Transcript 2015 Express Scripts PPT Template Guide and Tips

Pharma Pricing and Value:
The Elephants In the Room
Adam Kautzner
Vice President, Trend Management
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High drug cost fuels fear and anger
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Who can best fight for fair prices?
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The basic role of a pharmacy benefit manager
Member
Pharmacy
PBM
Take prescription and
ID card to pharmacy
Submit online claim
to PBM
Verify eligibility
Determine benefit
Drug utilization review
Receive
prescription drug
Fill prescription
Collect copayment
Send online response
Store information
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We do more to improve care and drive value
Member
Express Scripts
PharmacySM
Networks
Employer /
Plan Sponsor
Formulary Management
Retail Pharmacy
Clinical Support
Accredo®
Pharmaceutical
Companies
Physician
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We are aligned
with payers and patients
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Drug Trend in 2015: Continuing to grow
- 0.1%
traditional
17.7%
5.2%
total trend
specialty
Source: 2015 Drug Trend Report
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Brand Rx inflation grows
at unsustainable rate
%
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Increase in average
price of brand
medications
since 2008
Source: 2015 Drug Trend Report
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FDA new drug approvals
keep climbing
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Cost of drugs at introduction increases
Source: Express Scripts research
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Costly, high-use drugs drive up spend
Alzheimer’s
Cancer
High
Cholesterol
Hepatitis C
PREVALENCE
5.4 million
14 million
71 million
3.2 million
ANNUAL COST
$35,000
>$100,000
>$14,000
~$100,000
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Generic savings opportunities declining
$214 Billion
$35
$30
$ Billions
$25
$20
$15
$10
$5
$0
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Market conditions enable
price spikes in generics
•
•
•
•
•
Industry consolidation
Limited production
Pay to delay schemes
Captive pharmacies
New exclusivities
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Our mission:
Keep medicine
within reach
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Bold action and innovative solutions
help shape the industry
Introduced
formulary
exclusions
Launched
Hepatitis Cure
Value Program®
$4.9B exclusion
value to date
Lowered cost of a cure
by nearly 50%
2014
Launched
SafeGuardRxSM
Inflation Protection ProgramSM and
Oncology Care Value ProgramSM
Ensuring patient access/care;
Protecting plan interests
2016
2015
Advocated for
fair pricing on
Sovaldi®
(sofosbuvir)
$4B savings
nationwide (2015)
Introducing new
SafeGuardRxSM
solutions
Launched Cholesterol
Care Value ProgramSM
for PCSK9 inhibitors
Avoided up to 90% of spend
Implemented solution
to address unchecked
compound drug prices
$1.9B savings (2015)
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Broad challenges require a holistic approach
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Formulary management:
Lowest cost, broad access
National Preferred Formulary
Value of Exclusions
$4.9B TOTAL SAVINGS
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A COMPREHENSIVE SOLUTION
SafeGuardRxSM
•
•
•
•
Biggest pain points
Superior member care
Exceptional discounts
Shared risk
An umbrella for the future
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SAFEGUARDRx
Continuous innovation to meet market needs
NEW SOLUTIONS
Inflammatory Conditions
Care Value ProgramSM
Diabetes Care
Value ProgramSM
Market Events
Protection ProgramSM
Segments therapies by
indication while providing
specialized care through
Accredo®
Combines improved patient
care with additional cost
containment tools
Identifies issues and
rapidly deploys solutions to
protect against financially
damaging events
CURRENT SOLUTIONS
Hepatitis Cure
Value Program®
Oncology Care
Value ProgramSM
Cholesterol Care
Value ProgramSM
Inflation Protection
Program
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Cancer: Cost of care continues to rise
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•
•
•
More patients
More chronic therapy
Increasingly expensive drugs
Combination therapy
Cost for a course
of treatment:
$178,000
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Oncology drug prices dramatically increase
Monthly & Median Costs of Cancer Drugs
at the Time of FDA Approval
Monthly Price of Treatment (2014 $, log scale)
1965-2015
100-fold
price increase
Individual Drugs
Median Monthly Price
(per 5-year period)
Year of FDA Approval
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Survival benefit outpaced by price inflation
Price per life year gained
($1,000s of 2013 USD)
Price per life year gained versus
approval date of cancer drugs
Approval Date
The best fit line is: Price per life year gained = $54,100 + $8,500 x Approval year.
Approval Year = 0 for 1995, 1 for 1996, etc
Source: David H. Howard, et al, National Bureau of Economic Research
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One drug, two very different results
Tarceva on Pancreatic Cancer
1.0
1.0
DOUBLES
SURVIVAL
0.9
0.8
0.7
(5.2 months)
0.6
0.5
0.4
Tarceva
0.3
median PFS: 10.4
0.2
0.1
Placebo
0.0
3
6
9
EXTENDS SURVIVAL
ONLY 12 DAYS
0.9
0.8
0.7
(0.4 months)
0.6
0.5
0.4
Tarceva
0.3
0.2
median OS: 6.4
Placebo
0.1
median OS: 6.0
0.0
median PFS: 5.2
0
Overall Survival (OS) Probability
Progression-Free Survival (PFS) Probability
Tarceva on Non-Small Cell Lung Cancer
12 15 18 21 24 27 30 33 36 39 42 45
Duration of Progression-Free Survival (in months)
0
3
6
9
12
15
18
21
24
27
30
33
Overall Survival (in months)
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Indication-Based Management
Medications priced based on indication efficacy
BASED ON INDUSTRY THOUGHT
LEADERSHIP
Steve Pearson, MD,
MSc, FRCP
President of Institute for Clinical
and Economic Review
Peter Bach, MD
Director, Memorial Sloan Kettering’s
Center for Health Policy & Outcomes
M U LT I P L E I N D I C AT I O N F A C T O R S
CONSIDERED
Factor
Clinical
Factor
Outcomes
Factor
Unique
Attributes
Factor
Factor
Adverse
Events
Factor
INDEPENDENT
FEEDBACK ON COST
BASED ON EFFICACY
FAIR INDICATION PRICING
Demanding what patients deserve – The best care at a better price
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Managed supply chain
aligns cost and efficacy
• Appropriate pricing
by cancer type
• Exclusive coverage for
participating manufacturers
• Early discontinuation
reimbursement
• Point-of-sale discount
on select medications
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Beyond pricing: Oncology Care Value Program
addresses complexity of treating cancer
35%
of treatment plans deviate from
evidence-based guidelines
45%
of patients do not comply with or complete
prescribed treatments
75%
drug trend over five years
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Oncology Therapeutic Resource Center®:
Specialized pharmacists provide expert care
Deep clinical knowledge
Breast/
ovarian
cancer
GI/GU
cancer
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•
•
•
Hematologic
disorders
Pediatric
cancers
Lung
cancer
Physician outreach and clinical support
Holistic approach to patient care
Higher adherence
Reduced waste
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Another pain point: Inflammatory conditions
Family of autoimmune diseases affecting the joints, spine,
skin, gastrointestinal system, and internal organs
Prevalence in the U.S.
Rheumatoid Arthritis
1.5 million
Psoriasis & Psoriatic Arthritis
6.7 million
Ankylosing Spondylitis
0.5 million
Inflammatory Bowel Disease
• Crohn’s Disease
• Ulcerative Colitis
~1.3 million
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Inflammatory conditions:
Highest Specialty spend
Inflammatory Spend
2X
$200
$180
$3,036
$160
$140
Projected
$120
$100
average cost
per prescription
Actual
If trend continues,
inflammatory drugs will
$80
$60
‘15
‘16
1. Source: 2015 Drug Trend Report
‘17
‘18
nearly double
in spend by ’18
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Inflammatory Conditions Care
Value Program offers solutions
SM
• Segmented therapies for indication-level
management and greater competition
• Specialized patient care through
Inflammatory TRC
• Early discontinuation reimbursement
• Rigorous clinical documentation
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A changing landscape: Biosimilars, new drugs
and targeted therapies
Rheumatoid Arthritis-Like
Dermatological
GI
Rheumatoid
Arthritis
Ankylosing
Spondylitis
Psoriatic
Arthritis
Juvenile Idiopathic
Arthritis
Psoriasis
Crohn’s
Disease
Ulcerative
Colitis
1.5M
0.5M
0.6M
0.3M
7.5M
0.7M
0.7M
Humira
Enbrel
Xeljanz
Orencia
Remicade
Cimzia
Simponi
Actemra
Kineret
Rituxan
Simponi Aria
Humira
Cimzia
Enbrel
Simponi
Remicade
Humira
Otelza
Remicade
Cimzia
Enbrel
Simponi
Stelara
Humira
Enbrel
Actemra IV
Orencia IV
Remicade
Kineret
Humira
Otezla
Enbrel
Cosentyx
Stelara
Taltz
Remicade
Humira
Cimzia
Remicade
Humira
Simponi
Remicade
inflectra
Stelara IV
Xeljanz
inflectra
— IN THE PIPELINE —
adalimumab
baricitinib
etanercept
inflectra
sarilumab
Cosentyx
etanercept
Inflectra
brodalumab
Cosentyx
etanercept
inflectra
Taltz
N/A
adalimumab
brodalumab
etanercept
inflectra
sarilumab
Abundant treatment options create opportunity
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Segmenting the market
to drive value
• Rheumatoid arthritis
• Psoriasis & psoriatic arthritis
• Ankylosing spondylitis
• Crohn’s disease
and ulcerative colitis
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How indication-level management works
Medication change only impacts
new-to-therapy patients
Non-Preferred*
Preferred*
Rheumatoid Arthritis-Like
Dermatological
Gastrointestinal
Rheumatoid
Arthritis
Ankylosing
Spondylitis
Juvenile
Idiopathic
Arthritis
Psoriatic
Arthritis
Psoriasis
Crohn’s
Disease
Ulcerative
Colitis
Actemra1
Enbrel
Humira
Xeljanz
Enbrel
Humira
Cosentyx
Enbrel
Humira
Enbrel
Humira
Stelara
Cosentyx
Humira
Otezla
Stelara
Cosentyx
Humira
Humira
Cimzia2
Kineret2
Orencia2
Simponi
50mg2
Cimzia2
Simponi
50mg2
Cimzia2
Simponi
50mg2
Otezla
Enbrel
Taltz2
Cimzia2
Simponi
100mg
*Preferred and Non-Preferred are NPF and Basic Formulary. High-performance formulary may be more restricted or may differ.
1 Subject to change. 2 NPF exclusion.
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Patient and payer pain points go beyond pricing
Rheumatoid Arthritis patients are
7x more likely
to reduce work hours
and
6x more likely
to incur medical charges
Nearly 44% of patients are nonadherent to their medication
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Inflammatory Therapeutic Resource Center:
Expert clinical care improves outcomes
Thorough gap-in-care
intervention outreach
Extensive patient
training & education
Activities of Daily Living
screenings
Proactive therapyeffectiveness assessments
8% greater
adherence
Copay
assistance
Optimal adherence is defined as 80% or more
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Takeaways
1
The rising cost of prescription drugs is unsustainable
2
PBMs are uniquely positioned to drive value
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The constantly shifting health care landscape requires
an innovative approach
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Our holistic model leverages unique capabilities to improve
health and financial outcomes
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© 2016 Express Scripts Holding Company. All Rights Reserved.