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Transcript of 1 Expert pharmacy benefit management (PBM) consulting team In-house pharmacists, PBM and Medicare...
![Page 1: 1 Expert pharmacy benefit management (PBM) consulting team In-house pharmacists, PBM and Medicare Part D experts Former C-level PBM executives averaging.](https://reader034.fdocuments.in/reader034/viewer/2022051115/5697bf991a28abf838c91dda/html5/thumbnails/1.jpg)
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Expert pharmacy benefit management (PBM) consulting team In-house pharmacists, PBM and Medicare Part D experts Former C-level PBM executives averaging 20+ years
industry experience each Manage 18 million+ pharmacy lives Provide unbiased, impartial, expert advice Recommend solutions rather than products Acquired by Lockton in 2012
Specialize in working with self-funded employers, health plans, TPAs and other payers to: Optimize PBM arrangements Leverage improved vendor relationships Identify additional opportunities for cost savings Develop strategies in a dynamic marketplace
Provide full disclosure on all compensation
The Excelsior Solutions Difference
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Excelsior Pharmacy Analytics
Independent annual auditing of contractual guarantees
Based on all information affecting employer cost (discounts, dispensing fees, rebates, admin fees, brand vs. generic classification, formulary lists, drug mix management)
Employers receive penalty check if guarantees were not met
Ensure members are not being overcharged
INDEPENDENTAUDITS
Objective approach with transparency and no carrier/PBM-specific incentives
Rigorous financial valuation of all proposals
Clinical program evaluation
Winning PBM must submit to certain contract provisions, guarantees, and annual independent audits
PBM MARKETING AND RENEWALS
CONTRACTREVIEWS
Establish clear contractual definitions
Structure dollar-for-dollar performance guarantees
Secure objective audit procedures
Define clear algorithms for guarantee and penalty calculations
Pricing benchmarks
Disease analysis
Drug mix analysis and interchange opportunities
Contract review
Project employer savings if PBMs were shopped today
Brand vs. generic classification
Narcotic abuse
DIAGNOSTICSTUDIES
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Full Service Pharmacy Consulting
Creating Better Economics Full Market Evaluation
Assess current contract > Renegotiate – Moving into years 4 and 5 with Premera RFP that includes top PBM’s > Leverage health plan pricing Transparent contract > Insure terms and conditions drive most favorable results for client Allow collectives to participate
Trend Management RX Mart: Data Analytics
Excelsior’s proprietary data solution Holds PBM accountable to contract Provides in depth utilization review Drill down capabilities for each client's specific needs
Clinical Oversight Pharmacist review of data to determine most effective PBM programs, i.e. Step Therapy, QL,
PA Narrow network evaluation Specialty Rx consulting
Execution Ongoing Account Management
Implementation oversight Quarterly review meetings Plan design benchmarking and consulting Insuring PBM delivers on operational and service commitments
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RxMart Reporting – Holding your PBM accountable
How is your PBM performing?
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Pharmacy Analytics
YOUR MOST HIGHLY UTILIZED HEALTHCARE BENEFIT: PRESCRIPTION DRUGS
BILLIONSAre Wasted on drug choices
Contract Reviews
Diagnostic Studies
PBM Procuremen
t and Renewals
Independent Pricing Audits
Specialty Drug
Strategy
Detailed Claims Analysis Formulary Management
Financial Guarantees Specialty-Drug Management
Contract Optimization Medication Adherence Improvement
Plan Design Strategies Network and Channel Optimization
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1% of members = 25–30% of pharmacy spend
The Financial Significance of Specialty Pharmacy
53% of specialty paid under medical benefit,
managing cost requires site of care strategies6 9%
43%35%
13% Medical Specialty Costs
Other
Hospital Outpa-tient
Physician Office
Home Health
Hemophilia patient’s annual cost: $850K; effective patient care saves 62% of overall care cost5
Biosimilar appropriateness; 26% savings on $11B drug category4
Ensuring adherence monitoring, $200B annual US cost from drug misuse2
Lab verification; 1 Rx to 1 of the only 96% of Cystic Fibrosis patients not qualified for drug costs $300,000/yr3
Why Integrate the Specialty Medical and Pharmacy Strategies?Percentage of Membership Affecting Drug Spend
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
SpecialtyTraditional
99%
Percentage of Drug Spend
70%
30% 1%
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What It Is: Analyzes a client’s potential financial exposure to key specialty/high cost
drug categories Targets key drugs in the pipeline, recently released drugs, specialty
drugs, high cost diseases, and expanded indications for existing therapies
The tool was developed with FDA guidelines and is piloted with the following disease states: Hepatitis C High cholesterol PCSK9 Multiple Sclerosis Cystic Fibrosis Idiopathic Pulmonary Fibrosis
Uses medical and Rx data from InfoLock along with population disease rates
Model will continue to be refined with new drugs, disease states, & clinical data
Model shows minimum costs not inclusive of physician drug administration fees
What It Is Not: Predictive tool for a client’s TOTAL specialty spend
Specialty Drug Financial Impact Modeling Tool v1.0
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Potential Additional 2016 Rx Costs
Paid Claims
Idiopathic Pulmonary
Fibrosis (narrow definition):
Individuals with one or more paid claims
in the reporting period with ICD 9
code 516.3.
PCSK9 Inhibitors: Unique Members
with Elevated LDL-C despite being on statins or can't
tolerate.
Hepatitis C: Individuals with one or more paid claims in the reporting
period with ICD 9 codes 070.41, 070.44, 070.51,
070.54, 070.70 or 070.71.
Multiple Sclerosis:
Individuals with one or more paid claims
in the reporting period with ICD 9
code 340.
Cystic Fibrosis: Individuals with paid
claims for one inpatient visit or two outpatient visits with a diagnosis of Cystic
Fibrosis. Number below is 28% of CF
patients, minus those taking
Kalydeco
Total
Potential Members 1 202 24 28 1 8543
Treatment $96,000 $12,000 $85,000 $40,000 $300,000
Percent in 2016 50% 15% 20% 15% 100%
Budget Impact $48,000 $363,600 $408,000 $168,000 $300,000 $1,239,600
PMPY $6 $43 $48 $20 $35 $145
New Drug Introductions
Esbriet or Ofev, both approved
10/2014
Praluent (alirocumab) - 7/24/2015, Reptha
(evolocumab) - 8/27/2015
Includes Sovaldi, Harvoni, Viekira Pak & drugs that must be
taken with them
Zinbryta (daclizumab) 6/2015
Orkambi - 7/5/2015
UNIVERSITY OF ALASKA ----- Impact on 2016 Budget
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Savings Insight
Based upon the limited data available in the claims experience, it creates a challenge to provide a full assessment of the savings affiliated with the current arrangement
To project the estimated savings we’ve leveraged the average per script savings achieved over Lockton’s book of business in 2014
Total annualized savings opportunity: $200,000 to $350,000 Renogiate AWP discounts, Rebates,
Dispensing Fees Implement best-in-class contract
language Quarterly Audit provision with full
reconciliation annually
Lockton Companies, Proprietary and Confidential
Potential Annualized savings: $200k -
$350k
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Lockton Pharmacy Analytics
Specialty DrugSpend Mitigation
PBM Marketing
ClinicalSavingsAnalysis
ProspectiveCost Modeling
FormularyManagement
ContractOptimization
Member CostShare Strategies
Detailed ClaimsAnalysis
Lockton’s Pharmacy
Analytics practice supports
plan sponsors in assessing
the current and future cost
drivers of their pharmacy
benefit plan and deploying
strategies to enhance value
and mitigate spending.
Our experienced consultants
will provide plan sponsors
guidance on how to address
immediate needs and
opportunities while also
positioning the plan to
successfully manage future
challenges.