Transcript Excelsior PowerPoint

The Excelsior Solutions Difference

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
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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
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Provide full disclosure on all compensation
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Excelsior Pharmacy Analytics
CONTRACT
REVIEWS
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Establish clear
contractual definitions
Structure dollar-fordollar performance
guarantees
Secure objective audit
procedures
Define clear algorithms
for guarantee and
penalty calculations
DIAGNOSTIC
STUDIES
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Pricing benchmarks
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Disease analysis
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Drug mix analysis and
interchange
opportunities
INDEPENDENT
AUDITS
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Contract review
Project employer
savings if PBMs were
shopped today
Brand vs. generic
classification
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)
PBM MARKETING
AND RENEWALS
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Narcotic abuse
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Employers receive
penalty check if
guarantees were not
met
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
Ensure members are
not being overcharged
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Full Service Pharmacy Consulting
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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
Contract
Reviews
Detailed Claims Analysis
Formulary Management
Financial Guarantees
Specialty-Drug Management
Contract Optimization
Medication Adherence Improvement
Plan Design Strategies
Network and Channel Optimization
Diagnostic
Studies
PBM
Procurement
and Renewals
Independent
Pricing Audits
Specialty
Drug Strategy
BILLIONS
Are Wasted on drug choices
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The Financial Significance of Specialty Pharmacy
1% of members = 25–30% of
pharmacy spend
53% of specialty paid under medical benefit,
managing cost requires site of care strategies6
Medical Specialty Costs
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
30%
1%
Other
13% 9%
99%
70%
Hospital
Outpatient
Specialty
Traditional
35%
Percentage
of Drug
Spend
43%
Percentage of
Membership
Affecting Drug
Spend
Physician Office
Home Health
Why Integrate the Specialty Medical and Pharmacy Strategies?
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Hemophilia patient’s annual cost: $850K; effective patient care saves 62% of overall care cost5
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Biosimilar appropriateness; 26% savings on $11B drug category4
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Ensuring adherence monitoring, $200B annual US cost from drug misuse2
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Lab verification; 1 Rx to 1 of the only 96% of Cystic Fibrosis patients not qualified for drug costs
$300,000/yr3
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Specialty Drug Financial Impact Modeling Tool v1.0
What It Is:
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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:
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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:
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Predictive tool for a client’s TOTAL specialty spend
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Potential Additional 2016 Rx Costs
UNIVERSITY OF ALASKA ----- Impact on 2016 Budget
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
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28
1
8543
$12,000
$85,000
$40,000
$300,000
50%
15%
20%
15%
100%
$48,000
$363,600
$408,000
$168,000
$300,000
$1,239,600
$145
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.
Potential
Members
1
202
Treatment
$96,000
Percent in 2016
Budget Impact
Paid Claims
PMPY
New Drug
Introductions
$6
$43
$48
$20
$35
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
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Savings Insight
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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
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To project the estimated savings
we’ve leveraged the average per
script savings achieved over
Lockton’s book of business in 2014
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Total annualized savings
opportunity: $200,000 to $350,000
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Potential Annualized
savings: $200k - $350k
Renogiate AWP discounts, Rebates,
Dispensing Fees
Implement best-in-class contract language
Quarterly Audit provision with full
reconciliation annually
Lockton Companies, Proprietary and Confidential
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Lockton Pharmacy Analytics
Lockton’s Pharmacy Analytics
Member Cost
Share Strategies
practice supports plan sponsors
in assessing the current and
Detailed Claims
Analysis
future cost drivers of their
pharmacy benefit plan and
deploying strategies to enhance
Specialty Drug
Spend Mitigation
PBM Marketing
value and mitigate spending.
Our experienced consultants will
provide plan sponsors guidance
on how to address immediate
Clinical
Savings
Analysis
Prospective
Cost Modeling
needs and opportunities while
also positioning the plan to
successfully manage future
challenges.
Formulary
Management
Contract
Optimization
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