THANK YOU SPONSORS 2

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2 THANK YOU SPONSORS 2

3 How to: Power Up your pharmacy benefit plan Brent Matthews, Benefits Advisor/Principal, TrueNorth Companies Aaron Viertel, Director of Clinical Management, TrueNorth Companies 3

4 Today s Agenda Current healthcare environment and PBM (Pharmacy Benefit Management) Marketplace Key components of how PBMs make money PBM contracting strategies PBM management strategies and services 4

5 Nearly 13 Rxs per US citizen each year! 5

6 Denotes a category where nonmedication therapies may often be used 6

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8 In the last 10 years the US has more than a $102 billion dollar increase in total Rx costs! By 2020, costs are expected to be more than triple that of 20 years ago! 8

9 4% 9

10 Current PBM Marketplace Mergers and acquisitions are the new norm The Big 3 PBMs (Express Scripts, CVS Caremark, and OptumRx control between 75-80% of the market; All 3 companies are listed in the Top 22 of the Fortune 500 United Healthcare owns OptumRx (Restat, Catamaran, Catalyst, others) and the SXC claims platform BlueCross & BlueShield owns Prime Therapeutics Diplomat Pharmacy, Inc. acquired LDI Integrated Pharmacy Services for $595 million and NPS for $47 million Rite Aid acquired MedTrak and EnvisionRx and the Laker Software claims platform Medicare Part D is dominated by large PBMs 23% of enrollees use United Health, 18% Humana (highly promoted Walmart partnership), 14% CVS Health, and 8% Aetna, 7% Express Scripts, 3% Cigna (Source KFF analysis of CMS 2018 Part D plan files) 10

11 What does the future hold? CVS to Buy Aetna for $69 Billion in a Deal That May Reshape the Health Industry NY Times December 3, 2017 Rite Aid stock drops after failed Albertson s deal narrows its options Bloomberg August 9, 2018 Cigna to acquire Express Scripts for $52B in health care shakeup USA Today March 8, 2018 Amazon Buys Online Pharmacy PillPack for $1 Billion The Wall Street Journal June 28,

12 How do PBMs make money? Pass-through or Transparent Spread or Traditional 12

13 How does each model work? Pass-through or transparent All prescription claims are processed using a proprietary discount method by the PBM at the pharmacy(ies). The plan and its members are charged the same amount as the PBM s discounted amount, receiving 100% of the negotiated network discounts. Ex: $55 cash price $35 discounted network rate $10 member co-pay $25 plan pay Spread or traditional All prescription claims are processed using a proprietary discount method by the PBM at the pharmacy(ies). The plan and its members are charged a higher rate than the PBM s discounted amount, creating a spread. Ex: $55 cash price $35 discounted network rate $10 member co-pay $35 plan pay The pharmacy is reimbursed $35 in total but the plan is charged an additional $10 or an inflated ingredient cost and dispensing fee for the medication. The PBM keeps the $10 mark up as their admin revenue. When does $25 $10 $45? 13

14 How do rebates work? Manufacturers of brand medications pass rebates to PBMs when a medication is filled. A portion of, all, or no rebates are passed back to the PBM s client. PBMs negotiate placement rebates for putting brand medications on various tiers within their formulary(ies) or approved drug lists. PBMs exclude certain medications from their formulary(ies) to achieve higher rebates on the remaining competitor drug(s). PBMs negotiate volume rebates based on dispensing patterns within their mail-order facilities. PBMs sell data to the manufacturer 14

15 Basic components of a PBM contract Spread or pass-through Agreements are typically written to achieve one revenue stream or the other. Pass-through Agreements are typically written to provide clients/members 100% of the network discounted rate; No markup of drug cost; No roll-up of co-payments. Some pass-through agreements provide for minimum guaranteed discounts on brands/generics/specialty. 100% of rebates are passed on, at times with minimum guarantees per drug type Admin fees PM/PM or per paid claim Spread Agreements are written to provide a fixed discount on brands, generics, specialty; Contract language allows PBM to keep difference, Co-pay roll-ups Fixed discounts or minimum guaranteed discounts by drug type Fixed per rebate guaranteed dollar amounts or minimum guaranteed dollar amounts $0 admin fees, or PM/PM, or per paid claim PBMs may also dictate whether a drug is a generic or brand, what defines their MAC (or maximum allowable cost) list, the % of generic drugs on that list, what pharmacies are in network, and what formulary is used. 15

16 Sample Contract Language Drug Definitions A generic is any drug with more than two (2) manufacturers. A generic is any drug with two (2) or more manufacturers. 16

17 Sample Contract Language - Rebates The average 30-day retail rebate is $75-$100. The average 30-day specialty rebate is $400-$

18 Sample Contract Language Financial Terms 18

19 Sample Contract Language Financial Terms No admin fee doesn t really mean that the PBM is doing it for free. 19

20 How much can you save by closely managing your pharmacy benefit? Organization Plan Cost PM/PM Variance Generic Utilization Variance TrueNorth 1 (Highly managed block using a customized pharmacy benefit solution) $60.53** (all drugs) (non-specialty $41.83) Manufacturers Rebates reduce the plan s pm/pm cost by $5 to $10 on average (depending on generic utilization and plan design) MedTrak 2 $64.29** -$ % -2% Navitus 3 $76.56*** -$16.03 Not published 89% TrueNorth s Rx plan management results in over $45,000 less in plan cost per year vs. the next best option! 9 CIGNA 7 $83.14*** -$22.61 Not published UMR 4 $85.47*** -$24.94 Not published CVS Caremark 5 $88.94* (Managed Formularies) -$ % -3.5% BC&BS IL/Prime Therapeutics 8 $92.24*** -$ % -4.1% Wellmark BC&BS/CVS 6 $95.17* (all drugs) (non-specialty $60.13) -$34.64 Not published CVS Caremark 5 $108.42*(Standard Formulary) -$ % -5.2% *Post rebates; **Pre-rebates; ***Unknown 1 TrueNorth 2017 Aggregate Results (Highly managed block), Pre-rebates 2 MedTrak Book-of-business Jan-Mar 2018, Pre-rebates 3 Navitus 2017 Drug Trend Report 4 UMR PACE Report 2017 Book-of-business, 3 million members 5 CVS 2017 Drug Trend Report Post-rebates; 2017 Insights Q1 6 Wellmark/CVS 2017 Book-of-business Report 7 CIGNA Book-of-business report 2017, Commercial plans 8 BC & BS IL Benchmark March Based on a 1,000 life health plan 20

21 Power Up Your Prescription Benefit Plan PBM Contracting and Audit Services Using a proprietary claims analytics tool, we help clients keep their PBM honest : RFP Full scale PBM request-for-proposal and contract negotiation Claims re-pricing Process a set of Rx claims data against nationally accepted pricing parameters or proposed pricing PBM contract management Provide analysis of a client s current claims set against contracted terms Trend reports and plan design modeling to maximize plan savings 21