1. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 1 AGING-RELATED MEDICATIONS: COST AND UTILIZATION PATTERNS Presenter: Reethi Iyengar PhD * Co-authors: Rochelle Henderson PhD * Conference: American Public Health Association Yuhong Tian PhD * Date: October 30, 2012 Bradey Gotto PharmD ** * Express Scripts, Inc. ** United States Navy

2. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 2 PRESENTER DISCLOSURES Reethi N. Iyengar PhD MBA MHM The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: “No relationships to disclose” Co-author Disclaimer The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government

3. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 3 ① INTRODUCTION ② METHODS ③ RESULTS ④ PUBLIC HEALTH IMPLICATIONS AGENDA

4. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 4 Americans are living longer than ever before Living longer comes with a price – medical and medication needs INTRODUCTION Glimpse into the future: 88.5 million Americans will be over 65 by 2050

5. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 5 To examine incremental per-member-per-year (PMPY) pharmacy costs and utilization of aging-related medications To present the total spend and utilization trends of aging-related medications for Medicare * plans and privately insured population * Administered by the PBM AIM OF THE STUDY

6. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 6 Urinary Symptoms (Non-infection) Mental Alertness/Memory Issues Hormone Replacement Therapy (HRT) Insomnia Sexual Dysfunction Skin Aging Hair loss AGING-RELATED CONDITIONS

7. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 7 Design Retrospective analysis using pharmacy claims data from a large nationally representative pharmacy benefit management company Population and Timeline Medicare members: Aged 65 and above; Privately Insured members: All ages 2007 to 2011 Outcomes PMPY Cost and Utilization for aging-related medications Analysis Descriptive analysis of trend RESEARCH METHODOLOGY

8. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 8 Utilization for Medicare * Increased 32% Five Year Trend: Change from 2007 to 2011 PMPY Costs For Aging-Related Medications1.3% PMPY Utilization For Aging-Related Medications32.0% Year Total PMPY Costs Percentage Change in Annual Costs Total PMPY Utilization Percentage Change in Annual Utilization 2011$90.00-2.4%1.9313.3% 2010$92.18-12.4%1.704.8% 2009$105.268.3%1.62-1.2% 2008$97.169.4%1.6412.6% 2007$88.80-1.46- *Administered by the PBM

9. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 9 Costs Rose 35% For Privately Insured Members Five Year Trend: Change from 2007 to 2011 PMPY Costs For Aging-Related Medications34.7% PMPY Utilization For Aging-Related Medications12.2% Year Total PMPY Costs Percentage Change in Annual Costs Total PMPY Utilization Percentage Change in Annual Utilization 2011$73.335.8%0.870.6% 2010$69.340.2%0.86-0.4% 2009$69.1916.7%0.875.7% 2008$59.298.9%0.825.9% 2007$54.44-0.77-

10. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 10 Top Three Conditions By Cost in 2011: Medicare (84.6%) * Privately Insured (76.8%) * RankConditionRankCondition 1Urinary Symptoms (Non-infection)1Mental Alertness/Memory Issues 2Insomnia2Urinary Symptoms (Non-infection) 3Hormone Replacement Therapy3 * Percent of the 2011 total spend on aging-related medications Medicare and Privately Insured

11. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 11 2011: Medication Costs for Aging-related versus Chronic Conditions; Privately Insured in 2011

12. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 12 Aging-related medications: Incremental use and spend has increased in Medicare and Privately Insured members Spend is creating a cost burden paralleling that of life- threatening chronic conditions CONCLUSION

13. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 13 PUBLIC HEALTH IMPLICATIONS Increased spend on normal aging processes could limit dollars available for public health needs Aging-related spend could impact overall healthcare costs and cause reduction in benefits Increasing utilization may also signal a growing trend towards medicalization of normal aging Trends indicate a potential need for utilization management programs and cost containment strategies

14. Confidential and Proprietary Information © 2012 Express Scripts, Inc. All Rights Reserved 14 Reethi N. Iyengar Senior Manager Health Services Research Express Scripts rniyengar@express-scripts.com THANK YOU