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Specialty DrugManagement:What EmployersNeed To Know ARCHIMEDES 2018Confidential and Proprietary
2Agenda1. The Challenge2. Quantifying The Waste3. Employer Solutions ARCHIMEDES 2018Confidential and Proprietary
3The Specialty Challenge Price, Price, Price Vendor conflicts of interest Siloed vendors Lack of cost transparency Overprescribing and questionsof value ARCHIMEDES 2018Confidential and Proprietary
4Drug Pricing IsReceivingScrutinyH.P. Acthar PricingLifetime limits on coverageremoved by ACA ARCHIMEDES 2018Confidential and ProprietarySource: Truven. Accessed at -explained-on-bamlconference-call-201712?utm source hearst&utm medium referral&utm content allverticals& twitter impression true
PBM Conflicts of InterestFormularies are Rebate-Driven ARCHIMEDES 2018Confidential and ProprietaryPA Programs are Ineffective5Stockpiling
6Challenges with PriorAuthorization PBM conflicts of interest Physician office attestations Lack of best practices (e.g., documentation) Use of non-clinical PBM staff Lack of technology for decision support Lack of transparency ARCHIMEDES 2018Confidential and ProprietaryExamples of Inappropriate Use from One EmployerDrugType of UseDrug AOff-label for sleep apneaDrug BFirst-line use for asthmaalthough it is a second-lineagentDrug CInappropriate use for MSDrug DToo high a dose for weightDrug EOff-label for growthAnnualSavingsSource: Archimedes
7Stockpiling 64,000 of unusedspecialty drugs in thepatient’s garagerefrigerator PBM pressured patientto continue to refilldespite stockpiles ARCHIMEDES 2018Confidential and Proprietary
The Coverage ConundrumDrug nistrationNDC CodesReal-time adjudicationFormulary / RebatesPrior AuthorizationNetwork adeInflectraActemraRituxan ARCHIMEDES 2018Benefit ShoppingDuplicate ClaimsInappropriate UseSite of CarePharmacyInfusiblesMedicalConfidential and ProprietaryResultsHCPCS CodesDelayed adjudicationPrior AuthorizationNetwork Management8Wastefulspending
Remicade Cost by Channel(600 mg Infusion) 8,000 7,500 7,000 6,500 6,000 5,500 5,000 4,500 4,00010/1/201511/20/20151/9/2016Outpatient Hospital ARCHIMEDES 2018Confidential and Proprietary2/28/20164/18/2016Physician Office96/7/2016Home Infusion7/27/2016RxNumerous outpatient hospital claims exceeded 8,000.9/15/2016
Remicade Cost by Channel(600 mg Infusion) 8,000 7,500 7,000 6,500 6,000 5,500 5,000 4,500 4,00010/1/201511/20/20151/9/2016Outpatient Hospital ARCHIMEDES 2018Confidential and Proprietary2/28/20164/18/2016Physician Office106/7/2016Home Infusion7/27/2016RxNumerous outpatient hospital claims exceeded 8,000.9/15/2016
Remicade Cost by Channel(600 mg Infusion) 8,000 7,500 7,000 6,500 6,000 5,500 5,000 4,500 4,00010/1/201511/20/20151/9/2016Outpatient Hospital ARCHIMEDES 2018Confidential and Proprietary2/28/20164/18/2016Physician Office116/7/2016Home Infusion7/27/2016RxNumerous outpatient hospital claims exceeded 8,000.9/15/2016
Remicade Cost by ChannelNote new scale(600 mg Infusion) 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,00010/1/201511/20/20151/9/2016Outpatient Hospital ARCHIMEDES 2018Confidential and Proprietary2/28/20164/18/2016Physician Office126/7/2016Home Infusion7/27/20169/15/2016RxAn additional 26 Outpatient Hospital Infusions are above the 20,000 threshold.
13PhysicianChallengesSources: Morris et all, 2011, etc. ARCHIMEDES 2018Confidential and ProprietaryClinical practice is17 years behind thescience of medicinePhysicianreimbursementinfluences theirprescribingPhysicians do notknow the price ofdrugs And there is nomagical savingswhen they do knowthe price
Physician Reimbursement MattersStudy found that physicians receiving more generous drug reimbursement prescribed more costlychemotherapy agentsIncrease MD payment 1 and you increasedrug cost by ColorectalCancer 35.50BreastCancer 23.10 ARCHIMEDES 2018Confidential and ProprietaryLungCancer 13.0014Source; Jacobson. Health Affairs. 2006
15Genetic TestingNot Performed More than 200 FDA-approveddrugs have pharmacogenomicinformation in their labeling. The majority of drugs are in theoncology and other specialty The pharmacogenetic testingcan serve various purposes,including efficacy, ability tometabolize, and likelihood ofadverse events ARCHIMEDES 2018Confidential and ProprietaryPhysician reimbursement can affect quality, not just costsDrugMembersClaimsCostPercent of Spendon Memberswith MissingTestsRituxan3297 540,38345%Revlimid532 444,20856%Herceptin550 326,65923%Perjeta215 227,33945%Kalydeco19 221,663100%Xenazine112 181,625100%Gleevec212 74,30236%Faslodex320 58,26435%Note: Findings are a sample of the full results
16Quantifying theWaste ARCHIMEDES 2018Confidential and Proprietary
Home Infusion,Drug 22Administration, 12Other Facility, 30Physician Office, 74 7,000,000 6,000,000Overall Spend 505 PMPY 5,000,000 4,000,000OutpatientHospital, 91 3,000,000 2,000,000 1,000,000 0Outpatient HospitalPhysician OfficeHome InfusionRx ARCHIMEDES 2018Confidential and Proprietary17Rx, 276
18Specialty DrugSavingsOpportunities 50,000 lives 40 million in specialty drug spendPlan Sponsor ExampleSavings TypeMedical Savings Rx Savings Total SavingsSite of Care 2,120,509Clinical: Off-Label Use 159,257Provider Reimbursement 579,723 2,071,008 579,723 468,164 468,164Dose Management 284,296 284,296Cancer Supportive Care 65,423 721 66,144Weight-Based Dosing 3,308 32,791 36,099 30,146 30,146 10,921 16,830 973,751Duplicate Therapy Other Inappropriate Use 744,338 229,413 3,687,467 2,968,203TotalConfidential and Proprietary 1,911,751Quantity ManagementHepatitis C Overuse ARCHIMEDES 2018 2,120,5095,909 6,646,670
Pricing Relative to ASP, Outpatient Hospital 1,600,000300%266% 1,400,000250% 1,200,000 557,258 1,000,000182%197% 481,530 800,000182% 387,087196%214%200%187%159% 422,679 600,000200%157%150% 356,080100% 400,000 254,267 192,767 126,124PerjetaDarzalexEntyvio 200,000 180,732 93,341PrivigenBotox 00%RemicadeHerceptinAvastinNeulastaCompetitive Payment ARCHIMEDES 201850%Confidential and ProprietaryRituxanOverpayment19ASP Rate
21Billing Errors Keytruda payments to oneProvider appear to be excessive orin error. Provider billed plan 98,647 on 10dates of service for one patient. Billing for Keytruda is usuallybetween 9,000- 15,000 ARCHIMEDES 2018Confidential and Proprietary
21PriorAuthorizationProspective utilization managementreviews for specialty drugs toensure clinically appropriate use ARCHIMEDES 2018Confidential and ProprietaryExamples of Inappropriate Use from One EmployerDrugType of UseAnnual SavingsDrug AOff-label for sleep apnea 73,092Drug BFirst-line use for asthma although it is asecond-line agent 12,120Drug COff-label use for MSDrug DToo high a dose for weight 48,058Drug EOff-label for growth 49,333 169,293
22Prior Authorization - ActharPatient ProfileActions Taken 61 year old patient MDO attested that patienthad tried-and-failed lowercost steroids Claims data indicated diagnosisof multiple sclerosis Previous history of Acthar Geluse two years prior No other MS drugs Patient Prescribed Acthar Gel ARCHIMEDES 2018Confidential and Proprietary Documentation provided didnot support MS diagnosis orprior use of IV steroids (1stline) Peer-to-Peer conducted with3 previous and currentphysiciansResults Achieved Patient recommended for reevaluation IV steroid required before 2nd linedrugs Savings of: 72,472/dose
23EmployerSolutions ARCHIMEDES 2018Confidential and Proprietary
24Areas ofOpportunity ARCHIMEDES 2018Confidential and ProprietaryVisibility to Spend & PricingSite of Care OptimizationClinical ManagementReimbursement ManagementBetter Vendor ManagementCoordination Across Benefits
25The Do’s andDon’tsDo thisNot that ARCHIMEDES 2018Do NOT Focus on pricediscounts underpharmacyDo Limit specialty drugsto 30-day supply Allow auto-refill ofspecialty drugs Implement PApolicies acrossbenefits Carve-out of medicalwithout understandingyour economics Conduct clinicalaudits of yourvendors
26Site of CareManagementBest Practices Mandatory, not voluntary Use of outpatient hospital setting requiresprecertification with review against clinical criteria Members who do not meet criteria are redirected toless costly, clinically appropriate sites Broad drug list Clear member communications Consider implementing site of care management,even if there are not immediate savings, as a wayto reduce risk ARCHIMEDES 2018Confidential and Proprietary
27PriorAuthorizationBest Practices All specialty drugs should have Prior Authorization Limit coverage to 1 year or less, depending on therapy Customize criteria as needed Look at approval/denial rates 90% approval suggests a potential problem Ask for case-level approval history Periodically conduct a clinical audit of PA Consider carving out of PA from PBM to avoidconflict ARCHIMEDES 2018Confidential and Proprietary
28Specialty DrugSpecialty DrugCarve-OutCarve-OutBestPracticesActions Taken Enhanced Prior Authorization Optimized Formulary Copay Assistance Program Ongoing Retrospective DUR Regional Specialty Pharmacy Performance TransparencyResults AchievedSpecialty Rx Spend, PMPM 44.02 25.96 20.97201520162017Spend net of rebates ARCHIMEDES 2018Confidential and Proprietary
29Medical Benefit:Call to Action –Medical Benefit1. Ask your health plan for actionable Specialty reporting2. Begin to align benefits3. Implement a site of care program4. Implement available prior authorization/clinical reviews5. Evaluate options for specialty medical management ARCHIMEDES 2018Confidential and Proprietary
30Call to Action –PharmacyBenefitPharmacy Benefit:1. Ask your PBM for data on your specialty drug users andrecommendations for savings2. Implement all available prior authorizations3. Audit prior authorization process and operations4. Explore carve-out prior authorization from your PBM5. Evaluate options to carve-out of specialty drugmanagement from your PBM ARCHIMEDES 2018Confidential and Proprietary
Thanks!Brenda Motheral, BPharm, MBA, PhDCEO, Archimedesbmotheral@archimedesrx.comPhone: 615-418-7200Heather Sundar, PharmDSVP, Consulting and Employer SolutionsArchimedeshsundar@archimedesrx.comPhone: 618-606-1905 ARCHIMEDES 201831
Faslodex 3 20 58,264 35% More than 200 FDA-approved drugs have pharmacogenomic information in their labeling. The majority of drugs are in the oncology and other specialty The pharmacogenetic testing can serve variou
