are they? Compounds are the result of a licensed pharmacist combining, mixing or altering ingredients in response to a prescription Roughly 7,500 of 65,000 pharmacies specialize in compounding Compounded medications have a place in therapy. However, there are concerns about the exceptionally high costs of certain compounded products Costs per compounded claim increased 100% from 2012 to 2013 Costs per claim as high as $10,000+ In most instances, there are safe, effective, lower-cost alternatives to compounded medications 9 March 28, 2016

10 Pharmacy Benefit Marketplace Trends & Dynamics Various factors contributing to the rise in prescription drug costs, not all of which are predictable or can be controlled by plan sponsors Knowledge is power: understanding the trends in the marketplace better prepares sponsors take a proactive, not reactive, approach to rising costs. Take advantage of your vendor, consultant and other partner relationships to stay educated on industry trends especially those with potential to impact your program Opportunities to implement or enhance your current pharmacy benefit strategy to include: Pharmacy Plan Design Management Clinical and Utilization Program Management PBM Pricing/Contracting Specialty Drug Management Formulary Management Retiree Strategies 10 March 28, 2016

11 Pharmacy Plan Design Management Strategies Set a target participant cost-share (e.g., 15%, 20%) Plan design change options to consider for best performance Add coinsurance prevent participant cost-share erosion, which occurs with prescription product inflation Enhance incentives to use the most cost-effective products (e.g., generics) Increase the differential between generics and preferred brands to $20 Replace provision that allows participants to pay the same for single-source preferred brands (those without a generic equivalent) as generics with an offer to lower payments for desired behaviors (e.g., participation in a diabetes program, only when using the mail-order pharmacy) Help ensure the plan shares in savings available from better pricing terms at the mail order pharmacy while keeping out-of-pocket costs reasonable e.g., change the 90-DS/mail copays to 2.5 x 30-DS/Retail copays Encourage consumerism and the most cost effective delivery channels Balance with affordability and access, especially for the most vulnerable segment of your population (specialty drug patients, etc.) Leverage member communication and technology/tools 11 March 28, 2016

12 Clinical and Utilization Management Strategies Discuss benefit philosophy regarding programs that help ensure cost-effective, clinically appropriate drug utilization (to avoid costly waste) Quantity limits help prevent waste and promote safe, cost-effective regimens Prior authorization programs help prevent inappropriate use of high cost medications (e.g., specialty drugs) and/or those that may be abused/misused (e.g., testosterone products) Step therapy protocols help ensure the most cost-effective therapies are tried before coverage of more expensive products is provided Coverage exclusions Specialty pharmacy management Leverage your data in decision making processes 12 March 28, 2016

13 PBM Contracting Strategies Buyers Market Negotiate Competitive Pricing Understand various pricing arrangements available and evaluate options to ensure the best option for your organization ( traditional, pass-through, transparent, cost plus, actual acquisition cost, etc.) Clearly defined definitions (e.g. rebates, brand and all-in generic drugs) Clearly defined, measured, reconciled and auditable pricing guarantees for both specialty and non-specialty medications If multi-year contract, negotiate built in pricing escalators Eliminate cross subsidization 100% rebate share with minimum guarantees paid quarterly Inflationary caps/protection Align pricing and contractual guarantees with industry best practices 13 March 28, 2016

14 PBM Contracting Strategies Audit, Audit, Audit Ensure contract has comprehensive and ongoing auditing capabilities Develop an ongoing audit strategy of all administrators Pursue contracts with greater flexibility around services Carve out specialty fulfillment to a 3rd party with an emphasis on acquisition cost Consider use of a rebate aggregator as opposed to PBM Consider employing a separate vendor for PA services other than the PBM Avoids conflict of interest when they are the exclusive mail/specialty vendor 14 March 28, 2016

15 Questions to Consider When was the last time the pharmacy program was marketed? Has it been in the last 3 years? Are you getting a market competitive deal? Should different vendor business models be evaluated given all the marketplace change/consolidation? Are you satisfied with the service you are receiving from your PBM? How long since member cost share has been evaluated? Is it keeping up with drug cost inflation? Does it encourage use of the most cost effective products and cost efficient delivery channels? Does your pharmacy program have a comprehensive clinical and utilization management programs in place? 15 March 28, 2016

16 Formulary Strategies 16 March 28, 2016

17 Formulary Strategies Formulary strategies are important in helping to control rising health care cost and improve member health. In a continuously evolving market, evaluating formulary strategies is increasingly important. Formularies are designed to identify preferred drugs for the most common therapeutic classes, guide product placement for tiered cost sharing, and identify therapeutic classes with formulary excluded products. PBMs differ in their approach to formulary options, and this will change as the market dictates. 17 March 28, 2016

18 Formulary Options Standard Formulary Covers generics and most brands and specialty medications Typically uses a three-tier copay structure with generics in tier 1 Focus still on generic options when clinically appropriate Restricted Formulary Emphasis on lower cost brand and generic drugs, both traditional and specialty Commonly excludes higher cost, less effective therapies Usually used in combination with utilization management programs More Restricted Formulary Combination of tiering, utilization management, and limited preferred drug lists Used in combination with utilization management programs Excludes certain specialty and non-specialty medications 18 March 28, 2016

19 Plan Sponsor Control Standard Formulary High Plan Sponsor Control Typically requires little to no utilization management programs be in place Utilization management that may be required are: quantity limits, age, gender, and limited step therapy edits Gives plan sponsor the control to dictate their plan design Restricted Formulary Medium Plan Sponsor Control Typically requires utilization management programs be in place to take part in the formulary Utilization management that may be required are: quantity limits, age, gender, and step therapy edits, prior authorization, mandatory generics Requires plan sponsor to exclude certain drugs/drug classes from coverage, may require specific copay structures, gives plan sponsor less choice in plan design strategy More Restricted Formulary Low Plan Sponsor Control Typically requires high level of utilization management programs be in place to take part in the formulary Utilization management that may be required are: quantity limits, age, gender, and limited step therapy edits, prior authorization, delivery channel requirements, mandatory generics Requires additional exclusions, may require specific copay structures, may require restricted choice in where medications are obtained 19 March 28, 2016

20 Member Disruption Standard Formulary Low Member Disruption Provides broadest coverage of brand, generic, and specialty medications Typically no required clinical intervention or review for members prescriptions Typically less than 2% of members affected Restricted Formulary Medium Member Disruption Excludes certain drugs from coverage to drive members to effective lower cost alternative medications Members will face more clinical review edits due to utilization management tools being in place Typical 3-7% members affected More Restricted Formulary High Member Disruption Most restricted drug formulary will give members the least amount of options, higher degree of drug exclusions in combination with incentivized copay structures in place to drive members to effective low cost alternatives Members will experienced more clinical review edits due to most aggressive utilization management programs being in place Typically 10-20% members affected 20 March 28, 2016

21 Plan Sponsor Savings Standard Formulary Low Plan Sponsor Savings Least competitive pricing arrangements (discounts) More access to high cost/ non-preferred medications Typically plan sponsors see up to 1.5% savings of gross pharmacy costs Restricted Formulary Medium Plan Sponsor Savings Drug exclusions allow for deeper discounts and potentially higher rebates for drugs on the formulary Drives members to effective lower cost alternative medications while potentially increasing rebates on brand medications on the formulary Typically plan sponsors see up to 5% savings of gross pharmacy costs More Restricted Formulary High Plan Sponsor Savings Most restrictive drug list, requires members to use effective lower costs medications, potentially maximizes rebates on brand drugs on the formulary Utilization management programs limit high costs utilization to medically necessary utilization Typically plan sponsors see up to 9% savings of gross pharmacy costs 21 March 28, 2016

22 Questions to Consider Have you looked at formulary options with your PBM? Are you looking for ways to manage your pharmacy trend? Do you have the ability to make changes to your formulary without union/ committee approval? Is your organization sensitive to member disruption and noise? Will the PBM allow you to grandfather current utilizers? 22 March 28, 2016

23 Specialty Medications 23 March 28, 2016

24 Specialty Drug Economics Specialty Drugs Produced with living organisms; some target specific gene First-time management and sometimes cure of previously untreatable diseases Multiple Sclerosis; Hepatitis C; Rheumatoid Arthritis; Array of cancers Specialty Drug Administration Oral; self-injectable; infused; inhaled Newer drugs majority oral or self-injectable Can represent 35% - 50% + of pharmacy plan costs Average Cost per Rx: $4, (30 day supply) 24 March 28, 2016

25 Specialty Drug Economics (cont.) Specialty Drugs Many require special storage/handling Virtually no generic equivalents Emergence of biosimilars Same efficacy as brand, but not identical estimated savings of ~ 15% - 30% Newly approved drugs in pipeline treat more common conditions, i.e. heart disease, diabetes > 300 Specialty drugs in marketplace; > 900 in pipeline Utilization generally, 1% - 3% of plan members Annual PMPM trend 20% - 30% range Typically, Specialty members use 8 non-specialty drugs as well 25 March 28, 2016

26 Specialty Drug Economics (cont.) Non-Specialty Drugs Only certain self-injectables require special handling Generic equivalents represent 75% - 85% of employer utilization Generic drug discounts in 80% + range Expected newly approved FDA drugs over next 5 years 2 out of 10 non-specialty Utilization approximately 97% - 99% Annual PMPM Trend 10% - 15% range 26 March 28, 2016

27 Specialty Drug Economics (cont.) Pharmacy Plan Coding and Pricing Precise coding Unique 11-digit National Drug Code (NDC) number per drug Captures drug s manufacturer, quantity, form, and strength Pricing source Average Wholesale Price (AWP) Medical Plan Coding and Pricing Physician Office, Home Infusion, Clinic Coding & Reimbursement HCPC J and Q codes Unique to drug or drug class Pricing Source Average Sales Price (ASP) 27 March 28, 2016

28 Specialty Drug Economics (cont.) Outpatient Hospital Coding & Reimbursement Revenue code Codes unique to infusions only 28 March 28, 2016

29 Specialty Drug Economics (cont.) Pricing Transparency Pharmacy Physician s Office, Infusion Centers, Home Outpatient Hospital Pricing Source Average Wholesale Price (AWP) Average Sales Price (ASP) Percent of billed charges Pricing Transparency Highest Less Least 29 March 28, 2016

30 Specialty Drug Economics (cont.) Typically, ~ 50% of outpatient Specialty drug costs through Medical plan: Site of Care ~ % Distribution of Specialty Drug Costs ~ Relative Cost Outpatient Hospital 45% Physician s Office 35% 1.00 Home Infusion 13%.75 Other 7% N/A Drug Administration and Professional Fees N/A Outpatient hospital: 2 4X Physician s office 30 March 28, 2016

31 Specialty Drug Economics (cont.) Key Cost Drivers Price inflation Drug pricing Increased utilization New FDA-approved drugs New FDA-approved indications for current specialty drugs Robust drug pipeline > 900 in development Drug mix Move to higher cost, newer Specialty drugs 31 March 28, 2016

32 Biosimilars What are they? Unlike generics where the active ingredients are identical to the originator brand drug, biosimilars are similar yet not identical copies of originator specialty medications Cannot automatically be substituted First biosimilar approved in the United States by FDA, Zarxio, a biosimilar for Neupogen. Expected savings of 20-30% compared to Neupogen Additional biosimilars seeking approval Remicade, Epogen, Neulasta 32 March 28, 2016

33 Patient Assistance Programs Opportunity for both employer and member to benefit from manufacturer sponsored assistance programs Targeted for specific high cost therapies Hepatitis-C (Harvoni) Multiple Sclerosis (Copaxone, Rebif, etc.) Rheumatoid Arthritis/Crohn s (Enbrel, Humira, etc.) Therapy specific copayment implemented Member consent obtained at the time of initial fill/refill Warm transfer to manufacturer assistance line True out of pocket reporting Most are not based on financial need 33 March 28, 2016

34 They re here PCSK9 Inhibitors Used to manage cholesterol in those who because of genetic condition cannot be treated by other statin options or those cannot tolerate statins Two approved on the market currently Will cost $7,000 - $12,000 per year per patient Therapy will continue for patient s lifetime Expected to cost the US health care system as much as $150 billion per year PBMs aligning with one of the two drugs. This alignment will drive the formulary strategy that the PBM employs (e.g., excluding one of the two products) 34 March 28, 2016

35 Specialty Drug Analysis What is it? 1. Specialty drug spending assessment examines comprehensive current specialty program performance information with benchmarking (under both medical and pharmacy benefits) 2. Opportunity analysis with financial assessment (clinical management, reimbursement management and site of care management) 3. Strategy recommendations with quantified savings opportunities 35 March 28, 2016

36 Specialty Drug Analysis Results and Action Items 1.Provider network strategy/reimbursement Development of Centers of Excellence (COE) for specific therapies 2.Improved claim processing rules Resubmission of claims with invalid quantity Block miscellaneous J-Codes from reimbursement 3.Mitigate inappropriate utilization Harmonize management rules between pharmacy and medical Block claims for inappropriate day supply 4.Maximize site of care opportunities Develop strategy to identify most cost effective benefit for reimbursement Redirect claims from high to lower cost sites of administration 36 March 28, 2016

37 Questions to Consider Do you know what your specialty drug costs are? In your pharmacy benefit? In your medical benefit? Is there pressure from senior management to get your pharmacy costs under control? Do you have a strategy to address specialty drug costs? Have you considered an exclusive specialty arrangement with your PBM? 37 March 28, 2016

38 Retiree Benefit Strategies 38 March 28, 2016

39 Employer Retiree Rx Options Pre-Health Care Reform Retiree Drug Subsidy (RDS) Plan sponsor continues current prescription drug program Plan sponsor receives a subsidy for maintaining prescription drug benefits that is Actuarially Equivalent (AE) to standard Part D benefit RDS covers 20% to 25% of prescription drug cost Double tax benefit for corporate employers Employer Group Waiver Plan (EGWP) Employer contracts with a vendor (usually a PBM) to provide benefits that can match the employer s current plan design Eligible for direct subsidy instead of RDS Advantageous for plan that cannot satisfy AE requirements Governmentals can reflect under GASB 39 March 28, 2016

40 Employer Retiree Rx Options Post-Health Care Reform Retiree Drug Subsidy (RDS) RDS payments taxable starting in 2013 Reduces real value of RDS to taxable groups Standard Part D benefit donut hole phased out by 2020 No impact to actuarial equivalence testing Employer Group Waiver Plan Plus Wrap (EGWP+Wrap) Standard Part D benefit donut hole phased out by 2020 Additional federal funds available to EGWP Direct subsidy Catastrophic reinsurance 50% brand discount from drug manufacturers in coverage gap 40 March 28, 2016

41 EGWP vs. RDS Subsidy Forecasts Year EGWP RAdjDS EGWP CGDP EGWP Reins EGWP Total RDS 2015 $23 / $30 $26 / $36 $25 / $35 $74 / $101 $43 / $ $22 / $29 $27 / $37 $30 / $40 $79 / $106 $45 / $ $21 / $28 $28 / $38 $35 / $45 $84 / $111 $48 / $ $20 / $27 $28 / $38 $40 / $50 $88 / $115 $51 / $ $20 / $27 $29 / $39 $45 / $55 $94 / $121 $54 / $ $20 / $27 $30 / $40 $50 / $60 $100 / $127 $57 / $67 RAdjDS =Risk Adjusted Direct Subsidy CGDP = Coverage Gap Discount program Reins = Reinsurance RDS = Retiree Drug Subsidy Source: SilverScript Insurance Co March 28, 2016

42 EGWP: How it Works Employer PBM CMS Employer contracts with PBM Contract can be either self-insured or fully-insured PBM implements employer s plan design PBM receives financial subsidy from CMS PBM plan passes back all subsidies (in a self-insured plan) and charges administrative fee PBM assumes CMS compliance responsibilities 42 March 28, 2016

43 Medicare Part D Benefits 2011 and Beyond Donut Hole Coverage Expanded generic and brand coverage Donut hole filled in by % discount on brand drugs Discount determined after any PDP provided gap coverage Pharma discounts and additional federal subsidies make EGWP more valuable relative to RDS Year Generic Benefit Brand Benefit Brand Discount % 0% 50% % 0% 50% % 2.5% 50% % 2.5% 50% % 5% 50% % 5% 50% % 10% 50% % 15% 50% % 20% 50% % 25% 50% 43 March 28, 2016

44 EGWP Examples Plan Design (in Donut Hole) $200 cost for brand drug 20% coinsurance Rx Payment Coverage Current Plan EGWP + Wrap Gross Cost $200 $200 Base Plan Pays $160 $5 Discount N/A $100 Wrap Plan Pays N/A $55 Retiree Pays $40 $40 44 March 28, 2016

45 Are you a candidate for an EGWP? An employer participating in the RDS program A non-taxable entity A taxable entity with little or no tax liability An employer offering prescription drugs to Medicare-eligible retirees A plan sponsor with a drug plan that does not pass the actuarial equivalence test for RDS A government entity that wishes to reflect Medicare D impact in its GASB 43/45 accounting A post-65 retiree program with more than 100 eligible retirees and dependents 45 March 28, 2016

46 Why Consider an Employer Group Waiver Plan (EGWP)? Provides additional subsidies to reduce overall pharmacy costs Receive monthly subsides as well as quarterly and annual monies to help offset pharmacy costs Viewed as an administrative change - not a plan design change Depending on PBM, can customize to be seamless to retirees Reduces administrative burden versus RDS Responsibility for EGWP administration shifts from employer to the PBM PBM handles all appeals, grievances, compliance, etc. with assistance from the employer/union on eligible members for enrollments/disenrollments No actuarial attestations or reconciliations with CMS Eliminates need for creditable notice of coverage notifications Close coordination with client regarding enrollments/disenrollments 46 March 28, 2016

47 Case Study Large self-funded employer Approximately 15,000 Medicare-eligible retirees Previously receiving RDS Implementation Implemented for 1/1/2013 Started implementation in March 2012 Savings Implemented cash savings approximately $5 million over RDS The associated FAS expense savings for 2012 were roughly $38 million Employer s year-end 2011 APBO was reduced by $340 million due to the EGWP 47 March 28, 2016

48 Questions to Consider Are you still providing coverage to your post-65 Medicare-Eligible retirees? Are you a paternalistic organization that will not discontinue coverage for these retirees? Have you had an analysis performed to determine the value of an EGWP? If not EGWP, have you considered other strategies to manage your post-65 retirees? 48 March 28, 2016

49 Questions? Gail Levenson Principal, National Pharmacy Practice Alaina Sandhu Senior Consultant, National Pharmacy Practice 49 March 28, 2016

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