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1 Specialty Pharmacy Market Landscape Developed by: 2016

2 AGENDA TOPIC Specialty Pharmacy Overview Specialty Drug Trend Utilization Specialty Pharmacy Provider Profiles and Services Specialty Pharmacy Provider Process and Flow of Funds Impact of SPP on Value-Based Purchasing Current and Future Trends in SPP Appendix: Specialty Pharmacy Provider Profiles Glossary of Terms 2

3 LEARNING OBJECTIVES SPECIALTY PHARMACY The Specialty Pharmacy Plan Primer will provide deep insights into the following areas: Understand the role specialty pharmacies play in the delivery of healthcare Identify and understand the largest providers of specialty pharmacy services Gain insights into how market consolidation is impacting specialty pharmacy Describe the different types of specialty pharmacies and key attributes of the largest providers Understand how value-based healthcare is impacting specialty pharmacies 3

4 WHAT IS SPECIALTY PHARMACY? Specialty pharmacy (SPP) focuses on high cost, high touch medication therapy for patients with complex disease states. Medications in SPP range from oral to cutting edge injectable and biologic products. The disease states treated range from cancer, multiple sclerosis and rheumatoid arthritis to rare genetic conditions. SPPs provide most services to payers at no additional cost, while services provided to manufacturers are more often provided at an additional cost or fee-for-service basis. Core services provided to health plans most often include patient education materials, PA adjudication, medication adherence, and data reporting. Source: IMS Health Core services provided to manufacturers most often include REMs program administration. Source: HIRC,

5 BILLIONS ($) GROWTH OF SPECIALTY DRUG COSTS U.S. sales of specialty drugs totaled approximately $124 billion in 2014 and accounted for one third of the total U.S. pharmaceutical market. Between 2009 and 2014, sales of specialty drugs increased 58%, and are projected to increase another 67% by Specialty drugs are expected to account for 50% of the total U.S. spend within the next five years $300 Prescription Drug Spend $410 $374 33% 50% 26% 15% 27% 21% The average annual retail cost for a specialty medication to treat a chronic condition was almost $29,000 in 2009, with some drugs costing as much as $750, % 40% 29% * Brands Generic Specialty Projected Source: HIRC s Managed Markets and National Accounts Service, 2015 Specialty Pharmacy Times,

6 EVOLVING COMPETITIVE STRUCTURE OF THE PBM MARKET Three PBMs controlled about 66 percent of the PBM market in It s likely that three PBMs will control about 69 percent of the PBM market year end 2016, but they will not be the same three as in Medimpact, 5% Humana 6% All Others*, 7% PBM MARKET SHARE BY TOTAL ADJUSTED PRESCRIPTIONS 2014 Total adjusted prescriptions include claims at a PBM s network pharmacies, equivalent prescriptions and specialty claims filled by a PBM s mail pharmacy. Source: Deuche Bank Securities, Inc. Express Scripts 29% Medimpact, 5% Prime, 6% All Others*, 7% Express Scripts 29% Prime 6% Catamaran 9% Current Market Structure CVS/Caremark 12% Future Market Structure OptumRx 13% CVS/Caremark 24% Humana + Aetna Lives from Caremark 18% OptumRx + Catamaran 22% NOTABLE MARKET ACTIVITY OptumRx acquired Catamaran in 2014 and completed the merger in July The new OptumRx is expected to serve about 65 million lives and fulfill about one billion prescriptions in Aetna acquired Humana in 2015 and will likely completed the merger in mid Aetna leadership is expected to not renew its contract with Caremark and shift/carve-in its lives to Humana Pharmacy Solutions. Walgreens acquired Rite Aid in 2015 and will likely complete the merger in mid It will then control Rite Aid s wholly owned PBM subsidiary EnvisionRx, which will have access to over 13,000 pharmacies. 6

7 VALUE-BASED PURCHASING HAS A DIRECT IMPACT ON SPP Quality initiatives impact the delivery and reimbursement of providers. CMMI PCORI IPAB ICER Medicare Star NCQA/HEDIS QRS (Healthcare Exchanges) New Entities Increased Quality Measure Development Quality Delivery System Payment Reform Value-Based Purchasing Initiatives ACOs PCMH Bundled Payments Hospital Readmission Penalties Pay-for- Performance Bundled Payments 7

8 TRENDS IN SPP Expanding Patient Population Technology Expands Patient Centric Care Biosimilar Growth Health Care Reform will continue to bring new patients to the market Increasing access to healthcare for newly insured patients will increase the demand for specialty treatments Out of pocket costs may impact how much demand is realized There will be increased use of technology and data within SPP With text messaged reminders, digital sensors, and other types of improved data tracking, SPPs are leveraging technological advances to improve the patient experience Virtual healthcare offers other opportunities to expand patient education and support Data analysis can help prescribers, pharmacists, and manufacturers understand detailed dynamics of patient access and utilization SP has a uniquely strong prior record of direct interaction with physicians and patients Providers are looking for ways to improve interaction between caregivers to create a total care ecosystem that fits each patient s needs Fragmented solutions negatively impact the patient experience, so the market will be looking for unifying platforms to maximize the patient experience while providing aggregate data to measure the patient journey Expansion of biosimilars will require expanded patient education efforts. Branded biologic oncology products alone currently represent more than $20 billion in global spending and are anticipated to be the top target for biosimilar development over the next 5 years 2015 saw the first biosimilar, Zarxio, enter the US market at a 15 percent discount. With at least four more pending FDA review and dozens more somewhere in the review process, biosimilars are on the rise in

9 SPP MARKET: LOOKING FORWARD The future SPP market landscape will look different; consolidation will continue as SPPs engage in M&A to add strength and capability and smaller players will mature and specialize. Additionally, provider accountability will continue to grow, which may further fuel the emergence of ACO/health system SPPs. Hospitals/health systems will continue to build their own SPP capabilities, as it provides an attractive option to enhance patient management capabilities across both inpatient and outpatient settings. ACOs in particular may find developing their own SPP capabilities beneficial as they take on risk for medication costs. Health plan consolidation among national plans will strengthen their purchasing power and leverage in negotiating contracts for specialty medications; impact on other SPPs will depend on whether they are contracted with a plan involved in recent M&A activity, but will heighten the competitive environment for all. Health plans will continue attempts to improve medical benefits management through both internal and external SPP capabilities. ORGANIZED PROVIDERS HEALTH PLANS SPP STAKEHOLDERS: LARGE SPPs MID-SIZED/ SMALL SPPs - As additional SPP players enter the market, larger SPPs will work to keep market share by showcasing broad geographic distribution, robust programs, pricing advantages, and product access, and their broad array of services (e.g., infusion, medical benefits management). Larger PBM-owned SPPs will likely continue to expand excluded product lists in competitive medication classes. Limited distribution and narrower payer networks will force mid-size and smaller SPPs to compete more aggressively for access to lives and medications. To demonstrate their value, SPPs will continue to build their clinical capabilities, data reporting, hub and commercialization services. Sources: HIRC Interviews, Specialty Pharmacy Networks for Hospitals in the Offing from P&T (Pharmacy and Therapeutics), 2013 Pharmacy Market Share for Specialty Drugs--and the Biggest Players from Drug Channels, Six Factors Driving New Specialty Pharmacies from Pharmaceutical Commerce. 9

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