Put Money Back in Your Classroom Finding the hidden revenue in your pharmacy benefits

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1 Put Money Back in Your Classroom Finding the hidden revenue in your pharmacy benefits Presented by Howard Mazzafro, Vice President Innovative Slide 1 of 25 Solutions. Enduring Principles. Innovative Solutions. Enduring Principles.

2 Agenda Pharmacy Benefits Current Landscape Understanding Industry Stakeholders Components of a Pharmacy Program 2 Slide 2 of 25

3 Pharmacy Benefits The Current Landscape Innovative Slide 3 of 25 Solutions. Enduring Principles. Innovative Solutions. Enduring Principles.

4 Pharmacy Drug as a Percentage of Health Care Spend 4 Slide 4 of 25

5 Why be concerned? Specialty Medications will make up 30-40% of the cost of prescription drug benefits by Slide 5 of 25

6 Rx Costs Are Expensive Cost of products are very expensive, ranging from $2,500 to over $100,000 Some lines of therapy will cost over $100k per year Example: In of 13 drugs approved cost over $100k, with one drug $400k) Frequent Dosing Adjustments Intensive Clinical Monitoring Intensive Patient Training Limited or Exclusive Distribution Specialized Handling and Administration Cost >$500 per 30 Days ANEMIA HEMOPHILIA MULTIPLE SCLEROSIS CANCER HEPATITIS PULMONARY HYPERTENSION GROWTH DEFICIENCY INFERTILITY RHEUMATOID ARTHRITIS MANY OTHERS 6 Slide 6 of 25

7 Industry Stakeholders Create a Complex Process of Pricing Prescription Medications 7 Slide 7 of 25

8 Manufacturer Consolidation Warner Lambert Parke-Davis Warner Lambert Pfizer Pfizer Pfizer Pfizer Pharmacia Pharmacia Kabi Upjohn Monsanto/ Searle Pharmacia & Upjohn Searle Pharmacia Wyeth Wyeth American Home American Home 8 American Cyanamid Valued at over $600 Billion Slide 8 of 25

9 Manufacturer s Impact Control the research, development, manufacturing, availability and pricing of medications Control the protection of brand name drug patents Brand drugs losing patent protection -$73 billion dollars in the next five years. Manufacturers are no longer investing in development of Brand Molecule drugs. Focus is shifting to: Costly new generic alternatives Pharma optics Consolidation in the industry less competition = higher prices to consumers Direct to Consumer Advertising costs everyone $$ 9 Slide 9 of 25

10 Manufacturer Prices Soar Valeant drug, Mephyton, which helps blood clot better, has been increased eight times since July 2014 and now costs about $58.76 a tablet, up from $9.37. NY Times October 2015 Valeant drug, Edecrin, a diuretic, has gone up nine times since May 2014 and is now at $4,600 a vial, up from about $470. NY Times October 2015 Valeant increased the price of the drug in question, called dihydroergotamine or DHE 45, on four separate occasions between July 2014 and July 2015 taking the cost of 10 vials from $3,090 to $14,120 in 12 months. Financial Times February 2016 & Hillary Clinton lowa Jan Slide 10 of 25

11 Wholesaler Market Share Amerisource 26% U.S. Drug Distribution and Related Revenues* Cardinal 31% McKesson $116.9 Cardinal Health $95.1 Amerisource Bergen $77.7 Other Large Wholesalers $14.2 McKesson 38% *in billions 11 Slide 11 of 25

12 Wholesaler s Role Purchase, inventory and sell a manufacturer s product line Service pharmacy outlets; independent and chain drugstores, supermarkets, mass merchants (Costco, Walmart, Target) mail pharmacies, institutional, healthcare facilities (hospitals and physicians). Employer retail, mail and specialty pharmacy claims account for three-quarters of wholesaler revenues. 12 Slide 12 of 25

13 Pharmacy Benefit Managers (PBM) Who are they and what do they do? Serve as intermediaries between employers and wholesalers Administrative services in processing and analyzing prescription claims Contracting with a network of pharmacies Negotiating rebate arrangements Developing and managing formularies and prior authorization programs Operate mail order and specialty pharmacies Manage clinical programs 13 Slide 13 of 25

14 PBM Consolidation The 3 Largest PBMs in the Country WHI PharmaCare Caremark PCS Advance Paradigm Rx America DPS NPA Medco Catalyst FutureScripts Regence Rx Catamaran ValueRx NextRx Systemed ProVantage SxC NMHC HealthTrans Prescription Solutions 14 Slide 14 of 25

15 PBM Formulary Management 90% of the drugmaker s (Valeant) programs are either excluded from Caremark s formulary or have non-preferred Status. Fortune December 2015 Formulary exclusions have saved clients more than $3 billion, Express Scripts. The company also stated that retail pharmacies that have signed agreements with Valeant to prioritize the dispensing of Glumetza will not be allowed to process the transaction. Yahoo Finance January 2016 Recent agreements Valeant has signed with retail pharmacies now potentially encourage the pharmacies to bypass the more affordable generic, Express Scripts. Bloomberg January Slide 15 of 25

16 Industry Reality The PBM contracting process is extremely complex and only understood in complete detail by few experts. The fine print is where the money is made. Often, a PBMs efforts to capitalize on questions not asked during a RFP represent the best chance to win. Concern over where PBMs are making money, spread pricing vs. pass-through. Because of the above, the industry is under scrutiny with many thinking Transparency would be a cure all for the market conditions. 16 Slide 16 of 25

17 BUILDING A SOLID PHARMACY PROGRAM 17 Slide 17 of 25

18 What s Next for Plan Sponsors? What does your PBM do for you? Are they driving change in the market or simply responding to it? Are their interests aligned with yours? What are they doing proactively to help you control costs? Do you know what your true AWP discounts and Rebates are? Do you understand your PBM contract? 18 Slide 18 of 25

19 Advantages of Carving Out Cost control Direct decision-making power Increased flexibility to modify employee cost sharing Increased member and plan satisfaction Accountable pharmacy benefit expert backed by extensive resources Demonstrated clinical and cost management Benchmarking and experience available Extensive operational and clinical connectivity relationships Enhanced pharmacy reporting 19 Slide 19 of 25

20 Won t Transparency Save Us? Most think of transparency as pass-through, but unfortunately transparency for many PBMs is a pass- through of A Rate, not necessarily the Best Rate Example: These prescriptions were filled at the same pharmacy on the same day with two different plans that both had transparent deals with the same PBM lisinopril 40mg 30 $46.24 $ % Slide 20 of 25 NDC11 Name Qty AWP Ingredient Discount Cost lisinopril 40mg 30 $46.24 $ %

21 Pricing Strategies Adjusting the Levers The PBM business model typically involves generating profit from every transaction and relationship they are involved with: Retail Networks Spread on transactions Mail Mark up over cost Formulary Retain of a portion of the rebates Clinical Programs Charge per claim and share in client savings Rebates Additional source of revenue 21 Slide 21 of 25

22 Rebates Are more rebates always better for schools? Are you receiving 100% of rebates? How does your contract language impact your rebates? Rebate Bucket Manufacturer Revenues to PBMs Amount Base Rebates (Available to Share with Clients) 90% IMS National Programs (previously a Rebate)? Market Share Performance Programs (previously a Rebate)? Access Payments (previously a Rebate)? 3 rd / Non Disadvantage Arrangements (previously a Rebate)? MFG/PBM Admin Fees (previously a Rebate)? Inflation Protection Program (previously a Rebate)? Other $$ Received by PBM from Pharma (previously a Rebate)? 22 Slide 22 of 25

23 Why participate? Value Proposition: QUARTERLY AUDITS DEDICATED RESOURCES TRANSPARENCY AGGRESSIVE REBATE AND PERFORMANCE GUARANTEES VOLUME BASED PRICING CLINICAL INITIATIVES Working together, school districts will save significant dollars to invest in other areas such as hiring additional teachers, and other components that will effect student achievement. OPERATIONAL SUPPORT 23 Slide 23 of 25

24 Client Savings District # of Lives Savings Percent Saved A 1,400 $ 612, % B 575 $ 208, % C 6,000 $1,364, % D 4,500 $ 560, % These savings are from ingredient cost and rebates only and do not reflect the large additional savings available through KPPC s optional Pharmacy Care Management Program. 24 Slide 24 of 25

25 Aggressive Rebate and Performance Guarantees The Cooperative generally sees groups achieve an average savings of 12% to 30%. 100% Pass Through of Rebates - participants will receive 100% of manufacturer rebates collected by ESI based on their own claims experience, or a minimum guarantee, whichever is greater. The ESI contract does not pay BOCES commission revenue. Annual Market Checks are performed to ensure the Cooperative rates are competitive. Pricing adjustments will become effective immediately and will not be limited to individual contract renewal periods. 25 Slide 25 of 25

26 Value Based Pricing The purchasing power of a 420,000-life cooperative provides a level of savings not typically available to an individual client on a direct basis. The program is refreshed every year to deliver best-inclass pricing on a continuous basis. As the program grows all clients participate in the enhanced ability to drive savings because of the growing volume of drugs that are purchased. 26 Slide 26 of 25

27 Operational Support Implementation 90 Days Dedicated ESI Implementation Project Manager Dedicated team Accountability Oversight of Express Scripts Sales support to School Board Associations Ongoing account management Problem solving Escalated issue resolution 27 Slide 27 of 25

28 Dedicated Resources Dedicated team Jeffrey Hall, Senior Vice President Howard Mazzafro, Vice President 6 Additional Support Staff ESI Dedicated team Strategic Account Executive 1 Account Director 3 Account Executives 3 Senior Account Managers 3 Clinical Pharmacists 65 Call Center Representatives 28 Slide 28 of 25

29 Transparency A unique, custom contract without hidden payments to anyone. All pricing components are fully disclosed. No fees embedded in school claims are paid to anyone from Express Scripts, the current PBM vendor. 29 Slide 29 of 25

30 Learn More How to get more details on the KPPC Program: KPPC will review the details of your current pharmacy benefits program and provide a proposal at no cost. Please contact either of the following: Howard Mazzafro: (310) x3245 hmazzafro@keenan.com Brian Fassett (973) bfassett@rxprinciples.com 30 Slide 30 of 25

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