Transcript CareFirst Formulary 1
2015 CAREFIRST FORMULARY OPTIONS
200+ ASO ACCOUNTS
August 5, 2014
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PROPRIETARY AND CONFIDENTIAL
Agenda
• Purpose • Pharmacy Landscape • Guiding Principles • 2015 Options • Implementation
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PROPRIETARY AND CONFIDENTIAL
Purpose of Today’s Training
• Why we are here • Understanding CareFirst’s strategic decision • How CareFirst and downstream accounts benefit
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PROPRIETARY AND CONFIDENTIAL
Double Digit Increase in Pharmacy Trend Projected
PRICE DRUG MIX UTILIZATION
Overall cost of drug, including what Account and member pay Influencers
• Inflation • Source of drug • Lack of product competition • Site of service
Proportion of brand-name and generic drugs being dispensed Influencers
• Generics • Formulary • Pharmaceutical marketing • New agents
Intensity of drug use; approval of new drugs or indications Influencers
• Changes in treatment guidelines • Demographic/economic changes *By 2016. CVS Caremark drug trend forecast. Trend calculations based on a trend cohort group. Trend cohort group includes funded Accounts with retail claims for the calendar year and includes Accounts in the commercial segments (health plan and employer), Medicare and Medicaid. 30454
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PROPRIETARY AND CONFIDENTIAL
Multiple Market Factors Increase Pressure on Accounts to Control Pharmacy Spend
GENERIC LAUNCHES HAVE PEAKED; WILL NO LONGER OFFSET DRUG TREND •
Generic dispensing rate topped 80% in 2013;
2012 was peak of patent cliff at $35B* • 2014 generic launches make up
half the market value
of 2012 launches* MANUFACTURER RESPONSE: PRICE INCREASES; SHARE RETENTION STRATEGIES •
14.4% increase
in non-specialty brand AWP in 2013* • Manufacturers invested
$4 billion annually 1
between 2010 and 2011 to preserve market share and margin by going outside the standard supply chain SPECIALTY CONTINUES TO DRIVE UP COSTS • Specialty drugs accounted for
22.5%
of our Accounts’ pharmacy spend* – Relative increase of
more than 10%
in a single year*
Past plan performance is no guarantee of future results – accounts must employ a defined strategy to offset ongoing marketplace tactics
*CVS/caremark Internal Analysis, 2013. 1. As reported by PCMA: Cleveland Research, “How Co-pay Discount Cards Are Affecting Drug Spend,” Presented at Pharmacy Benefits Academy, August 2011 31392e 5 PROPRIETARY AND CONFIDENTIAL
Our Proactive Approach Positions Accounts at the Forefront of Market Changes
• • •
Industry-leading formulary strategy:
Built from our experience in anticipating marketplace changes
Encourage continued savings:
Help Accounts stay ahead of market shifts with innovative formulary and pipeline management
Building on our success:
Continue to help maximize savings for Accounts while minimizing plan member disruption
THE 2014 CVS/CAREMARK FORMULARY STRATEGY RESULTED IN: $41.13
Average plan savings per transitioned prescription*
$28.69
Average member savings per transitioned prescription*
2.5%
Overall effective increase in GDR in targeted drug classes*
A strategic approach to formulary management proactively positions Accounts to help mitigate the effects of future trend increases
*Indicates an average savings based on cohort results. Actual savings may vary per plan. Contact your CVS/caremark Account team for a personalized savings analysis.
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Guiding Principles of Formulary Management
Rx Maintain clinical integrity
Target classes with sufficient generic availability, clinically interchangeable brands; evaluate appropriate specialty classes*
Secure competitive pricing for our Accounts
Continually assess marketplace to identify lower-cost options and opportunities to maximize manufacturer rebate values
Educate and engage members and physicians
Help e nsure access to the drugs members need to stay healthy; provide resources for physicians to support member transition
20 years experience providing unique formulary strategies to meet Account goals
*Specialty classes with similarity between chemical entities 31392e 7 PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary Options in 2015
CAREFIRST FORMULARY 1
•
Open
Formulary •Currently in place for CareFirst (all business) •Tiering changes on some drugs to drive member behavior •Quarterly tier changes
CAREFIRST FORMULARY 2
• Covers generics and
most
brands • ~70 excluded products • Exclusions updated yearly • Up to 3-4% savings of drug spend compared to CareFirst Formulary 1*
SAVINGS
CAREFIRST FORMULARY 3
• Covers
most
generics and brands and specialty • ~200 excluded products • Exclusions updated quarterly • Up to 3-4% savings of drug spend compared to CareFirst Formulary 2* 1. Source: CVS Caremark Enterprise Analytics, 2012. Projections based on CVS Caremark data. Individual results will vary based on plan design, formulary status, demographic characteristics and other factors. Based on Account specific modeling of CareFirst BCBS *Based on ingredient cost Drug Spend. Drug Spend pharmacy savings include rebate impact. Account savings may vary by plan design, pricing arrangement, drug mix and at-risk market launches. Member savings will vary based on several factors, some of which include plan design, plan performance, etc. 30454 8 PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 1: Open Formulary
• • • • Enhanced the current CareFirst open formulary to increase the overall rebate value Broad access to over 5,000 drugs with no brand drug exclusions Formulary tiering to drive member behavior – 10.5% of the members were positively impacted by drugs moved to a lower cost sharing tier (July 15, 2014) – Less than 2% of the members will have drugs moved to a higher cost sharing tier (January 1, 2015) Quarterly tier changes – Targeted member communications will be sent to affected members 30 - 45 days prior to the effective date Default option for CareFirst accounts Note: CareFirst Formulary 1 is a Custom Opt-out Formulary
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PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 2: Generic and Rebate Improvement Formulary Effective 1/1/15
• • • • • • For 200+ ASO accounts looking to be more aggressive in their pursuit of rebates ~70 drugs excluded – alternative medications available – 2-3% of members affected by drug exclusions and negative tier changes Exclusions updated annually Increased rebate guarantees over CareFirst Formulary 1 Reduces overall spend by nearly 3-4% compared to CareFirst Formulary 1 Quarterly tier changes – Targeted member and physician communications 30-90 days prior to the effective date Note: CareFirst Formulary 2 is Standard Formulary
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PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 3: Higher Control Formulary (Lowest Net Spend) Effective 1/1/15
• For 200+ ASO accounts seeking the lowest possible costs while retaining coverage within each therapeutic class • Focuses on driving to generic drugs & driving higher rebate value • • • ~ 200 drugs excluded
– preferred alternative medications available
• 4-5% of members affected by drug exclusions and negative tier changes Exclusions and tier changes updated quarterly Creates savings by driving members to the lowest cost drugs • Up to 3-4% savings of drug spend compared to CareFirst Formulary 2* Note: CareFirst Formulary 3 is Advanced Control Formulary
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PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 3: Integrates Preferred Product Strategy and Generics
• • Extend savings by leveraging preferred product strategy along with shift to generics – Quarterly updates – Advanced specialty controls included Helps ensure trend management against costly new products that do not deliver clinical advantages – Day one control of new product launches and line extensions, until reviewed Note: CareFirst Formulary 2 is Standard Formulary 30454
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PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 3 Specialty Drives Additional Plan Savings
• • • Help manage specialty drug spend: – Included in the new formulary option – Addresses both appropriate utilization and preferred drug selection Currently focused on seven** therapy classes: MS, Biologic Disease Modifying Agents (Rheumatoid Arthritis), fertility, hepatitis C interferons, growth hormone, PAH, osteoarthritis – Quarterly updates Day one control of new product launches and line extensions, until reviewed; unless given pivotal drug status
Specialty growth expected to quadruple by 2018 1 – new specialty control strategies needed to address rapid growth
**Number of classes may change. Accounts must accept all classes 1. The Growing Cost of Specialty Pharmacy —Is it Sustainable? February 18, 2013) Note: CareFirst Formulary 3 is Advanced Control Formulary 30454 13 PROPRIETARY AND CONFIDENTIAL
INTERNAL/FOR TRAINING PURPOSES ONLY
Comparing CareFirst Formularies
Drug Coverage Design CAREFIRST FORMULARY 1
All drugs covered per plan design Tier placement and member copay only
CAREFIRST FORMULARY 2
Focus on generics and select brands. Exclusion updated annually Tier placement and member copays; promotes generic dispensing when available
CAREFIRST FORMULARY 3
Select brand exclusions. May be updated quarterly Tier placement and member copays; mandatory medical necessity review; drives lowest net cost
Excluded Medications
Zero ~70 ~200
Member Impact
None ~2-3% of members affected moving from CareFirst Formulary 1 to CareFirst Formulary 2 ~4-5% members affected moving from CareFirst Formulary 2 to CareFirst Formulary 3.
Rebate Impact
**check with UW for account specific info
Drug Spend Savings
Increased over CareFirst 2014 Formulary Increased drug spend savings over CareFirst 2014 Formulary Increased rebate value over CareFirst Formulary 1 Up to 3-4% savings of drug spend savings* compared to CareFirst Formulary 1 Highest rebate value Up to 3-4% of drug spend savings* compared to CareFirst Formulary 2
Implementation Lead Time
n/a 90 days 90 days *Savings based on drug ingredient cost. Savings include rebate impact. Account savings may vary by plan design, pricing arrangement, drug mix and at-risk market launches. Member savings will vary based on several factors, some of which include plan design, plan performance, etc. Note: CareFirst Formulary 1 is a Custom Opt-out Formulary, CareFirst Formulary 2 is Standard Formulary, CareFirst Formulary 3 is Advanced Control Formulary 14 PROPRIETARY AND CONFIDENTIAL
Account Formulary Strategy – Key Considerations
INTERNAL/FOR TRAINING PURPOSES ONLY
Account Philosophy Need for greatest savings/value Union or other factors that may limit design choices Past experience with similar approach Marketplace considerations
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Support a Smooth Transition with Effective Member and Physician Engagement
•Member communication focuses on new savings options; encourages outreach to prescriber •Current drug and recommended drug are clearly listed
MID-OCTOBER MID-NOVEMBER
•Provides support in contacting physician, if requested by member
We leverage best practices for the most comprehensive engagement strategies.
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Communication Strategy
CareFirst Formulary 1
: •
Member Communications Only
– Targeted Negative Tier Change Notifications » Mailed 30-45 days prior to Implementation date (Mid-November) and quarterly thereafter » Final drug list targeted for 10/1/2014 – updated impact report expected by 10/5/14
CareFirst Formularies 2 & 3:
•
Member Communications
– Targeted Negative Tier Change Notifications » Mailed 30-45 days prior to Implementation date (Mid-November) and quarterly thereafter – Targeted Excluded Drug Notifications » Phase 1 Mailed Beginning October (and quarterly thereafter for CareFirst Formulary 3) » Phase 2 Mailed Mid-November (and quarterly thereafter for CareFirst Formulary 3) (CareFirst Formulary 2 doesn’t have quarterly exclusions – yearly only) •
Physician Communications
– Targeted Member Specific Excluded Drug Notifications » Mailed Approximately 3 weeks after Member Letters (End – Early November) and quarterly thereafter
Medical Necessity Exception Process
: In place for physicians to submit on behalf of their members for medical necessity review
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PROPRIETARY AND CONFIDENTIAL
Questions?
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PROPRIETARY AND CONFIDENTIAL
• ID Cards • CareFirst Marketing Materials • Installation
CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. which are independent licensees of the Blue Cross and Blue Shield Association. ® Registered trademark of the Blue Cross and Blue Shield Association. ®′ Registered trademark of CareFirst of Maryland, Inc.
PROPRIETARY AND CONFIDENTIAL
ID Cards Mock-Up – 200+ ASO (Facets)
ID cards will now include an indicator of which formulary: RX = CareFirst Formulary 1 RX2 = CareFirst Formulary 2 RX3 = CareFirst Formulary 3
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PROPRIETARY AND CONFIDENTIAL
ID Cards Mock-Up – Large Group (NASCO) Before Legend on card strip After 21
PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 2 & 3 Quote and Installation Process Account Manager
• Request a quote business as usual from Underwriting • Notify your Underwriter if sold
Service Rep
• Facets – No additional paperwork – Service Rep indicates “Formulary 2 or Formulary 3” in SOCS form comments • NASCO – Pharmacy NAEGS & FirstForm updates – Service Rep indicates “Formulary 2 or Formulary 3” in SOCS form comments
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PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary Communication Resources Marketing Piece Purpose Audience
Formulary Comparison Sheet Member Communications on Formularies 1, 2 and 3 Member Communications on Formularies 2 and 3 Provider Communications on Formularies 2 and 3 Formulary Drug Removal Listing – Formulary 2 Formulary Drug Removal Listing – Formulary 3 Pre-Log In Drug Search Tool Member On-Line Tools (My Account) Sheet for sales to use in discussing formulary options with employer groups Negative tier change letters sent to impacted members Drug exclusions letters sent to impacted members Drug exclusion letters sent to providers of impacted members For Formulary 2, list indicating alternatives to drugs being excluded For Formulary 3, list indicating alternatives to drugs being excluded • 24 hour drug tool to identify if drug covered on formulary. • Also provides formulary PDF and Preferred Drug List
(updated quarterly: 1/1; 4/1; 7/1; 10/1)
24 hour drug tools for ordering and refilling drugs and more Employer Member Member Provider Members Members Prospects and Members Member
Source
SOS CVS
Resource Number
SUM2656-1P CVS CVS SOS SOS SUM2657-1P SUM2658-1P www.carefirst.com/rx My Account www.CareFirst.com
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PROPRIETARY AND CONFIDENTIAL
CareFirst Formulary 1 Member Communications Value Add: Negative Notice of Tier Change (Drug moving to higher cost sharing tier)
• Previously posted in Vitality • NEW: 30-45 days prior to effective date, mailing sent to members taking a drug being moved to a higher cost-sharing tier (negative tier change notice) * • Notice gives members lower-cost alternative(s) • Call to action to provide information to provider * NOTE: These negative change notices do NOT include notification of drugs changing tiers due to generic drug introduction. Per CVS, this is not a notifiable situation as this is an open formulary and the member had the choice to select the generic and not pay the higher cost share of the non preferred brand.
• • When a generic becomes available, the preferred brand drug moves to a non-preferred brand drug status (as noted in the contract) • When member goes to the pharmacy, the member is notified by the pharmacist about the availability of the generic drug.
98% of members will buy the generic alternative 24
PROPRIETARY AND CONFIDENTIAL
Formulary 2 Drug Removal List (MOCK-UP): Updated Annually 25
PROPRIETARY AND CONFIDENTIAL
Drug Search Tool – Pre-Log In
Search Function may change for 2015
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PROPRIETARY AND CONFIDENTIAL
Secure Log In--My Account
My Account
“Drug and Pharmacy Resources”
include: 1. My Drug Home 2. Drug coverage and cost (Drug Pricing) 3. View Drug claims 4. Find a Pharmacy 5. Order and refill prescriptions (Mail Order) 1 2 3 4 5
NOTE:
The Drug Pricing Tool provides pricing information for the plan the member currently has. A member cannot access pricing information for a plan that is effective in the future.
Example, Marta changes benefits effective January 2015. She will not be able to get drug pricing information on her new plan until January 2015.
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PROPRIETARY AND CONFIDENTIAL