Agenda. Sponsored by: MobilPoints at each table provide additional resources, accessible right on your smart phone

Transcription

1 September 29, 2015

2 Agenda 8:00-8:10 am Introduction Helen Stevenson & Dave Blevins 8:10-8:25 am How did we get here? Helen Stevenson 8:25-8:55 am Does Stop Loss still stop the loss? Gary Walters 8:55-9:20 am Managed Drug Plan solutions Helen Stevenson 9:20-9:25 am Q&A Helen Stevenson and Dave Blevins 9:25-9:35 am Benefits in unionized groups Jeff Wareham 9:35-9:50 am Medical Marijuana Mike Boivin 9:50-10:00 am Q&A all presenters Sponsored by: MobilPoints at each table provide additional resources, accessible right on your smart phone

3 A Decade of Change: 2005 Generics. Prices 63% - 70% of brand Brand drugs. Looming patent cliff Many blockbuster drugs still had patents (NEXIUM, CRESTOR, LIPITOR, etc.) Short pipeline with relatively few breakthrough products Plan dynamics. 90% of plans had open formularies ODB dynamics. Drug reforms begin

4 A Decade of Change: 2010 Generics. Prices further lowered to 18% to 25% of brand. Absence of mandatory generic substitution limited benefit of generic pricing reforms for private plans Brand drugs. Few late-stage blockbuster drugs. Enormous patent cliff of big blockbuster drugs begins, continuing for next few years Plan dynamics. Growth in # plan members, # claims per plan member. Strategies included dispensing fee caps, increased generic substitution ODB dynamics. Generic pricing reforms deliver savings to public plans. Growth rate decreasing, and stabilizing

5 A Decade of Change: 2014 Generics. Prices between 18% to 25% of brand. Several carriers put mandatory generic substitution as default Enormous patent cliff: >20% of plan drug spend (in 2010) was for brand name drugs that would be genericized during period Brand drugs. Increased spending on new, specialty drugs mid (Hep C drugs), as well as few very high cost drugs for rare diseases Plan dynamics. Savings from generics largely offset by increased spending in other classes. Short-term strategies with passive gains ODB dynamics. Growth rate reduced to 2.8% as result of reforms

6 A Decade of Change: 2015 Generics. Flattening generic utilization. Only managed plans could boost generic utilization and further take advantage of lower prices Brand drugs. Specialty drugs gripping plans. Widespread testing for some conditions, such as Hep C. Plan dynamics. Increased spending overall. 8 to 10x cost premium for brand products vs. similarly effective generic drugs within the class. Stop-loss charges increasing. Plans facing sustainability challenges. ODB dynamics. Growth rates returning to pre-reform levels (6 to 8%), with some areas seeing unprecedented increases (i.e. oral & IV cancer drugs) Cost pressure on Trillium Drug Program, and EAP

7 Enter these drugs in Sovaldi. Harvoni. Holkira Pak. Hep C medications Praulent. Repatha. Cholesterol (specifically HeFH) Invokana. Forxiga. Diabetes medications Dozens of oral cancer drugs. More oral drugs for RA & MS Vimizim. Mucopolysaccharidosis (MPS) type IVA Soliris. Paroxysmal nocturnal hemoglobinuria (PNH), and Atypical Haemolytic Uremic Syndrome (AHUS)

8 Does stop loss stop the loss? Gary Walters Senior Vice President Pricing & Group Reinsurance, RGA

9 Back to these drugs Sovaldi, Harvoni, Holkira Pak Never before have drugs been priced so high to treat such a large population Bloomberg Business, June 3, 2015 Vimizim Public-private misalignment? CDR Do not list; some provinces will not cover Praulent, Repatha It is clear that PCSK9 inhibitors are on a path to become the costliest therapy class this country has ever seen Express Scripts US Invokana, Forxiga Third new class of diabetes drugs in last few years, with dramatic cost increase. Heath Canada initiated safety review in June risk of serious side effect. Class action underway Soliris one of the world s most expensive drugs ; $700,000 per patient in Canada more than anywhere else in the world Dozens of oral cancer drugs Cancer drug spend increasing 23% YoY Ontario Public Drug Programs, March 2015

10 And these drugs

11 PCSK9 Inhibitors: Praluent & Repatha Current per claimant spend on cholesterol drugs $175 Current average annual spend per claimant for cholesterol meds Enter PCSK9 inhibitors, Praluent & Repatha. Per claimant spend could increase from $175 per year to >$8,300 per year*, as of end 2015 Projected per claimant spend on cholesterol drugs, for open plans + $2,403 Projected average annual spend per claimant on an open plan + 1,272% Projected increase in average annual spend per claimant Projected per claimant spend on cholesterol drugs, for plans powered by Reformulary $283 Projected average annual spend once PCSK9 inhibitors added to the Reformulary ** 62% Projected increase in average annual spend per claimant Based on 48,065 claimants in period Sept to Aug % of claimants filled at least 1 prescription for cholesterol medication + Assumes 50% adoption * Based on manufacturer submission; includes mark-up & concomitant statin therapy ** Based on 2.6% prevalence of patients with HeFH taking cholesterol meds

12 Impact of 1 Drug (PCSK9 Inhibitor) on Total Plan Costs over 3 Years 37% INCREASE $459,484 $467,698 $628,231 $229,792 $223,845 $314,116 $22,974 $23,384 $31,412

13 Actual Impact of New Hep C Drugs on Employer Plan Case Study RESULTS B2B Employer Plan 2,200 lives $2 million drug plan spend pre-reformulary $111,919 spent on biologics for 0.23% of members Implemented the Reformulary in 2014 SAVINGS: Net of dispensing fee, plan spend was $1.5 million HEP C: Increase in hep C spend, from $476 to $176,000 for 0.07% of members MANAGE: 16.1% savings offset increased specialty drug spend 7.4% RESULTING IN net savings

14 What does this mean for current plans? OPEN FORMULARY VS MANAGED PLAN Every new drug added immediately at whatever price: irrespective of whether it works well Plan costs increase with no added value 2-tier formulary (brand-generic) lowest-cost interchangeable prior authorization Evidence-based formulary all new drugs reviewed based on clinical and cost-effectiveness evidence before being placed on formulary all drugs included, but on different tiers and at different co-pays depending on value (clinical/cost) clinical criteria for high-cost and specialty drugs

15 What does this mean for the future? OPEN FORMULARY VS MANAGED PLAN Tidal wave of new high-cost drugs could cripple open plans Evidence-based formularies ensure sustainable future Open formularies do not fit into a sustainable future in drug benefits

16 The Reformulary Built on evidence, our formulary uses tiers and co-pays to promote drugs that provide the best healthcare value. By encouraging employees to use similarly effective drugs that are the most affordable, this ensures longterm sustainability of your drug plan Employers have realized savings of between 9% and 15% in drug spend

17 Reformulary encompasses many valuable strategies: Communication tools, including personalized letters & DrugFinder Generic substitution Works well with preferred pharmacy networks All-in- One Therapeutic alternatives Evidence-based decisions means better alignment with public plans Special authorization for specialty & high cost drugs

18 W H Y R E F O R M U L A R Y 1. We do the homework Each drug on our formulary has been evaluated by an impartial & independent Expert Committee, comprising practicing physicians and pharmacists. They evaluate: Clinical effectiveness Cost-effectiveness Real-world evidence (patient experiences in the real-world) Based on this evidence-based review, we categorize drugs as preferred and non-preferred, with different co-pays

19 Preferred and Non-Preferred Drugs Preferred drugs (tier 1) Drugs that offer the best healthcare value, and are always the most affordable (lowest member co-pay) Non-preferred drugs (tier 2) Drugs that provide less healthcare value than preferred drugs. For every nonpreferred drug, there is a clinically similar alternative on tier 1 at lowest co-pay Non-preferred drugs (tier 3) Drugs that provide the least healthcare value, and have the highest member copay. For every nonpreferred drug, there is a clinically similar alternative on tier 1

20 Impactful Management of Specialty Drugs High cost specialty drugs are reviewed by our Expert Committee. We prepare detailed clinical criteria based on evidence, as to which drugs are most appropriate for which groups of patients. Drugs such as: Sovaldi Harvoni Vimizim Kalydeco Inflectra Praluent* Repatha These drugs require prior approval, meaning that members must meet the specific clinical criteria in order to be approved for coverage * Not yet approved in Canada; will be reviewed by our Expert Committee and likely only available via Special Authorization

21 Why Reformulary 2. We make it easy for people to switch To ensure a smooth transition, plan members get access to these engagement tools Dr Mike video Most members are not impacted by moving to the Reformulary

22

23 Why Reformulary 3. Proven Savings. Sustainable Future Employers have realized savings of between 9% and 15% in drug spend Sun Life News As there are now proven savings of the Evidence-Based Drug Plan [the Reformulary], SLF is offering a pooling discount of 15% on pooling charges for clients with the Evidence-Based Drug Plan [Reformulary] and any future clients.

24 Support for advisors/brokers ReModel quick estimate of your client s potential savings based on implementing the Reformulary; models top 100 DINs (no fee) Full Model detailed, claims level modelling of potential savings & member impact based on implementing the Reformulary (fee) Ongoing, accessible client support

25 Short Q&A Dave Blevins and Helen Stevenson

26 Shared Savings: New Opportunities for Unions? Jeff Wareham Former National Representative, Pension and Benefits, CAW (Unifor) Consultant, Reformulary Group

27 Cannabis, Medical Marijuana Mike Boivin Community pharmacist; Continuing Education expert Special advisor, Reformulary Expert Committee

28 Final Q&A All presenters Sponsored by: Thank you!