What to Expect for Pharmacy Benefits and Drug Cost Trends for 2018 & 2019 Mid-Sized Retirement and Healthcare Plan Management Conference 2018. Innovative Rx Strategies, LLC. All rights reserved.
The Ever Changing PBM Landscape and What It Means for 2018 & 2019 CVS Health purchases Aetna for $69B to create retail pharmacy/pbm/health plan behemoth. Diplomat Specialty Pharmacy acquires NPS and LDI. Express Scripts acquisition of medical benefits management firm evicore for $3.6B to provide evidence based medical management services. Walgreens spends $4.375B to buy 1932 Rite Aid pharmacies and then closes 600 of the Rite Aid pharmacies it purchased. Joint Venture between Walgreens and Prime Therapeutic for specialty pharmacy and mail. Anthem moves from Express Scripts to Caremark to start new PBM called IngenioRx effective 1/1/2020
Take Advantage of Changing Marketplace Market by Negotiating Better Pricing Terms with Your PBM Now is the time to take advantage of a market check provision in your PBM contract to improve retail, mail, and specialty discounts as well as rebates. If you don t have a market check provision in your PBM contract, ask anyway, particularly if you are in the second year of a three-year PBM contract. A Word of Caution The wording in your market check provision is critical; don t allow language that basically compares yourself against yourself. It is worth the time and effort to improve your pricing by doing a Market Check RFP.
It s All About the Generics Each 1% increase in generic utilization will lower drug cost by 2.5%. A number of brand drugs are projected to lose patent protection in 2018 including Levitra, Lyrica, Symbicort and Xolair. Generics already represent approximately 85-88% of all prescriptions dispensed expected to exceed 90% by end of 2018. Generics are more profitable for PBMs than brand drugs. Pharmacies will be highly motivated to pull-thru the newly released generics increased profit margins. Drug Manufacturers will stop paying rebates once their brand drug is generically available. Is your PBM using generics to buy-down your brand discounts? Negotiate generic effective rate ( GER ) guarantee with your PBM. 2018. Innovative Rx Strategies, LLC. All rights reserved.
Generic Drug Price Inflation Costs for generic drugs are increasing expect to see as much as a 15% increase in generic pricing in 2018. Price Inflation for prescription drugs is expected to be 9% in 2018. Some generic drugs are in limited supply Fewer drug manufacturers making generics End Result Certain generic drugs may no longer qualify to be on MAC list; priced at a higher non-mac/brand drug rate Strategies to Mitigate Impact Monitor deletion of generics from a PBM s MAC List Understand what is and is not in PBM s generic bucket Do not allow non-mac generics to be priced at brand discount Negotiate a GER guarantee that includes all generic drug claims Implement preferred/non-preferred generic copays 2018. Innovative Rx Strategies, LLC. All rights reserved.
Copay Trends Co-insurance with minimum and maximum copays Minimum copays create zero-balance due (ZBD) claims For example: with a $15 minimum generic copay 45-50% of all generic claims will have a $0 cost to the employer Specialty drugs are either in the 3 rd tier (non-preferred brand) or in their own 4 th tier With co-insurance the Specialty drugs will typically pay at the maximum copay amount
Drug Coverage Trends Exclusionary Formularies a) Drive significantly higher rebates b) Insulin coverage has the most member disruption Excluding High Cost Generics a) Generic AWPs are based on the Brand s AWP b) Discount off of AWP may be in target range c) Actual cost is higher than alternative generics within the therapeutic class Excluding Brands Comprised of Low Cost Generics a) One PBM calls this their Stupid Drug List b) Cover individual drugs, not combination
Member Cost Share Significant Decrease Historical goal was to have members share 20% of cost Increase in specialty drug utilization has decreased member cost share to 10-14% Challenge is where to set specialty copays If copay too high member can t afford the drug Affordability is a key factor in member compliance Must implement clinical controls on specialty drugs to ensure proper utilization Quantity level limits Step therapies Therapeutic Interchange Programs (TIP) on naïve fills 2018. Innovative Rx Strategies, LLC. All rights reserved.
Using Drug Manufacturer Coupons to Lower Specialty Drug Costs Specialty drug manufacturer coupons can help employer s lower their specialty drug costs. Consider implementing a Variable Copay Program to take advantage of manufacturer coupons that reduce plan costs by increasing copays for select specialty drugs. If a member uses a manufacturer coupon to pay for the cost of a drug only allow a portion of the coupon to apply to the member s copay while the remaining value of the coupon is used by the plan to lower specialty drug cost. Will other pharmaceutical manufacturers follow Amgen in limiting coverage of out-of-pocket costs for members enrolled in a plan that has an accumulator adjustment program in place? 2018. Innovative Rx Strategies, LLC. All rights reserved.
Restricted Pharmacy Networks Restricted pharmacy networks have been available for 15 years Typically a restricted network will either exclude CVS or Walgreens Walgreens acquisition of Rite Aid stores could increase the number of excluded pharmacies! Restricted networks will be limited to ERISA plans due to state Any Willing Provider statutes PBMs have historically offer a 1% better Retail brand discount No improvement on Retail generic discount guarantee No improvement in Mail discounts or Rebates Must evaluate if potential saving is worth the member disruption
Ninety (90) Days Supply at Retail Programs 90 day at retail programs are very popular with members who want fill their maintenance drugs at their local drug store. PBMs offer an open 90 day at retail program that allows maintenance drugs to be filled at any retail pharmacy; pricing not as good as mail order discounts. Caremark pioneered Maintenance Choice that allowed members to get a 90 day fill at a CVS pharmacy at the mail order discounts and copays; proved to be very successful. Walgreens introduced Walgreens90 to counter Maintenance Choice. Walgreens now has contracts with Express Scripts, OptumRx, Envision, and Prime to offer Walgreens 90 program. Voluntary or Mandatory program?
Specialty Drugs Specialty drugs are the fastest growing component of prescription drug costs is expected to increase 30-40% annually Key contributors include drugs for rheumatoid arthritis (26.8%), multiple sclerosis (20.1%) and oncology (16.9%) Pharmaceutical pipeline is filled with specialty drugs 55% of Phase 3 & 4 molecules awaiting FDA approval are specialty drugs Cost Control Strategies: 1. PBM contract should specify the discount on each specialty drug with an overall specialty drug discount guarantee 2. Specialty drugs should be limited to a 30 days supply 3. Establish specialty drug copay tiers Preferred and Non-Preferred 4. Develop step-therapy protocols 5. Consider a plan stop-loss limits for specialty drugs 2018. Innovative Rx Strategies, LLC. All rights reserved.
Value of Rebates In 2018, 90% of claims will be for a generic drug 8% will be for a traditional brand drug 2% will be for a specialty drug (innovator & biosimilar) PBMs negotiate formulary and market share rebates with drug manufactures. Formulary exclusions increase rebate amounts by driving market share Specialty drug rebates are significant! Price Protection/Inflation Guarantee Rebates Caps the AWP increase on specialty drugs AWP increase in excess of the cap are rebated back to client 2018. Innovative Rx Strategies, LLC. All rights reserved.
Value Based Contracting Employers are frustrated with whether high cost prescription drugs are worth the cost. There is a missing link between cost and outcome. Payors need to insist upon more accountability from their PBM and need to pressure the PBM and pharma to demonstrate value and outcomes. Focus on total cost of care; not the cost of single products. Do the drugs selected by the PBM for their formulary really work the way they say they will? Fee for value Should employers receive a deeper discount if a high cost drug doesn t perform? Evaluate medical and pharmacy claims data to ensure a drug you are paying for is actually working.
Increased use of Third Party Administrators (TPAs) Small to mid-sized employers are transitioning from health plans to TPAs Going self-funded and saving insured premium up charge Employers can save $1,000-$1,200 PEPY by doing a PBM carve-out and unbundling their prescription plan from the medical carrier and engaging directly with a PBM through a TPA Captive Benefit Program a) Combines medical, pharmacy, dental with a stop loss b) PMPM fee with an annual reconciliation not insurance!
Drug Cost Trends in 2018 and Beyond Key Take Aways Ask your PBM for better pricing Strategies are available to increase utilization of lower cost generics Monitor and manage generic price inflation Member cost share is decreasing due to increasing Specialty claims Take advantage of manufacturer s coupons to lower cost of Specialty drugs Restricted pharmacy networks may not be worth the disruption Is a 90 days supply retail network a viable option? Specialty rebates are significant! Value based contracting will help address total cost of care 2018. Innovative Rx Strategies, LLC. All rights reserved.