1. The current pharmacy landscape
Rebecca Mitchem
Senior Director
Aetna Specialty Pharmacy
July 2017

2. Today’s Conversation
Overall prescription drug spend High cost drugs that are driving the spend Strategies for managing or controlling the spend

3. Total US Healthcare Spending $3.2 Trillion
$325 Billion Drug Spend
2015

4. Healthcare Spend 20% of healthcare dollars are spent on medication.
Specialty medications are the largest driver of pharmacy trends.
New specialty medications are treating more common conditions like cardiovascular disease and rheumatoid arthritis.
This could dramatically increase cost for treatment of these more common conditions

5. 2016 Top Traditional Drug Classes
diclofenac lidocaine clobetasol
VICTOZA GLUMETZA INVOKANA
VYVANSE amphetamine/dextroamphetamine ER methylphenidate ER
LEVEMIR HUMALOG LANTUS
ANDROGEL FORTEO
PREMARIN 5

6. 2016 Top Specialty Drug Classes
HUMIRA ENBREL STELARA
TRUVADA ATRIPLA STRIBILD
COPAXONE TECFIDERA GILENYA
IBRABCE SPRYCEL GLEEVEC
REVLIMID
XOLAIR 6

7. What is a specialty drug?
While there is no formal industry definition, these drugs are usually protein based and bio-engineered or genetically engineered.
Average cost $4,500/month
Mostly self-injected or infused drugs
More side effects.
Require “cold pack” shipping

8. Specialty drugs treat many disease states
Hemophilia
Immune Deficiencies
Hepatitis C
Infertility
Growth Hormone
Enzyme Deficiencies
Multiple Sclerosis
Anemia
Cancer
Psoriasis
Osteoarthritis
Asthma
Psoriatic Arthritis
Osteoporosis
Rheumatoid Arthritis
Crohn’s Disease
Post-transplant
Alcohol Dependency
Macular Degeneration
Deep Vein Thrombosis
HIV
Respiratory Syncytial Virus
Parkinson’s
Pulmonary Arterial Hypertension

9. Drug Trends 3,500 Drugs 350 drugs 99% of prescriptions
Growing 2% - 3% a year
Growing at 10% - 20% a year
1% of Rx’s = 10% of TOTAL Health Care Spend

10. Trends that impact the bottom line
Make this two slides
Trends that impact the bottom line
68% of plan sponsors said specialty drug management is their biggest concern over the next five years.1
Specialty drugs are estimated to reach 50% of total costs by
Foot notes where is #2?
This slide was split between this page and the next… how does that effect footnotes?
Trends in Specialty Drug Benefits, PBMI.
2 National Business Group on Health, Policy Recommendations to Promote Sustainable, Affordable Pricing for Specialty Pharmaceuticals. January Accessed at

11. AVERAGE SPECIALTY SPEND BY BENEFIT TYPE 1
Coverage of specialty drugs
AVERAGE SPECIALTY SPEND BY BENEFIT TYPE 1
Pharmacy benefit – drugs mostly taken at home by the patient without medical supervision.
Medical benefit – drugs given by a health care professional in a hospital, doctor’s office or at home.
Drugs covered on the medical benefit, are given where the prescriber directs.
Pharmacy
70%
Medical
30%
1 Aetna Commercial All Funding Jan-Dec 2016.

12. Distribution by channel
Commercial, Fully Insured plans for May,, 2017

13. Top therapies
Commercial, Fully Insured plans for May,, 2017

14. Pharmacy has a “1% problem”
Type
Cost per Rx
% Mix
Generic
$30
80%
Brand
$250
19%
Specialty
$4,500 1%

15. PBM approach to specialty management
Create a benefit design that balances member out-of-pocket cost with access
Select the right formulary strategy for your population
Cover high cost medications when medically necessary
Redirect patients, when appropriate, to lower cost sites of care
Provide superior clinical support
Manage holistically across both medical and pharmacy benefits
*Aetna Specialty Pharmacy and the Specialty Pharmacy Network may not be available to California HMO members. Doctors may have agreed to dispense and administer these drugs to members themselves. Or they may write a prescription so that members can fill them at any participating retail or mail-order pharmacy.

16. 40 60% 500 Ensuring appropriate use with precertification 12%
Across 40
drug classes
60%
of specialty drugs managed through precertification
Maximum thresholds for more than
500
drugs
12%
reduction in specialty drug spend in 20151
1 Aetna National Precertification List Savings Data Analysis, 2015.

17. Finding the best place for infusion care
Before the first infusion: We may recommend alternate lower-cost sites to the prescribing physician.
Reviewing infusion claims: A team of specialty pharmacy experts review claims to help members find convenient, more cost-effective sites of care like home infusion.
$17.7 million
saved in 2015, without member disruption*
*Aetna program analysis.

18. Capture the value of biosimilars
There is no standard policy that works for all specialty medicines.
They are all unique.
Aetna reviews every drug launch independently using all of the information available to create a context for our coverage policies. In some cases, biosimilars may not be the best option for a member. We will always explore ways to decrease the unit cost of specialty drugs and help patients and payers to make informed choices.
Biosimilars could lead to a $44.2 billion reduction in spending on specialty drugs from 2014 to 2024.
The Cost Savings Potential of Biosimilar Drugs in the United States, Andrew W. Mulcahy, Zachary Predmore, and Soeren Mattkehttp://

19. In the quest to manage pharmacy spend, we can’t lose sight of the patient
Improving outcomes and eliminating efficiencies
Engaging members in the right care for them
Managing through the lens of total cost of care
Appropriate use: ensuring rigorous review of medical evidence and drug pipeline to ensure patients have access to effective therapies. This includes establishment of clinical criteria for initial authorization, reauthorization protocols, provider engagement and innovation with respect to authorization streamlining/HIT maximization
Patient Engagement and Management: supporting patients and their caregivers with resources to make daily living easier, managing their controllable lifestyle factors, and coordinating necessary care across pharmacy, medical and other ancillary services (home infusion, community resources, financial support services, etc.). This also means educating patients on their therapies including side effects, when to ask for help, and specialized resources by disease state to help our patients stay on therapy (as proven by our industry leading adherence rates for patients using ASRx)
Negotiating Price: establishing and effectively using tools to manage unit price including formularies across medical and pharmacy products, fee schedules for medically benefitted drugs, effective site of care programs, and preferred channel use
We work across all benefits for a holistic approach that improves outcomes and eliminates waste.
We meet members where they are in their health journey and deliver care in ways that work for them.
Drug cost only tells one part of the story and the allure of unit cost discounts could end up increasing your overall cost. 19

20. Identifying High Risk Specialty Members
Reports identify members who are:
Newly diagnosed with a disease that requires treatment with a specialty drug
New to specialty therapy or switching drugs
Non-compliant
Members needing additional support referred to for Care Management from:
Case and Disease Management
New to diagnosis/ therapy
Non-compliant
Referrals

21. Compliance and Persistency
Education
Medication
Disease
Importance of medication compliance
Communication
Clinical support 24 hours a day, 7 days a week
Proactive refill reminders
Provider collaboration
Identify barriers to adherence:
Side effect management
Copay assistance coordination
Medication reminder tips
Care Management Programs
Optional
Additional support
Available for all patients

22. Specialty Health Care Management Team
Disease & Drug education, tools, resources, with expedited referrals
Member managed by one clinician for personalized care and single point of contact
Collaboration with Case and Disease Management, Behavioral Health and other Aetna programs
Integrated computer system to share clinical information with Aetna Clinicians
Coordination with internal Registered Dieticians
Side effect monitoring and management
Copay assistance coordination
Adherence monitoring and intervention to support medication compliance

23. Case study: Shirley’s journey with Multiple Sclerosis
When her doctor changed her medication, she partnered with us to get the support she needed to manage her condition.
Introduced Shirley to support program
Connected her to her Aetna nurse
Educated her on her new medication
Checked for gaps in her care
Discovered Shirley’s struggle with depression
Referred her to specialists for support
Worked with her providers to ensure success
Encouraged her to continue persevering
Actual Member Experience

24. Proven Results: Personalized Care drives better MS outcomes13
Adherence Rate
Annual Relapse Rate % 25 %
For patients engaged with the Aetna Specialty Health Care Management team
Preliminary results from Aetna study to evaluate the value of Aetna Specialty Pharmacy services in Multiple Sclerosis patients, August 2015

25. Thank you